User login
Cardiology News is an independent news source that provides cardiologists with timely and relevant news and commentary about clinical developments and the impact of health care policy on cardiology and the cardiologist's practice. Cardiology News Digital Network is the online destination and multimedia properties of Cardiology News, the independent news publication for cardiologists. Cardiology news is the leading source of news and commentary about clinical developments in cardiology as well as health care policy and regulations that affect the cardiologist's practice. Cardiology News Digital Network is owned by Frontline Medical Communications.
Comorbidities more common in hospitalized COVID-19 patients
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
FROM MMWR
SARS serum neutralizing antibodies may inform the treatment of COVID-19
The immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, raising the likelihood that the similarly behaving SARS-CoV-2 might provoke the same response, according to an online communication published in the Journal of Microbiology, Immunology and Infection.
The authors cited a cohort study of convalescent SARS-CoV patients (56 cases, from the Beijing hospital of the Armed Forces Police, China) that showed that specific IgG antibodies and neutralizing antibodies were highly correlated, peaking at month 4 after the onset of disease and decreasing gradually thereafter.
This and other studies suggest that the immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, according to the authors.
However, of particular concern is the fact that only 11.8% of patients acquire specific SARS-CoV Abs in the early period after recovery at day 7, not reaching 100% until day 90, which highlights the importance of the detection of antibody titers for convalescent COVID-19 patients, according to the authors. “Otherwise, these patients with low titers of antibodies may not be efficient for the clearance of SARS-CoV-2.”
The authors also cited a recent study that showed how neutralizing antibody from a convalescent SARS patient could block the SARS-CoV-2 from entering into target cells in vitro, and suggested that previous experimental SARS-CoV vaccines and neutralizing antibodies could provide novel preventive and therapeutic options for COVID-19.
“These experiences from SARS-CoV are expected to have some implications for the treatment, management and surveillance of SARS-CoV-2 patients,” the authors concluded.
SOURCE: Lin Q et al. J Microbiol Immunol Infect. 2020 Mar 25. https://doi.org/10.1016/j.jmii.2020.03.015.
The immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, raising the likelihood that the similarly behaving SARS-CoV-2 might provoke the same response, according to an online communication published in the Journal of Microbiology, Immunology and Infection.
The authors cited a cohort study of convalescent SARS-CoV patients (56 cases, from the Beijing hospital of the Armed Forces Police, China) that showed that specific IgG antibodies and neutralizing antibodies were highly correlated, peaking at month 4 after the onset of disease and decreasing gradually thereafter.
This and other studies suggest that the immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, according to the authors.
However, of particular concern is the fact that only 11.8% of patients acquire specific SARS-CoV Abs in the early period after recovery at day 7, not reaching 100% until day 90, which highlights the importance of the detection of antibody titers for convalescent COVID-19 patients, according to the authors. “Otherwise, these patients with low titers of antibodies may not be efficient for the clearance of SARS-CoV-2.”
The authors also cited a recent study that showed how neutralizing antibody from a convalescent SARS patient could block the SARS-CoV-2 from entering into target cells in vitro, and suggested that previous experimental SARS-CoV vaccines and neutralizing antibodies could provide novel preventive and therapeutic options for COVID-19.
“These experiences from SARS-CoV are expected to have some implications for the treatment, management and surveillance of SARS-CoV-2 patients,” the authors concluded.
SOURCE: Lin Q et al. J Microbiol Immunol Infect. 2020 Mar 25. https://doi.org/10.1016/j.jmii.2020.03.015.
The immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, raising the likelihood that the similarly behaving SARS-CoV-2 might provoke the same response, according to an online communication published in the Journal of Microbiology, Immunology and Infection.
The authors cited a cohort study of convalescent SARS-CoV patients (56 cases, from the Beijing hospital of the Armed Forces Police, China) that showed that specific IgG antibodies and neutralizing antibodies were highly correlated, peaking at month 4 after the onset of disease and decreasing gradually thereafter.
This and other studies suggest that the immune responses of specific antibodies were maintained in more than 90% of recovered SARS-CoV patients for 2 years, according to the authors.
However, of particular concern is the fact that only 11.8% of patients acquire specific SARS-CoV Abs in the early period after recovery at day 7, not reaching 100% until day 90, which highlights the importance of the detection of antibody titers for convalescent COVID-19 patients, according to the authors. “Otherwise, these patients with low titers of antibodies may not be efficient for the clearance of SARS-CoV-2.”
The authors also cited a recent study that showed how neutralizing antibody from a convalescent SARS patient could block the SARS-CoV-2 from entering into target cells in vitro, and suggested that previous experimental SARS-CoV vaccines and neutralizing antibodies could provide novel preventive and therapeutic options for COVID-19.
“These experiences from SARS-CoV are expected to have some implications for the treatment, management and surveillance of SARS-CoV-2 patients,” the authors concluded.
SOURCE: Lin Q et al. J Microbiol Immunol Infect. 2020 Mar 25. https://doi.org/10.1016/j.jmii.2020.03.015.
FROM THE JOURNAL OF MICROBIOLOGY, IMMUNOLOGY AND INFECTION
COVID-19: More hydroxychloroquine data from France, more questions
A controversial study led by Didier Raoult, MD, PhD, on the combination of hydroxychloroquine and azithromycin in patients with COVID-19 was published March 20. The latest results from the same Marseille team, which involve 80 patients, were reported on March 27.
The investigators report a significant reduction in the viral load (83% patients had negative results on quantitative polymerase chain reaction testing at day 7, and 93% had negative results on day 8). There was a “clinical improvement compared to the natural progression.” One death occurred, and three patients were transferred to intensive care units.
If the data seem encouraging, the lack of a control arm in the study leaves clinicians perplexed, however.
Benjamin Davido, MD, an infectious disease specialist at Raymond-Poincaré Hospital in Garches, Paris, spoke in an interview about the implications of these new results.
What do you think about the new results presented by Prof. Raoult’s team? Do they confirm the effectiveness of hydroxychloroquine?
These results are complementary [to the original results] but don’t offer any new information or new statistical evidence. They are absolutely superimposable and say overall that, between 5 and 7 days [of treatment], very few patients shed the virus. But that is not the question that everyone is asking.
Even if we don’t necessarily have to conduct a randomized study, we should at least compare the treatment, either against another therapy – which could be hydroxychloroquine monotherapy, or just standard of care. It needed an authentic control arm.
To recruit 80 patients so quickly, the researchers probably took people with essentially ambulatory forms of the disease (there was a call for screening in the south of France) – therefore, by definition, less severe cases.
But to describe such a population of patients as going home and saying, “There were very few hospitalizations and it is going well,” does not in any way prove that the treatment reduces hospitalizations.
The argument for not having a control arm in this study was that it would be unethical. What do you think?
I agree with this argument when it comes to patients presenting with risk factors or who are starting to develop pneumonia.
But I don’t think this is the case at the beginning of the illness. Of course, you don’t want to wait to have severe disease or for the patient to be in intensive care to start treatment. In these cases, it is indeed very difficult to find a control arm.
In the ongoing Discovery trial, which involves more than 3,000 patients in Europe, including 800 in France, the patients have severe disease, and there are five treatment arms. Moreover, hydroxychloroquine is given without azithromycin. What do you think of this?
I think it’s a mistake. It will not answer the question of the effectiveness of hydroxychloroquine in COVID-19, especially as they’re not studying azithromycin in a situation where the compound seems necessary for the effectiveness of the treatment.
In addition, Discovery reinforces the notion of studying Kaletra [lopinavir/ritonavir, AbbVie] again, while Chinese researchers have shown that it does not work, the argument being that Kaletra was given too late (N Engl J Med. 2020 Mar 18. doi: 10.1056/NEJMoa2001282). Therefore, if we make the same mistakes from a methodological point of view, we will end up with negative results.
What should have been done in the Marseille study?
The question is: Are there more or fewer hospitalizations when we treat a homogeneous population straight away?
The answer could be very clear, as a control already exists! They are the patients that flow into our hospitals every day – ironically, these 80 patients [in the latest results, presented March 27] could be among the 80% who had a form similar to nasopharyngitis and resolved.
In this illness, we know that there are 80% spontaneous recoveries and 20% so-called severe forms. Therefore, with 80 patients, we are very underpowered. The cohort is too small for a disease in which 80% of the evolution is benign.
It would take 1,000 patients, and then, even without a control arm, we would have an answer.
On March 26, Didier Raoult’s team also announced having already treated 700 patients with hydroxychloroquine, with only one death. Therefore, if this cohort increases significantly in Marseille and we see that, on the map, there are fewer issues with patient flow and saturation in Marseille and that there are fewer patients in intensive care, you will have to wonder about the effect of hydroxychloroquine.
We will find out very quickly. If it really works, and they treat all the patients presenting at Timone Hospital, we will soon have the answer. It will be a real-life study.
What are the other studies on hydroxychloroquine that could give us answers?
There was a Chinese study that did not show a difference in effectiveness between hydroxychloroquine and placebo, but that was, again, conducted in only around 20 patients (J Zhejiang Univ (Med Sci). 2020. doi: 10.3785/j.issn.1008-9292.2020.03.03). This cohort is too small and tells us nothing; it cannot show anything. We must wait for the results of larger trials being conducted in China.
It surprises me that, today, we still do not have Italian data on the use of chloroquine-type drugs ... perhaps because they have a care pathway that means there is no outpatient treatment and that they arrive already with severe disease. The Italian recommendations nevertheless indicate the use of hydroxychloroquine.
I also wonder about the lack of studies of cohorts where, in retrospect, we could have followed people previously treated with hydroxychloroquine for chronic diseases (e.g., rheumatoid arthritis, lupus, etc.). Or we could identify all those patients on the health insurance system who had prescriptions.
That is how we discovered the AIDS epidemic in San Francisco: There was an increase in the number of prescriptions for trimethoprim/sulfamethoxazole (Bactrim) that corresponded to a population subtype (homosexual), and we realized that it was for a disease that resembled pneumocystosis. We discovered that via the drug!
If hydroxychloroquine is effective, it is enough to look at people who took it before the epidemic and see how they fared. And there, we do not need a control arm. This could give us some direction. The March 26 decree of the new Véran Law states that community pharmacies can dispense to patients with a previous prescription, so we can find these individuals.
Do you think that the lack of, or difficulty in setting up, studies on hydroxychloroquine in France is linked to decisions that are more political than scientific?
Perhaps the contaminated blood scandal still casts a shadow in France, and there is a great deal of anxiety over the fact that we are already in a crisis, and we do not want a second one. I can understand that.
However, just a week ago, access to this drug (and others with market approval that have been on the market for several years) was blocked in hospital central pharmacies, while we are the medical specialists with the authorization! It was unacceptable.
It was sorted out 48 hours ago: hydroxychloroquine is now available in the hospital, and to my knowledge, we no longer have a problem obtaining it.
It took time to alleviate doubts over the major health risks with this drug. [Officials] seemed almost like amateurs in their hesitation; I think they lacked foresight. We have forgotten that the treatment advocated by Prof. Didier Raoult is not chloroquine but rather hydroxychloroquine, and we know that the adverse effects are less [with hydroxychloroquine] than with chloroquine.
You yourself have treated patients with chloroquine, despite the risk for toxicity highlighted by some.
Initially, when we first started treating patients, we thought of chloroquine because we did not have data on hydroxychloroquine, only Chinese data with chloroquine. We therefore prescribed chloroquine several days before prescribing hydroxychloroquine.
The question of the toxicity of chloroquine was not unjustified, but I think we took far too much time to decide on the toxicity of hydroxychloroquine. Is [the latter] political? I don’t know. It was widely publicized, which amazes me for a drug that is already available.
On the other hand, everyone was talking at the same time about the toxicity of NSAIDs. ... One has the impression it was to create a diversion. I think there were double standards at play and a scapegoat was needed to gain some time and ask questions.
What is sure is that it is probably not for financial reasons, as hydroxychloroquine costs nothing. That’s to say there were probably pharmaceutical issues at stake for possible competitors of hydroxychloroquine; I do not want to get into this debate, and it doesn’t matter, as long as we have an answer.
Today, the only thing we have advanced on is the “safety” of hydroxychloroquine, the low risk to the general population. ... On the other hand, we have still not made any progress on the evidence of efficacy, compared with other treatments.
Personally, I really believe in hydroxychloroquine. It would nevertheless be a shame to think we had found the fountain of youth and realize, in 4 weeks, that we have the same number of deaths. That is the problem. I hope that we will soon have solid data so we do not waste time focusing solely on hydroxychloroquine.
What are the other avenues of research that grab your attention?
The Discovery trial will probably give an answer on remdesivir [GS-5734, Gilead], which is a direct antiviral and could be interesting. But there are other studies being conducted currently in China.
There is also favipiravir [T-705, Avigan, Toyama Chemical], which is an anti-influenza drug used in Japan, which could explain, in part, the control of the epidemic in that country. There are effects in vitro on coronavirus. But it is not at all studied in France at the moment. Therefore, we should not focus exclusively on hydroxychloroquine; we must keep a close eye on other molecules, in particular the “old” drugs, like this antiviral.
The study was supported by the Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, the National Research Agency, under the Investissements d’avenir program, Région Provence Alpes Côte d’Azur, and European funding FEDER PRIMI. The authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
A controversial study led by Didier Raoult, MD, PhD, on the combination of hydroxychloroquine and azithromycin in patients with COVID-19 was published March 20. The latest results from the same Marseille team, which involve 80 patients, were reported on March 27.
The investigators report a significant reduction in the viral load (83% patients had negative results on quantitative polymerase chain reaction testing at day 7, and 93% had negative results on day 8). There was a “clinical improvement compared to the natural progression.” One death occurred, and three patients were transferred to intensive care units.
If the data seem encouraging, the lack of a control arm in the study leaves clinicians perplexed, however.
Benjamin Davido, MD, an infectious disease specialist at Raymond-Poincaré Hospital in Garches, Paris, spoke in an interview about the implications of these new results.
What do you think about the new results presented by Prof. Raoult’s team? Do they confirm the effectiveness of hydroxychloroquine?
These results are complementary [to the original results] but don’t offer any new information or new statistical evidence. They are absolutely superimposable and say overall that, between 5 and 7 days [of treatment], very few patients shed the virus. But that is not the question that everyone is asking.
Even if we don’t necessarily have to conduct a randomized study, we should at least compare the treatment, either against another therapy – which could be hydroxychloroquine monotherapy, or just standard of care. It needed an authentic control arm.
To recruit 80 patients so quickly, the researchers probably took people with essentially ambulatory forms of the disease (there was a call for screening in the south of France) – therefore, by definition, less severe cases.
But to describe such a population of patients as going home and saying, “There were very few hospitalizations and it is going well,” does not in any way prove that the treatment reduces hospitalizations.
The argument for not having a control arm in this study was that it would be unethical. What do you think?
I agree with this argument when it comes to patients presenting with risk factors or who are starting to develop pneumonia.
But I don’t think this is the case at the beginning of the illness. Of course, you don’t want to wait to have severe disease or for the patient to be in intensive care to start treatment. In these cases, it is indeed very difficult to find a control arm.
In the ongoing Discovery trial, which involves more than 3,000 patients in Europe, including 800 in France, the patients have severe disease, and there are five treatment arms. Moreover, hydroxychloroquine is given without azithromycin. What do you think of this?
I think it’s a mistake. It will not answer the question of the effectiveness of hydroxychloroquine in COVID-19, especially as they’re not studying azithromycin in a situation where the compound seems necessary for the effectiveness of the treatment.
In addition, Discovery reinforces the notion of studying Kaletra [lopinavir/ritonavir, AbbVie] again, while Chinese researchers have shown that it does not work, the argument being that Kaletra was given too late (N Engl J Med. 2020 Mar 18. doi: 10.1056/NEJMoa2001282). Therefore, if we make the same mistakes from a methodological point of view, we will end up with negative results.
What should have been done in the Marseille study?
The question is: Are there more or fewer hospitalizations when we treat a homogeneous population straight away?
The answer could be very clear, as a control already exists! They are the patients that flow into our hospitals every day – ironically, these 80 patients [in the latest results, presented March 27] could be among the 80% who had a form similar to nasopharyngitis and resolved.
In this illness, we know that there are 80% spontaneous recoveries and 20% so-called severe forms. Therefore, with 80 patients, we are very underpowered. The cohort is too small for a disease in which 80% of the evolution is benign.
It would take 1,000 patients, and then, even without a control arm, we would have an answer.
On March 26, Didier Raoult’s team also announced having already treated 700 patients with hydroxychloroquine, with only one death. Therefore, if this cohort increases significantly in Marseille and we see that, on the map, there are fewer issues with patient flow and saturation in Marseille and that there are fewer patients in intensive care, you will have to wonder about the effect of hydroxychloroquine.
We will find out very quickly. If it really works, and they treat all the patients presenting at Timone Hospital, we will soon have the answer. It will be a real-life study.
What are the other studies on hydroxychloroquine that could give us answers?
There was a Chinese study that did not show a difference in effectiveness between hydroxychloroquine and placebo, but that was, again, conducted in only around 20 patients (J Zhejiang Univ (Med Sci). 2020. doi: 10.3785/j.issn.1008-9292.2020.03.03). This cohort is too small and tells us nothing; it cannot show anything. We must wait for the results of larger trials being conducted in China.
It surprises me that, today, we still do not have Italian data on the use of chloroquine-type drugs ... perhaps because they have a care pathway that means there is no outpatient treatment and that they arrive already with severe disease. The Italian recommendations nevertheless indicate the use of hydroxychloroquine.
I also wonder about the lack of studies of cohorts where, in retrospect, we could have followed people previously treated with hydroxychloroquine for chronic diseases (e.g., rheumatoid arthritis, lupus, etc.). Or we could identify all those patients on the health insurance system who had prescriptions.
That is how we discovered the AIDS epidemic in San Francisco: There was an increase in the number of prescriptions for trimethoprim/sulfamethoxazole (Bactrim) that corresponded to a population subtype (homosexual), and we realized that it was for a disease that resembled pneumocystosis. We discovered that via the drug!
If hydroxychloroquine is effective, it is enough to look at people who took it before the epidemic and see how they fared. And there, we do not need a control arm. This could give us some direction. The March 26 decree of the new Véran Law states that community pharmacies can dispense to patients with a previous prescription, so we can find these individuals.
Do you think that the lack of, or difficulty in setting up, studies on hydroxychloroquine in France is linked to decisions that are more political than scientific?
Perhaps the contaminated blood scandal still casts a shadow in France, and there is a great deal of anxiety over the fact that we are already in a crisis, and we do not want a second one. I can understand that.
However, just a week ago, access to this drug (and others with market approval that have been on the market for several years) was blocked in hospital central pharmacies, while we are the medical specialists with the authorization! It was unacceptable.
It was sorted out 48 hours ago: hydroxychloroquine is now available in the hospital, and to my knowledge, we no longer have a problem obtaining it.
It took time to alleviate doubts over the major health risks with this drug. [Officials] seemed almost like amateurs in their hesitation; I think they lacked foresight. We have forgotten that the treatment advocated by Prof. Didier Raoult is not chloroquine but rather hydroxychloroquine, and we know that the adverse effects are less [with hydroxychloroquine] than with chloroquine.
You yourself have treated patients with chloroquine, despite the risk for toxicity highlighted by some.
Initially, when we first started treating patients, we thought of chloroquine because we did not have data on hydroxychloroquine, only Chinese data with chloroquine. We therefore prescribed chloroquine several days before prescribing hydroxychloroquine.
The question of the toxicity of chloroquine was not unjustified, but I think we took far too much time to decide on the toxicity of hydroxychloroquine. Is [the latter] political? I don’t know. It was widely publicized, which amazes me for a drug that is already available.
On the other hand, everyone was talking at the same time about the toxicity of NSAIDs. ... One has the impression it was to create a diversion. I think there were double standards at play and a scapegoat was needed to gain some time and ask questions.
What is sure is that it is probably not for financial reasons, as hydroxychloroquine costs nothing. That’s to say there were probably pharmaceutical issues at stake for possible competitors of hydroxychloroquine; I do not want to get into this debate, and it doesn’t matter, as long as we have an answer.
Today, the only thing we have advanced on is the “safety” of hydroxychloroquine, the low risk to the general population. ... On the other hand, we have still not made any progress on the evidence of efficacy, compared with other treatments.
Personally, I really believe in hydroxychloroquine. It would nevertheless be a shame to think we had found the fountain of youth and realize, in 4 weeks, that we have the same number of deaths. That is the problem. I hope that we will soon have solid data so we do not waste time focusing solely on hydroxychloroquine.
What are the other avenues of research that grab your attention?
The Discovery trial will probably give an answer on remdesivir [GS-5734, Gilead], which is a direct antiviral and could be interesting. But there are other studies being conducted currently in China.
There is also favipiravir [T-705, Avigan, Toyama Chemical], which is an anti-influenza drug used in Japan, which could explain, in part, the control of the epidemic in that country. There are effects in vitro on coronavirus. But it is not at all studied in France at the moment. Therefore, we should not focus exclusively on hydroxychloroquine; we must keep a close eye on other molecules, in particular the “old” drugs, like this antiviral.
The study was supported by the Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, the National Research Agency, under the Investissements d’avenir program, Région Provence Alpes Côte d’Azur, and European funding FEDER PRIMI. The authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
A controversial study led by Didier Raoult, MD, PhD, on the combination of hydroxychloroquine and azithromycin in patients with COVID-19 was published March 20. The latest results from the same Marseille team, which involve 80 patients, were reported on March 27.
The investigators report a significant reduction in the viral load (83% patients had negative results on quantitative polymerase chain reaction testing at day 7, and 93% had negative results on day 8). There was a “clinical improvement compared to the natural progression.” One death occurred, and three patients were transferred to intensive care units.
If the data seem encouraging, the lack of a control arm in the study leaves clinicians perplexed, however.
Benjamin Davido, MD, an infectious disease specialist at Raymond-Poincaré Hospital in Garches, Paris, spoke in an interview about the implications of these new results.
What do you think about the new results presented by Prof. Raoult’s team? Do they confirm the effectiveness of hydroxychloroquine?
These results are complementary [to the original results] but don’t offer any new information or new statistical evidence. They are absolutely superimposable and say overall that, between 5 and 7 days [of treatment], very few patients shed the virus. But that is not the question that everyone is asking.
Even if we don’t necessarily have to conduct a randomized study, we should at least compare the treatment, either against another therapy – which could be hydroxychloroquine monotherapy, or just standard of care. It needed an authentic control arm.
To recruit 80 patients so quickly, the researchers probably took people with essentially ambulatory forms of the disease (there was a call for screening in the south of France) – therefore, by definition, less severe cases.
But to describe such a population of patients as going home and saying, “There were very few hospitalizations and it is going well,” does not in any way prove that the treatment reduces hospitalizations.
The argument for not having a control arm in this study was that it would be unethical. What do you think?
I agree with this argument when it comes to patients presenting with risk factors or who are starting to develop pneumonia.
But I don’t think this is the case at the beginning of the illness. Of course, you don’t want to wait to have severe disease or for the patient to be in intensive care to start treatment. In these cases, it is indeed very difficult to find a control arm.
In the ongoing Discovery trial, which involves more than 3,000 patients in Europe, including 800 in France, the patients have severe disease, and there are five treatment arms. Moreover, hydroxychloroquine is given without azithromycin. What do you think of this?
I think it’s a mistake. It will not answer the question of the effectiveness of hydroxychloroquine in COVID-19, especially as they’re not studying azithromycin in a situation where the compound seems necessary for the effectiveness of the treatment.
In addition, Discovery reinforces the notion of studying Kaletra [lopinavir/ritonavir, AbbVie] again, while Chinese researchers have shown that it does not work, the argument being that Kaletra was given too late (N Engl J Med. 2020 Mar 18. doi: 10.1056/NEJMoa2001282). Therefore, if we make the same mistakes from a methodological point of view, we will end up with negative results.
What should have been done in the Marseille study?
The question is: Are there more or fewer hospitalizations when we treat a homogeneous population straight away?
The answer could be very clear, as a control already exists! They are the patients that flow into our hospitals every day – ironically, these 80 patients [in the latest results, presented March 27] could be among the 80% who had a form similar to nasopharyngitis and resolved.
In this illness, we know that there are 80% spontaneous recoveries and 20% so-called severe forms. Therefore, with 80 patients, we are very underpowered. The cohort is too small for a disease in which 80% of the evolution is benign.
It would take 1,000 patients, and then, even without a control arm, we would have an answer.
On March 26, Didier Raoult’s team also announced having already treated 700 patients with hydroxychloroquine, with only one death. Therefore, if this cohort increases significantly in Marseille and we see that, on the map, there are fewer issues with patient flow and saturation in Marseille and that there are fewer patients in intensive care, you will have to wonder about the effect of hydroxychloroquine.
We will find out very quickly. If it really works, and they treat all the patients presenting at Timone Hospital, we will soon have the answer. It will be a real-life study.
What are the other studies on hydroxychloroquine that could give us answers?
There was a Chinese study that did not show a difference in effectiveness between hydroxychloroquine and placebo, but that was, again, conducted in only around 20 patients (J Zhejiang Univ (Med Sci). 2020. doi: 10.3785/j.issn.1008-9292.2020.03.03). This cohort is too small and tells us nothing; it cannot show anything. We must wait for the results of larger trials being conducted in China.
It surprises me that, today, we still do not have Italian data on the use of chloroquine-type drugs ... perhaps because they have a care pathway that means there is no outpatient treatment and that they arrive already with severe disease. The Italian recommendations nevertheless indicate the use of hydroxychloroquine.
I also wonder about the lack of studies of cohorts where, in retrospect, we could have followed people previously treated with hydroxychloroquine for chronic diseases (e.g., rheumatoid arthritis, lupus, etc.). Or we could identify all those patients on the health insurance system who had prescriptions.
That is how we discovered the AIDS epidemic in San Francisco: There was an increase in the number of prescriptions for trimethoprim/sulfamethoxazole (Bactrim) that corresponded to a population subtype (homosexual), and we realized that it was for a disease that resembled pneumocystosis. We discovered that via the drug!
If hydroxychloroquine is effective, it is enough to look at people who took it before the epidemic and see how they fared. And there, we do not need a control arm. This could give us some direction. The March 26 decree of the new Véran Law states that community pharmacies can dispense to patients with a previous prescription, so we can find these individuals.
Do you think that the lack of, or difficulty in setting up, studies on hydroxychloroquine in France is linked to decisions that are more political than scientific?
Perhaps the contaminated blood scandal still casts a shadow in France, and there is a great deal of anxiety over the fact that we are already in a crisis, and we do not want a second one. I can understand that.
However, just a week ago, access to this drug (and others with market approval that have been on the market for several years) was blocked in hospital central pharmacies, while we are the medical specialists with the authorization! It was unacceptable.
It was sorted out 48 hours ago: hydroxychloroquine is now available in the hospital, and to my knowledge, we no longer have a problem obtaining it.
It took time to alleviate doubts over the major health risks with this drug. [Officials] seemed almost like amateurs in their hesitation; I think they lacked foresight. We have forgotten that the treatment advocated by Prof. Didier Raoult is not chloroquine but rather hydroxychloroquine, and we know that the adverse effects are less [with hydroxychloroquine] than with chloroquine.
You yourself have treated patients with chloroquine, despite the risk for toxicity highlighted by some.
Initially, when we first started treating patients, we thought of chloroquine because we did not have data on hydroxychloroquine, only Chinese data with chloroquine. We therefore prescribed chloroquine several days before prescribing hydroxychloroquine.
The question of the toxicity of chloroquine was not unjustified, but I think we took far too much time to decide on the toxicity of hydroxychloroquine. Is [the latter] political? I don’t know. It was widely publicized, which amazes me for a drug that is already available.
On the other hand, everyone was talking at the same time about the toxicity of NSAIDs. ... One has the impression it was to create a diversion. I think there were double standards at play and a scapegoat was needed to gain some time and ask questions.
What is sure is that it is probably not for financial reasons, as hydroxychloroquine costs nothing. That’s to say there were probably pharmaceutical issues at stake for possible competitors of hydroxychloroquine; I do not want to get into this debate, and it doesn’t matter, as long as we have an answer.
Today, the only thing we have advanced on is the “safety” of hydroxychloroquine, the low risk to the general population. ... On the other hand, we have still not made any progress on the evidence of efficacy, compared with other treatments.
Personally, I really believe in hydroxychloroquine. It would nevertheless be a shame to think we had found the fountain of youth and realize, in 4 weeks, that we have the same number of deaths. That is the problem. I hope that we will soon have solid data so we do not waste time focusing solely on hydroxychloroquine.
What are the other avenues of research that grab your attention?
The Discovery trial will probably give an answer on remdesivir [GS-5734, Gilead], which is a direct antiviral and could be interesting. But there are other studies being conducted currently in China.
There is also favipiravir [T-705, Avigan, Toyama Chemical], which is an anti-influenza drug used in Japan, which could explain, in part, the control of the epidemic in that country. There are effects in vitro on coronavirus. But it is not at all studied in France at the moment. Therefore, we should not focus exclusively on hydroxychloroquine; we must keep a close eye on other molecules, in particular the “old” drugs, like this antiviral.
The study was supported by the Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, the National Research Agency, under the Investissements d’avenir program, Région Provence Alpes Côte d’Azur, and European funding FEDER PRIMI. The authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
What if a COVID-19 test is negative?
In a physician WhatsApp group, a doctor posted he had fever of 101 °F and muscle ache, gently confessing that it felt like his typical “man flu” which heals with rest and scotch. Nevertheless, he worried that he had coronavirus. When the reverse transcription polymerase chain reaction (RT-PCR) for the virus on his nasal swab came back negative, he jubilantly announced his relief.
Like Twitter, in WhatsApp emotions quickly outstrip facts. After he received a flurry of cheerful emojis, I ruined the party, advising that, despite the negative test, he assume he’s infected and quarantine for 2 weeks, with a bottle of scotch.
It’s conventional wisdom that the secret sauce to fighting the pandemic is testing for the virus. To gauge the breadth of the response against the pandemic we must know who and how many are infected. The depth of the response will be different if 25% of the population is infected than 1%. Testing is the third way, rejecting the false choice between death and economic depression. Without testing, strategy is faith based.
Our reliance on testing has clinical precedence – scarcely any decision in medicine is made without laboratory tests or imaging. Testing is as ingrained in medicine as the GPS is in driving. We use it even when we know our way home. But tests impose a question – what’ll you do differently if the test is negative?
That depends on the test’s performance and the consequences of being wrong. Though coronavirus damages the lungs with reckless abandon, it’s oddly a shy virus. In many patients, it takes 3-4 swabs to get a positive RT-PCR. The Chinese ophthalmologist, Li Wenliang, who originally sounded the alarm about coronavirus, had several negative tests. He died from the infection.
In one Chinese study, the sensitivity of RT-PCR – that’s the proportion of the infected who test positive – was around 70%. To put this in perspective, of 1,000 people infected with coronavirus, 700 will test positive but 300 will test negative.
Is this good enough?
Three hundred “false-negative” people may believe they’re not contagious because they got a clean chit and could infect others. False negatives could undo the hard work of containment.
Surely, better an imperfect test than no test. Isn’t flying with partially accurate weather information safer than no information? Here, aviation analogies aren’t helpful. Better to think of a forest fire.
Imagine only 80% of a burning forest is doused because it’s mistakenly believed that 20% of the forest isn’t burning because we can’t see it burning. It must be extinguished before it relights the whole forest, but to douse it you must know it’s burning – a Catch-22. That “20% of the forest” is a false negative – it’s burning but you think it’s not burning.
Because coronavirus isn’t planning to leave in a hurry and long-term lockdown has grave economic consequences, testing may enable precision quarantining of people, communities, and cities. Rather than applying a one-size-fits-all lockdown on the whole nation, testing could tell us who can work and who should stay home. Why should Austin, if it has a low prevalence of infection, shut shop just because of New York City’s high prevalence?
Testing enables us to think globally but act locally. But it’s the asymptomatic people who drive the epidemic. To emphasize – asymptomatics are yet to have symptoms such as cough and fever. They’re feeling well and don’t know they’ve been colonized by the virus. Theoretically, if we test en masse we can find asymptomatics. If only those who test positive are quarantined, the rest can have some breathing space. Will this approach work?
RT-PCR’s sensitivity, which is low in early illness, is even lower in asymptomatics, likely because of lower viral load, which means even more false negatives. The virus’s average incubation time of 5 days is enough time for false negative asymptomatics – remember they resemble the uninfected – to visit Disney World and infect another four.
Whether false negatives behave like tinder or a controllable fire will determine the testing strategy’s success. The net contagiousness of false negatives depends how many there are, which depends on how many are infected. To know how many are infected we need to test. Or, to know whether to believe a negative test in any person we must test widely – another Catch-22.
Maybe we need a bigger test.
Chest CT is an alternative. It’s rapid – takes less than an hour whereas RT-PCR can take over a day to report. In one study CT had a sensitivity of 97% in symptomatic patients and was often positive before RT-PCR. But there are caveats.
The real sensitivity of CT is likely much lower than 97% because the study has biases which inflate performance. CT, like RT-PCR, has a low sensitivity in early illness and even lower sensitivity in asymptomatic carriers for the same reason – lower viral load. Furthermore, CT has to be disinfected to prevent spread, which limits its access for other patients.
Coronavirus’s signature on CT – white patches in lungs, known as ground glass opacities – doesn’t have the uniqueness of the Mark of Zorro, and looks like lung injury from other rogue actors, which means we can mistake other serious conditions for coronavirus. Imagine hyenas in wolf’s clothing.
No test is perfect. We still use imaging despite its imperfections. But, let’s ask: What would you do differently if the test is negative and you have mild symptoms of cough and fever? Should you not self-isolate? What if you’re falsely negative and still contagious? If the advice dispensed whether the test is positive or negative is the same – i.e. quarantine for 2 weeks – what’s the test’s value?
Perhaps people will more likely comply with voluntary quarantine if they know they’re infected. Information can nudge behavior. But the logical corollary is that to comply with social distancing you need to be tested. People flocking to CT scans to affirm they’re not infected could infect those hitherto uninfected. A pandemic is no time to test nudge theories.
Does that mean testing has no value? Testing is valuable in managing populations. To individuals, the results must be framed wisely, such as by advising those who test positive to quarantine because “you’re infected” and those who test negative to keep social distancing because “you could still be infected.”
Even when policy goals are uniform, messaging can be oppositional. “Get yourself tested now” contradicts “you must hunker down now.” When messages contradict, one must choose which message to amplify.
The calculus of testing can change with new tests such as antibodies. The value of testing depends also on what isolation entails. A couple of weeks watching Netflix on your couch isn’t a big ask. If quarantine means being detained in an isolation center fenced by barbed wires, the cost of frivolous quarantining is higher and testing becomes more valuable.
I knew the doctor with the negative RT-PCR well. He’s heroically nonchalant about his wellbeing, an endearing quality that’s a liability in a contagion. In no time he’d be back in the hospital; or helping his elderly parents with grocery. Not all false negatives are equal. False-negative doctors could infect not just their patients but their colleagues, leaving fewer firefighters to fight fires.
It is better to mistake the man flu for coronavirus than coronavirus for the man flu. All he has to do is hunker down, which is what we should all be doing as much as we can.
Dr. Jha is a contributing editor to The Health Care Blog, where this article first appeared. He can be reached @RogueRad.
This article appeared on Medscape.com.
In a physician WhatsApp group, a doctor posted he had fever of 101 °F and muscle ache, gently confessing that it felt like his typical “man flu” which heals with rest and scotch. Nevertheless, he worried that he had coronavirus. When the reverse transcription polymerase chain reaction (RT-PCR) for the virus on his nasal swab came back negative, he jubilantly announced his relief.
Like Twitter, in WhatsApp emotions quickly outstrip facts. After he received a flurry of cheerful emojis, I ruined the party, advising that, despite the negative test, he assume he’s infected and quarantine for 2 weeks, with a bottle of scotch.
It’s conventional wisdom that the secret sauce to fighting the pandemic is testing for the virus. To gauge the breadth of the response against the pandemic we must know who and how many are infected. The depth of the response will be different if 25% of the population is infected than 1%. Testing is the third way, rejecting the false choice between death and economic depression. Without testing, strategy is faith based.
Our reliance on testing has clinical precedence – scarcely any decision in medicine is made without laboratory tests or imaging. Testing is as ingrained in medicine as the GPS is in driving. We use it even when we know our way home. But tests impose a question – what’ll you do differently if the test is negative?
That depends on the test’s performance and the consequences of being wrong. Though coronavirus damages the lungs with reckless abandon, it’s oddly a shy virus. In many patients, it takes 3-4 swabs to get a positive RT-PCR. The Chinese ophthalmologist, Li Wenliang, who originally sounded the alarm about coronavirus, had several negative tests. He died from the infection.
In one Chinese study, the sensitivity of RT-PCR – that’s the proportion of the infected who test positive – was around 70%. To put this in perspective, of 1,000 people infected with coronavirus, 700 will test positive but 300 will test negative.
Is this good enough?
Three hundred “false-negative” people may believe they’re not contagious because they got a clean chit and could infect others. False negatives could undo the hard work of containment.
Surely, better an imperfect test than no test. Isn’t flying with partially accurate weather information safer than no information? Here, aviation analogies aren’t helpful. Better to think of a forest fire.
Imagine only 80% of a burning forest is doused because it’s mistakenly believed that 20% of the forest isn’t burning because we can’t see it burning. It must be extinguished before it relights the whole forest, but to douse it you must know it’s burning – a Catch-22. That “20% of the forest” is a false negative – it’s burning but you think it’s not burning.
Because coronavirus isn’t planning to leave in a hurry and long-term lockdown has grave economic consequences, testing may enable precision quarantining of people, communities, and cities. Rather than applying a one-size-fits-all lockdown on the whole nation, testing could tell us who can work and who should stay home. Why should Austin, if it has a low prevalence of infection, shut shop just because of New York City’s high prevalence?
Testing enables us to think globally but act locally. But it’s the asymptomatic people who drive the epidemic. To emphasize – asymptomatics are yet to have symptoms such as cough and fever. They’re feeling well and don’t know they’ve been colonized by the virus. Theoretically, if we test en masse we can find asymptomatics. If only those who test positive are quarantined, the rest can have some breathing space. Will this approach work?
RT-PCR’s sensitivity, which is low in early illness, is even lower in asymptomatics, likely because of lower viral load, which means even more false negatives. The virus’s average incubation time of 5 days is enough time for false negative asymptomatics – remember they resemble the uninfected – to visit Disney World and infect another four.
Whether false negatives behave like tinder or a controllable fire will determine the testing strategy’s success. The net contagiousness of false negatives depends how many there are, which depends on how many are infected. To know how many are infected we need to test. Or, to know whether to believe a negative test in any person we must test widely – another Catch-22.
Maybe we need a bigger test.
Chest CT is an alternative. It’s rapid – takes less than an hour whereas RT-PCR can take over a day to report. In one study CT had a sensitivity of 97% in symptomatic patients and was often positive before RT-PCR. But there are caveats.
The real sensitivity of CT is likely much lower than 97% because the study has biases which inflate performance. CT, like RT-PCR, has a low sensitivity in early illness and even lower sensitivity in asymptomatic carriers for the same reason – lower viral load. Furthermore, CT has to be disinfected to prevent spread, which limits its access for other patients.
Coronavirus’s signature on CT – white patches in lungs, known as ground glass opacities – doesn’t have the uniqueness of the Mark of Zorro, and looks like lung injury from other rogue actors, which means we can mistake other serious conditions for coronavirus. Imagine hyenas in wolf’s clothing.
No test is perfect. We still use imaging despite its imperfections. But, let’s ask: What would you do differently if the test is negative and you have mild symptoms of cough and fever? Should you not self-isolate? What if you’re falsely negative and still contagious? If the advice dispensed whether the test is positive or negative is the same – i.e. quarantine for 2 weeks – what’s the test’s value?
Perhaps people will more likely comply with voluntary quarantine if they know they’re infected. Information can nudge behavior. But the logical corollary is that to comply with social distancing you need to be tested. People flocking to CT scans to affirm they’re not infected could infect those hitherto uninfected. A pandemic is no time to test nudge theories.
Does that mean testing has no value? Testing is valuable in managing populations. To individuals, the results must be framed wisely, such as by advising those who test positive to quarantine because “you’re infected” and those who test negative to keep social distancing because “you could still be infected.”
Even when policy goals are uniform, messaging can be oppositional. “Get yourself tested now” contradicts “you must hunker down now.” When messages contradict, one must choose which message to amplify.
The calculus of testing can change with new tests such as antibodies. The value of testing depends also on what isolation entails. A couple of weeks watching Netflix on your couch isn’t a big ask. If quarantine means being detained in an isolation center fenced by barbed wires, the cost of frivolous quarantining is higher and testing becomes more valuable.
I knew the doctor with the negative RT-PCR well. He’s heroically nonchalant about his wellbeing, an endearing quality that’s a liability in a contagion. In no time he’d be back in the hospital; or helping his elderly parents with grocery. Not all false negatives are equal. False-negative doctors could infect not just their patients but their colleagues, leaving fewer firefighters to fight fires.
It is better to mistake the man flu for coronavirus than coronavirus for the man flu. All he has to do is hunker down, which is what we should all be doing as much as we can.
Dr. Jha is a contributing editor to The Health Care Blog, where this article first appeared. He can be reached @RogueRad.
This article appeared on Medscape.com.
In a physician WhatsApp group, a doctor posted he had fever of 101 °F and muscle ache, gently confessing that it felt like his typical “man flu” which heals with rest and scotch. Nevertheless, he worried that he had coronavirus. When the reverse transcription polymerase chain reaction (RT-PCR) for the virus on his nasal swab came back negative, he jubilantly announced his relief.
Like Twitter, in WhatsApp emotions quickly outstrip facts. After he received a flurry of cheerful emojis, I ruined the party, advising that, despite the negative test, he assume he’s infected and quarantine for 2 weeks, with a bottle of scotch.
It’s conventional wisdom that the secret sauce to fighting the pandemic is testing for the virus. To gauge the breadth of the response against the pandemic we must know who and how many are infected. The depth of the response will be different if 25% of the population is infected than 1%. Testing is the third way, rejecting the false choice between death and economic depression. Without testing, strategy is faith based.
Our reliance on testing has clinical precedence – scarcely any decision in medicine is made without laboratory tests or imaging. Testing is as ingrained in medicine as the GPS is in driving. We use it even when we know our way home. But tests impose a question – what’ll you do differently if the test is negative?
That depends on the test’s performance and the consequences of being wrong. Though coronavirus damages the lungs with reckless abandon, it’s oddly a shy virus. In many patients, it takes 3-4 swabs to get a positive RT-PCR. The Chinese ophthalmologist, Li Wenliang, who originally sounded the alarm about coronavirus, had several negative tests. He died from the infection.
In one Chinese study, the sensitivity of RT-PCR – that’s the proportion of the infected who test positive – was around 70%. To put this in perspective, of 1,000 people infected with coronavirus, 700 will test positive but 300 will test negative.
Is this good enough?
Three hundred “false-negative” people may believe they’re not contagious because they got a clean chit and could infect others. False negatives could undo the hard work of containment.
Surely, better an imperfect test than no test. Isn’t flying with partially accurate weather information safer than no information? Here, aviation analogies aren’t helpful. Better to think of a forest fire.
Imagine only 80% of a burning forest is doused because it’s mistakenly believed that 20% of the forest isn’t burning because we can’t see it burning. It must be extinguished before it relights the whole forest, but to douse it you must know it’s burning – a Catch-22. That “20% of the forest” is a false negative – it’s burning but you think it’s not burning.
Because coronavirus isn’t planning to leave in a hurry and long-term lockdown has grave economic consequences, testing may enable precision quarantining of people, communities, and cities. Rather than applying a one-size-fits-all lockdown on the whole nation, testing could tell us who can work and who should stay home. Why should Austin, if it has a low prevalence of infection, shut shop just because of New York City’s high prevalence?
Testing enables us to think globally but act locally. But it’s the asymptomatic people who drive the epidemic. To emphasize – asymptomatics are yet to have symptoms such as cough and fever. They’re feeling well and don’t know they’ve been colonized by the virus. Theoretically, if we test en masse we can find asymptomatics. If only those who test positive are quarantined, the rest can have some breathing space. Will this approach work?
RT-PCR’s sensitivity, which is low in early illness, is even lower in asymptomatics, likely because of lower viral load, which means even more false negatives. The virus’s average incubation time of 5 days is enough time for false negative asymptomatics – remember they resemble the uninfected – to visit Disney World and infect another four.
Whether false negatives behave like tinder or a controllable fire will determine the testing strategy’s success. The net contagiousness of false negatives depends how many there are, which depends on how many are infected. To know how many are infected we need to test. Or, to know whether to believe a negative test in any person we must test widely – another Catch-22.
Maybe we need a bigger test.
Chest CT is an alternative. It’s rapid – takes less than an hour whereas RT-PCR can take over a day to report. In one study CT had a sensitivity of 97% in symptomatic patients and was often positive before RT-PCR. But there are caveats.
The real sensitivity of CT is likely much lower than 97% because the study has biases which inflate performance. CT, like RT-PCR, has a low sensitivity in early illness and even lower sensitivity in asymptomatic carriers for the same reason – lower viral load. Furthermore, CT has to be disinfected to prevent spread, which limits its access for other patients.
Coronavirus’s signature on CT – white patches in lungs, known as ground glass opacities – doesn’t have the uniqueness of the Mark of Zorro, and looks like lung injury from other rogue actors, which means we can mistake other serious conditions for coronavirus. Imagine hyenas in wolf’s clothing.
No test is perfect. We still use imaging despite its imperfections. But, let’s ask: What would you do differently if the test is negative and you have mild symptoms of cough and fever? Should you not self-isolate? What if you’re falsely negative and still contagious? If the advice dispensed whether the test is positive or negative is the same – i.e. quarantine for 2 weeks – what’s the test’s value?
Perhaps people will more likely comply with voluntary quarantine if they know they’re infected. Information can nudge behavior. But the logical corollary is that to comply with social distancing you need to be tested. People flocking to CT scans to affirm they’re not infected could infect those hitherto uninfected. A pandemic is no time to test nudge theories.
Does that mean testing has no value? Testing is valuable in managing populations. To individuals, the results must be framed wisely, such as by advising those who test positive to quarantine because “you’re infected” and those who test negative to keep social distancing because “you could still be infected.”
Even when policy goals are uniform, messaging can be oppositional. “Get yourself tested now” contradicts “you must hunker down now.” When messages contradict, one must choose which message to amplify.
The calculus of testing can change with new tests such as antibodies. The value of testing depends also on what isolation entails. A couple of weeks watching Netflix on your couch isn’t a big ask. If quarantine means being detained in an isolation center fenced by barbed wires, the cost of frivolous quarantining is higher and testing becomes more valuable.
I knew the doctor with the negative RT-PCR well. He’s heroically nonchalant about his wellbeing, an endearing quality that’s a liability in a contagion. In no time he’d be back in the hospital; or helping his elderly parents with grocery. Not all false negatives are equal. False-negative doctors could infect not just their patients but their colleagues, leaving fewer firefighters to fight fires.
It is better to mistake the man flu for coronavirus than coronavirus for the man flu. All he has to do is hunker down, which is what we should all be doing as much as we can.
Dr. Jha is a contributing editor to The Health Care Blog, where this article first appeared. He can be reached @RogueRad.
This article appeared on Medscape.com.
San Diego County CMO vigorously leads COVID-19 response team
SAN DIEGO – On the days family physician Nick Yphantides, MD, announces updates on the COVID-19 epidemic to San Diego County residents, he can’t help but think about his late father.
In June of 2009, 75-year-old George Yphantides, a Steinway-trained piano technician who lived in Escondido, Calif., became the third person in the United States to die from complications of the pandemic H1N1 swine flu – just days before a vaccine became available.
“I loved my dad,” Dr. Yphantides, who has been San Diego County’s Chief Medical Officer since the year of his father’s death, said in an interview. “So, when you take a step back and take into consideration my sense of purpose in serving the 3.3 million residents of San Diego County, my passion based on my personal Christian faith, and my activation in terms of what happened to my dad, I have such a storm of internal sense of urgency right now.”
San Diego County and public health officials got experience with COVID-19 in advance of the country’s widely documented cases of community-based transmission. Around 9 pm on Jan. 31, 2020 – the Friday of Super Bowl weekend – Dr. Yphantides answered a phone call from Eric C. McDonald, MD, the county’s medical director of epidemiology. Dr. McDonald informed him that in a few days, a plane full of American citizens traveling from Wuhan, China, would be landing at Marine Corp Air Station Miramar in San Diego for a 2-week quarantine and that the task of providing medical support to any affected individuals fell on county officials.
“I will never forget that phone call,” he said. “We did have two positive cases. What we experienced with those evacuees was amazing surge preparation, and without exaggeration, I have worked 18-20 hours a day since that day.”
Fast forward to March 31, 2020, the county’s confirmed COVID-19 caseload had grown to 734, up 131 from the day before. As of the final day of March, nine people have died, with an age range between 25 and 87 years. Of confirmed cases, 61% are between the ages of 20 and 49, 43% are female, 19% have required hospitalization, 7% have required admission to intensive care, and the mortality rate has been 1.2%. Data currently show optimal proactive hospital capacity.
In the opinion of Dr. Yphantides, the 734 COVID-19 cases represent a tip of the iceberg. “How big is that iceberg? I can’t tell you yet,” he said.
"I see this as the Super Bowl of public health,” he exclaimed.
At least some of Dr. Yphantides’ vigor seems to be fueled by his pride in his team of professionals who have been helping him respond to the surge of COVID-19 cases.
As the county’s CMO, Dr. Yphantides serves as the liaison for the entire Emergency Medical System, the entire local health care delivery system, the entire physician and medical society network, the payor system, and the proportion of the area population using Medi-Cal.
Dr. Yphantides, who attended medical school at the University of California, San Diego, said that, compared with other regions of the country, San Diego County has made “tremendous progress” in overcoming many chronic lifestyle illnesses. For example, cardiovascular disease is no longer the number one cause of death in the county; it’s bookended by cancer and Alzheimer’s disease.
“In the context of the COVID-19 response, [the county’s health care team established] an entire incident command system in our emergency operations center. Our emergency operations center is activated to the top level,” he said.
Dr. Yphantides shares public communication efforts with Dr. McDonald and Wilma J. Wooten, MD, the county’s public health officer. The San Diego County CMO also engages with policymakers, including the board of supervisors, local mayors, state legislators, and national legislators.
“Because of the relational trust capital that I have in this community, I get pulled into unexpected rooms of discussion,” he said. This included meeting with top executives from the San Diego Padres in early March, putting them on notice that the 2020 Major League Baseball season would likely be postponed. (This was officially announced on March 16.)
“We have made some decisions that have devastated some people economically. Talk about flipping the switch. We are living and making history every day. It is unbelievable,” he said.
“San Diego is a more aged population compared to many other parts of the country. ... [Part] of the reason why I’m so frantically doing everything I can to prepare, to batten down the hatches, and to optimize our health care delivery system is because we have a population that collectively is more at risk [for more serious complications from COVID-19]. A lot of what drives me is advocacy,” Dr. Yphantides noted.
A colleague’s perspective
Kristi L. Koenig, MD, medical director of emergency medical services for the County of San Diego, characterized Dr. Yphantides’ management style as collaborative. “Under his leadership, we have the perspective of ‘just focus on patient care, get it done, be creative, work together as a team,’ ” said Dr. Koenig, who coedited the textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices” (Cambridge University Press, 2016). “He’s decisive and he’s responsive. You don’t have to wait a long time to get a decision, which is very important right now because this is so fast moving.”
Dr. Koenig, who has worked with Dr. Yphantides for 3 years, said that she routinely feeds him information that might help the team navigate its response to COVID-19. “For example, if I see an idea for how to get more [personal protective equipment] and feed it to him, he might have a contact somewhere in a factory that could make the PPE,” she said. “We work together by my reminding him to keep it within the incident command system structure, so that we can coordinate all the resources and not duplicate efforts.”
He uses his personal connections in a way to implement ideas that are beneficial to the overall goal of decreasing morbidity and mortality,” Dr. Koenig added.
Predictions for San Diego County
Dr. Yphantides said he considers San Diego to still be in the calm before the storm and that he is working hard to “board up his community.” The county CMO is also trying to prepare the health care delivery system to optimize its capacity, of doing interventions with hopes of lowering the curve and enhancing the capacity, he said.
When the storm hits, “it’s going be brutal, because we’re going to lose life,” Dr. Yphantides said.
“I am praying that maybe by some of our efforts, instead of a Category 5 storm, it’ll be a Category 3 storm,” he remarked.
The future of health care
Dr. Yphantides views the COVID-19 pandemic as “an absolute game-changer” in terms of what the future of health care delivery will look like in the United States. “Whether the right word is the ‘Amazonification’ of health care, or the ‘Uberization’ of health care, I don’t know, but the essence of how we deliver care is radically being transformed literally before our eyes,” he said. “I would encourage my colleagues to embrace that” and take care of their people by doing whatever it takes under this unprecedented paradigm.
Meanwhile, Dr. Yphantides braces for a potential surge of COVID-19 cases in San Diego County in the coming weeks. He honors the memory of his dad, and he expresses thanks for his mom, who cares for his two teenaged daughters while he helps steward the region’s response to the pandemic.
“Without my mom I could not function in the way that I’m currently functioning,” he said. “So, when you add all of those factors up, and wrap it with a bowtie of sincere love and passion for my community, there’s a fire that’s burning inside of me right now.”
SAN DIEGO – On the days family physician Nick Yphantides, MD, announces updates on the COVID-19 epidemic to San Diego County residents, he can’t help but think about his late father.
In June of 2009, 75-year-old George Yphantides, a Steinway-trained piano technician who lived in Escondido, Calif., became the third person in the United States to die from complications of the pandemic H1N1 swine flu – just days before a vaccine became available.
“I loved my dad,” Dr. Yphantides, who has been San Diego County’s Chief Medical Officer since the year of his father’s death, said in an interview. “So, when you take a step back and take into consideration my sense of purpose in serving the 3.3 million residents of San Diego County, my passion based on my personal Christian faith, and my activation in terms of what happened to my dad, I have such a storm of internal sense of urgency right now.”
San Diego County and public health officials got experience with COVID-19 in advance of the country’s widely documented cases of community-based transmission. Around 9 pm on Jan. 31, 2020 – the Friday of Super Bowl weekend – Dr. Yphantides answered a phone call from Eric C. McDonald, MD, the county’s medical director of epidemiology. Dr. McDonald informed him that in a few days, a plane full of American citizens traveling from Wuhan, China, would be landing at Marine Corp Air Station Miramar in San Diego for a 2-week quarantine and that the task of providing medical support to any affected individuals fell on county officials.
“I will never forget that phone call,” he said. “We did have two positive cases. What we experienced with those evacuees was amazing surge preparation, and without exaggeration, I have worked 18-20 hours a day since that day.”
Fast forward to March 31, 2020, the county’s confirmed COVID-19 caseload had grown to 734, up 131 from the day before. As of the final day of March, nine people have died, with an age range between 25 and 87 years. Of confirmed cases, 61% are between the ages of 20 and 49, 43% are female, 19% have required hospitalization, 7% have required admission to intensive care, and the mortality rate has been 1.2%. Data currently show optimal proactive hospital capacity.
In the opinion of Dr. Yphantides, the 734 COVID-19 cases represent a tip of the iceberg. “How big is that iceberg? I can’t tell you yet,” he said.
"I see this as the Super Bowl of public health,” he exclaimed.
At least some of Dr. Yphantides’ vigor seems to be fueled by his pride in his team of professionals who have been helping him respond to the surge of COVID-19 cases.
As the county’s CMO, Dr. Yphantides serves as the liaison for the entire Emergency Medical System, the entire local health care delivery system, the entire physician and medical society network, the payor system, and the proportion of the area population using Medi-Cal.
Dr. Yphantides, who attended medical school at the University of California, San Diego, said that, compared with other regions of the country, San Diego County has made “tremendous progress” in overcoming many chronic lifestyle illnesses. For example, cardiovascular disease is no longer the number one cause of death in the county; it’s bookended by cancer and Alzheimer’s disease.
“In the context of the COVID-19 response, [the county’s health care team established] an entire incident command system in our emergency operations center. Our emergency operations center is activated to the top level,” he said.
Dr. Yphantides shares public communication efforts with Dr. McDonald and Wilma J. Wooten, MD, the county’s public health officer. The San Diego County CMO also engages with policymakers, including the board of supervisors, local mayors, state legislators, and national legislators.
“Because of the relational trust capital that I have in this community, I get pulled into unexpected rooms of discussion,” he said. This included meeting with top executives from the San Diego Padres in early March, putting them on notice that the 2020 Major League Baseball season would likely be postponed. (This was officially announced on March 16.)
“We have made some decisions that have devastated some people economically. Talk about flipping the switch. We are living and making history every day. It is unbelievable,” he said.
“San Diego is a more aged population compared to many other parts of the country. ... [Part] of the reason why I’m so frantically doing everything I can to prepare, to batten down the hatches, and to optimize our health care delivery system is because we have a population that collectively is more at risk [for more serious complications from COVID-19]. A lot of what drives me is advocacy,” Dr. Yphantides noted.
A colleague’s perspective
Kristi L. Koenig, MD, medical director of emergency medical services for the County of San Diego, characterized Dr. Yphantides’ management style as collaborative. “Under his leadership, we have the perspective of ‘just focus on patient care, get it done, be creative, work together as a team,’ ” said Dr. Koenig, who coedited the textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices” (Cambridge University Press, 2016). “He’s decisive and he’s responsive. You don’t have to wait a long time to get a decision, which is very important right now because this is so fast moving.”
Dr. Koenig, who has worked with Dr. Yphantides for 3 years, said that she routinely feeds him information that might help the team navigate its response to COVID-19. “For example, if I see an idea for how to get more [personal protective equipment] and feed it to him, he might have a contact somewhere in a factory that could make the PPE,” she said. “We work together by my reminding him to keep it within the incident command system structure, so that we can coordinate all the resources and not duplicate efforts.”
He uses his personal connections in a way to implement ideas that are beneficial to the overall goal of decreasing morbidity and mortality,” Dr. Koenig added.
Predictions for San Diego County
Dr. Yphantides said he considers San Diego to still be in the calm before the storm and that he is working hard to “board up his community.” The county CMO is also trying to prepare the health care delivery system to optimize its capacity, of doing interventions with hopes of lowering the curve and enhancing the capacity, he said.
When the storm hits, “it’s going be brutal, because we’re going to lose life,” Dr. Yphantides said.
“I am praying that maybe by some of our efforts, instead of a Category 5 storm, it’ll be a Category 3 storm,” he remarked.
The future of health care
Dr. Yphantides views the COVID-19 pandemic as “an absolute game-changer” in terms of what the future of health care delivery will look like in the United States. “Whether the right word is the ‘Amazonification’ of health care, or the ‘Uberization’ of health care, I don’t know, but the essence of how we deliver care is radically being transformed literally before our eyes,” he said. “I would encourage my colleagues to embrace that” and take care of their people by doing whatever it takes under this unprecedented paradigm.
Meanwhile, Dr. Yphantides braces for a potential surge of COVID-19 cases in San Diego County in the coming weeks. He honors the memory of his dad, and he expresses thanks for his mom, who cares for his two teenaged daughters while he helps steward the region’s response to the pandemic.
“Without my mom I could not function in the way that I’m currently functioning,” he said. “So, when you add all of those factors up, and wrap it with a bowtie of sincere love and passion for my community, there’s a fire that’s burning inside of me right now.”
SAN DIEGO – On the days family physician Nick Yphantides, MD, announces updates on the COVID-19 epidemic to San Diego County residents, he can’t help but think about his late father.
In June of 2009, 75-year-old George Yphantides, a Steinway-trained piano technician who lived in Escondido, Calif., became the third person in the United States to die from complications of the pandemic H1N1 swine flu – just days before a vaccine became available.
“I loved my dad,” Dr. Yphantides, who has been San Diego County’s Chief Medical Officer since the year of his father’s death, said in an interview. “So, when you take a step back and take into consideration my sense of purpose in serving the 3.3 million residents of San Diego County, my passion based on my personal Christian faith, and my activation in terms of what happened to my dad, I have such a storm of internal sense of urgency right now.”
San Diego County and public health officials got experience with COVID-19 in advance of the country’s widely documented cases of community-based transmission. Around 9 pm on Jan. 31, 2020 – the Friday of Super Bowl weekend – Dr. Yphantides answered a phone call from Eric C. McDonald, MD, the county’s medical director of epidemiology. Dr. McDonald informed him that in a few days, a plane full of American citizens traveling from Wuhan, China, would be landing at Marine Corp Air Station Miramar in San Diego for a 2-week quarantine and that the task of providing medical support to any affected individuals fell on county officials.
“I will never forget that phone call,” he said. “We did have two positive cases. What we experienced with those evacuees was amazing surge preparation, and without exaggeration, I have worked 18-20 hours a day since that day.”
Fast forward to March 31, 2020, the county’s confirmed COVID-19 caseload had grown to 734, up 131 from the day before. As of the final day of March, nine people have died, with an age range between 25 and 87 years. Of confirmed cases, 61% are between the ages of 20 and 49, 43% are female, 19% have required hospitalization, 7% have required admission to intensive care, and the mortality rate has been 1.2%. Data currently show optimal proactive hospital capacity.
In the opinion of Dr. Yphantides, the 734 COVID-19 cases represent a tip of the iceberg. “How big is that iceberg? I can’t tell you yet,” he said.
"I see this as the Super Bowl of public health,” he exclaimed.
At least some of Dr. Yphantides’ vigor seems to be fueled by his pride in his team of professionals who have been helping him respond to the surge of COVID-19 cases.
As the county’s CMO, Dr. Yphantides serves as the liaison for the entire Emergency Medical System, the entire local health care delivery system, the entire physician and medical society network, the payor system, and the proportion of the area population using Medi-Cal.
Dr. Yphantides, who attended medical school at the University of California, San Diego, said that, compared with other regions of the country, San Diego County has made “tremendous progress” in overcoming many chronic lifestyle illnesses. For example, cardiovascular disease is no longer the number one cause of death in the county; it’s bookended by cancer and Alzheimer’s disease.
“In the context of the COVID-19 response, [the county’s health care team established] an entire incident command system in our emergency operations center. Our emergency operations center is activated to the top level,” he said.
Dr. Yphantides shares public communication efforts with Dr. McDonald and Wilma J. Wooten, MD, the county’s public health officer. The San Diego County CMO also engages with policymakers, including the board of supervisors, local mayors, state legislators, and national legislators.
“Because of the relational trust capital that I have in this community, I get pulled into unexpected rooms of discussion,” he said. This included meeting with top executives from the San Diego Padres in early March, putting them on notice that the 2020 Major League Baseball season would likely be postponed. (This was officially announced on March 16.)
“We have made some decisions that have devastated some people economically. Talk about flipping the switch. We are living and making history every day. It is unbelievable,” he said.
“San Diego is a more aged population compared to many other parts of the country. ... [Part] of the reason why I’m so frantically doing everything I can to prepare, to batten down the hatches, and to optimize our health care delivery system is because we have a population that collectively is more at risk [for more serious complications from COVID-19]. A lot of what drives me is advocacy,” Dr. Yphantides noted.
A colleague’s perspective
Kristi L. Koenig, MD, medical director of emergency medical services for the County of San Diego, characterized Dr. Yphantides’ management style as collaborative. “Under his leadership, we have the perspective of ‘just focus on patient care, get it done, be creative, work together as a team,’ ” said Dr. Koenig, who coedited the textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices” (Cambridge University Press, 2016). “He’s decisive and he’s responsive. You don’t have to wait a long time to get a decision, which is very important right now because this is so fast moving.”
Dr. Koenig, who has worked with Dr. Yphantides for 3 years, said that she routinely feeds him information that might help the team navigate its response to COVID-19. “For example, if I see an idea for how to get more [personal protective equipment] and feed it to him, he might have a contact somewhere in a factory that could make the PPE,” she said. “We work together by my reminding him to keep it within the incident command system structure, so that we can coordinate all the resources and not duplicate efforts.”
He uses his personal connections in a way to implement ideas that are beneficial to the overall goal of decreasing morbidity and mortality,” Dr. Koenig added.
Predictions for San Diego County
Dr. Yphantides said he considers San Diego to still be in the calm before the storm and that he is working hard to “board up his community.” The county CMO is also trying to prepare the health care delivery system to optimize its capacity, of doing interventions with hopes of lowering the curve and enhancing the capacity, he said.
When the storm hits, “it’s going be brutal, because we’re going to lose life,” Dr. Yphantides said.
“I am praying that maybe by some of our efforts, instead of a Category 5 storm, it’ll be a Category 3 storm,” he remarked.
The future of health care
Dr. Yphantides views the COVID-19 pandemic as “an absolute game-changer” in terms of what the future of health care delivery will look like in the United States. “Whether the right word is the ‘Amazonification’ of health care, or the ‘Uberization’ of health care, I don’t know, but the essence of how we deliver care is radically being transformed literally before our eyes,” he said. “I would encourage my colleagues to embrace that” and take care of their people by doing whatever it takes under this unprecedented paradigm.
Meanwhile, Dr. Yphantides braces for a potential surge of COVID-19 cases in San Diego County in the coming weeks. He honors the memory of his dad, and he expresses thanks for his mom, who cares for his two teenaged daughters while he helps steward the region’s response to the pandemic.
“Without my mom I could not function in the way that I’m currently functioning,” he said. “So, when you add all of those factors up, and wrap it with a bowtie of sincere love and passion for my community, there’s a fire that’s burning inside of me right now.”
Case fatality rate for COVID-19 near 1.4%, increases with age
The risk for death from COVID-19 is 1.38% overall, according to a new study. However, the fatality rate rises with age, from well below 1% among children aged 9 years or younger to nearly 8% for seniors aged 80 years or older, the latest statistics show.
“These early estimates give an indication of the fatality ratio across the spectrum of COVID-19 disease and show a strong age gradient in risk of death,” Robert Verity, PhD, of University College London, and colleagues, wrote in a study published online in the Lancet Infectious Diseases.
Among those infected with SARS-CoV-2, the virus that causes COVID-19, the risk for hospitalization also increases with age. Specifically, 11.8% of people in their 60s require admission, as do 16.6% of people in their 70s and 18.4% for those in their 80s or older.
The case fatality estimates are based on data regarding individual patients who died from COVID-19 in Hubei, China, through Feb. 8, as well as those who died in Hong Kong, Macau, and 37 countries outside China through Feb. 25.
“It is clear from the data that have emerged from China that case fatality ratio increases substantially with age. Our results suggest a very low fatality ratio in those under the age of 20 years. As there are very few cases in this age group, it remains unclear whether this reflects a low risk of death or a difference in susceptibility, although early results indicate young people are not at lower risk of infection than adults,” Dr. Verity and colleagues wrote.
The authors emphasized that serologic testing of adolescents and children will be vital to understanding how individuals younger than 20 years may be driving viral transmission.
In an accompanying editorial Shigui Ruan, PhD, of the department of mathematics at the University of Miami in Coral Gables, Fla., wrote that early detection, diagnosis, isolation, and treatment, as practiced in China, may help to prevent more deaths
“Even though the fatality rate is low for younger people, it is very clear that any suggestion of COVID-19 being just like influenza is false: Even for those aged 20-29 years, once infected with SARS-CoV-2, the mortality rate is 33 times higher than that from seasonal influenza,” he noted.
Dr. Ruan, who uses applied mathematics to model disease transmission, noted that otherwise healthy people stand a good chance – approximately 95% – of surviving COVID-19, but the odds of survival for people with comorbidities will be “considerably decreased.”
Time to death or discharge
Dr. Verity and colleagues first used data on deaths of 24 patients in mainland China and on 165 persons who recovered from infection outside of China to estimate the time between onset of symptoms and either death or discharge from the hospital. They estimated that the mean duration from symptom onset to death is 17.8 days, and the mean duration to discharge is 24.7 days.
They then estimated age-stratified case fatality ratios among all clinically diagnosed and laboratory-confirmed cases in mainland China to the end of the study period (70,117 cases).
The estimated crude case fatality ratio, adjusted for censoring, was 3.67%. With further adjustment for demographic characteristics and under-ascertainment, the authors’ best estimate of a case fatality ratio in China is 1.38%.
The following figure shows adjusted fatality infection rates by age group.
The investigators noted that the case fatality estimate is lower than the estimates for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks, both caused by coronaviruses, but “is substantially higher than estimates from the 2009 H1N1 influenza pandemic.”
Earlier reports suggested that the overall fatality rate in China through Feb. 11 was 2.3%. The rate in Hubei province, which is believed to be where the infection started, was 2.9%.
Hospitalizations rise with age
The investigators also estimated the proportion of infected patients who require hospitalization. Their estimation was based on data from a subset of cases reported in mainland China. The hospitalization estimates range from zero among the youngest patients to 18% among the oldest.
“Although China has succeeded in containing the disease spread for 2 months, such containment is unlikely to be achievable in most countries. Thus, much of the world will experience very large community epidemics of COVID-19 over the coming weeks and months. Our estimates of the underlying infection fatality ratio of this virus will inform assessments of health effects likely to be experienced in different countries, and thus decisions around appropriate mitigation policies to be adopted,” Dr. Verity and colleagues concluded.
In his editorial, Dr. Ruan agreed with that assessment. “Although China seems to be out of the woods now, many other countries are facing tremendous pressure from the COVID-19 pandemic,” he wrote. “The strategies of early detection, early diagnosis, early isolation, and early treatment that were practiced in China are likely to be not only useful in controlling the outbreak but also contribute to decreasing the case fatality ratio of the disease.”
The study was supported by the UK Medical Research Council. Dr. Verity and Dr. Ruan have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
The risk for death from COVID-19 is 1.38% overall, according to a new study. However, the fatality rate rises with age, from well below 1% among children aged 9 years or younger to nearly 8% for seniors aged 80 years or older, the latest statistics show.
“These early estimates give an indication of the fatality ratio across the spectrum of COVID-19 disease and show a strong age gradient in risk of death,” Robert Verity, PhD, of University College London, and colleagues, wrote in a study published online in the Lancet Infectious Diseases.
Among those infected with SARS-CoV-2, the virus that causes COVID-19, the risk for hospitalization also increases with age. Specifically, 11.8% of people in their 60s require admission, as do 16.6% of people in their 70s and 18.4% for those in their 80s or older.
The case fatality estimates are based on data regarding individual patients who died from COVID-19 in Hubei, China, through Feb. 8, as well as those who died in Hong Kong, Macau, and 37 countries outside China through Feb. 25.
“It is clear from the data that have emerged from China that case fatality ratio increases substantially with age. Our results suggest a very low fatality ratio in those under the age of 20 years. As there are very few cases in this age group, it remains unclear whether this reflects a low risk of death or a difference in susceptibility, although early results indicate young people are not at lower risk of infection than adults,” Dr. Verity and colleagues wrote.
The authors emphasized that serologic testing of adolescents and children will be vital to understanding how individuals younger than 20 years may be driving viral transmission.
In an accompanying editorial Shigui Ruan, PhD, of the department of mathematics at the University of Miami in Coral Gables, Fla., wrote that early detection, diagnosis, isolation, and treatment, as practiced in China, may help to prevent more deaths
“Even though the fatality rate is low for younger people, it is very clear that any suggestion of COVID-19 being just like influenza is false: Even for those aged 20-29 years, once infected with SARS-CoV-2, the mortality rate is 33 times higher than that from seasonal influenza,” he noted.
Dr. Ruan, who uses applied mathematics to model disease transmission, noted that otherwise healthy people stand a good chance – approximately 95% – of surviving COVID-19, but the odds of survival for people with comorbidities will be “considerably decreased.”
Time to death or discharge
Dr. Verity and colleagues first used data on deaths of 24 patients in mainland China and on 165 persons who recovered from infection outside of China to estimate the time between onset of symptoms and either death or discharge from the hospital. They estimated that the mean duration from symptom onset to death is 17.8 days, and the mean duration to discharge is 24.7 days.
They then estimated age-stratified case fatality ratios among all clinically diagnosed and laboratory-confirmed cases in mainland China to the end of the study period (70,117 cases).
The estimated crude case fatality ratio, adjusted for censoring, was 3.67%. With further adjustment for demographic characteristics and under-ascertainment, the authors’ best estimate of a case fatality ratio in China is 1.38%.
The following figure shows adjusted fatality infection rates by age group.
The investigators noted that the case fatality estimate is lower than the estimates for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks, both caused by coronaviruses, but “is substantially higher than estimates from the 2009 H1N1 influenza pandemic.”
Earlier reports suggested that the overall fatality rate in China through Feb. 11 was 2.3%. The rate in Hubei province, which is believed to be where the infection started, was 2.9%.
Hospitalizations rise with age
The investigators also estimated the proportion of infected patients who require hospitalization. Their estimation was based on data from a subset of cases reported in mainland China. The hospitalization estimates range from zero among the youngest patients to 18% among the oldest.
“Although China has succeeded in containing the disease spread for 2 months, such containment is unlikely to be achievable in most countries. Thus, much of the world will experience very large community epidemics of COVID-19 over the coming weeks and months. Our estimates of the underlying infection fatality ratio of this virus will inform assessments of health effects likely to be experienced in different countries, and thus decisions around appropriate mitigation policies to be adopted,” Dr. Verity and colleagues concluded.
In his editorial, Dr. Ruan agreed with that assessment. “Although China seems to be out of the woods now, many other countries are facing tremendous pressure from the COVID-19 pandemic,” he wrote. “The strategies of early detection, early diagnosis, early isolation, and early treatment that were practiced in China are likely to be not only useful in controlling the outbreak but also contribute to decreasing the case fatality ratio of the disease.”
The study was supported by the UK Medical Research Council. Dr. Verity and Dr. Ruan have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
The risk for death from COVID-19 is 1.38% overall, according to a new study. However, the fatality rate rises with age, from well below 1% among children aged 9 years or younger to nearly 8% for seniors aged 80 years or older, the latest statistics show.
“These early estimates give an indication of the fatality ratio across the spectrum of COVID-19 disease and show a strong age gradient in risk of death,” Robert Verity, PhD, of University College London, and colleagues, wrote in a study published online in the Lancet Infectious Diseases.
Among those infected with SARS-CoV-2, the virus that causes COVID-19, the risk for hospitalization also increases with age. Specifically, 11.8% of people in their 60s require admission, as do 16.6% of people in their 70s and 18.4% for those in their 80s or older.
The case fatality estimates are based on data regarding individual patients who died from COVID-19 in Hubei, China, through Feb. 8, as well as those who died in Hong Kong, Macau, and 37 countries outside China through Feb. 25.
“It is clear from the data that have emerged from China that case fatality ratio increases substantially with age. Our results suggest a very low fatality ratio in those under the age of 20 years. As there are very few cases in this age group, it remains unclear whether this reflects a low risk of death or a difference in susceptibility, although early results indicate young people are not at lower risk of infection than adults,” Dr. Verity and colleagues wrote.
The authors emphasized that serologic testing of adolescents and children will be vital to understanding how individuals younger than 20 years may be driving viral transmission.
In an accompanying editorial Shigui Ruan, PhD, of the department of mathematics at the University of Miami in Coral Gables, Fla., wrote that early detection, diagnosis, isolation, and treatment, as practiced in China, may help to prevent more deaths
“Even though the fatality rate is low for younger people, it is very clear that any suggestion of COVID-19 being just like influenza is false: Even for those aged 20-29 years, once infected with SARS-CoV-2, the mortality rate is 33 times higher than that from seasonal influenza,” he noted.
Dr. Ruan, who uses applied mathematics to model disease transmission, noted that otherwise healthy people stand a good chance – approximately 95% – of surviving COVID-19, but the odds of survival for people with comorbidities will be “considerably decreased.”
Time to death or discharge
Dr. Verity and colleagues first used data on deaths of 24 patients in mainland China and on 165 persons who recovered from infection outside of China to estimate the time between onset of symptoms and either death or discharge from the hospital. They estimated that the mean duration from symptom onset to death is 17.8 days, and the mean duration to discharge is 24.7 days.
They then estimated age-stratified case fatality ratios among all clinically diagnosed and laboratory-confirmed cases in mainland China to the end of the study period (70,117 cases).
The estimated crude case fatality ratio, adjusted for censoring, was 3.67%. With further adjustment for demographic characteristics and under-ascertainment, the authors’ best estimate of a case fatality ratio in China is 1.38%.
The following figure shows adjusted fatality infection rates by age group.
The investigators noted that the case fatality estimate is lower than the estimates for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks, both caused by coronaviruses, but “is substantially higher than estimates from the 2009 H1N1 influenza pandemic.”
Earlier reports suggested that the overall fatality rate in China through Feb. 11 was 2.3%. The rate in Hubei province, which is believed to be where the infection started, was 2.9%.
Hospitalizations rise with age
The investigators also estimated the proportion of infected patients who require hospitalization. Their estimation was based on data from a subset of cases reported in mainland China. The hospitalization estimates range from zero among the youngest patients to 18% among the oldest.
“Although China has succeeded in containing the disease spread for 2 months, such containment is unlikely to be achievable in most countries. Thus, much of the world will experience very large community epidemics of COVID-19 over the coming weeks and months. Our estimates of the underlying infection fatality ratio of this virus will inform assessments of health effects likely to be experienced in different countries, and thus decisions around appropriate mitigation policies to be adopted,” Dr. Verity and colleagues concluded.
In his editorial, Dr. Ruan agreed with that assessment. “Although China seems to be out of the woods now, many other countries are facing tremendous pressure from the COVID-19 pandemic,” he wrote. “The strategies of early detection, early diagnosis, early isolation, and early treatment that were practiced in China are likely to be not only useful in controlling the outbreak but also contribute to decreasing the case fatality ratio of the disease.”
The study was supported by the UK Medical Research Council. Dr. Verity and Dr. Ruan have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
COVID-19: Adjusting practice in acute leukemia care
The SARS-CoV-2 pandemic poses significant risks to leukemia patients and their providers, impacting every aspect of care from diagnosis through therapy, according to an editorial letter published online in Leukemia Research.
One key concern to be considered is the risk of missed or delayed diagnosis due to the pandemic conditions. An estimated 50%-75% of patients with acute leukemia are febrile at diagnosis and this puts them at high risk of a misdiagnosis of COVID-19 upon initial evaluation. As with other oncological conditions (primary mediastinal lymphoma or lung cancer, for example), which often present with a cough with or without fever, their symptoms “are likely to be considered trivial after a negative SARS-CoV-2 test,” with patients then being sent home without further assessment. In a rapidly progressing disease such as acute leukemia, this could lead to critical delays in therapeutic intervention.
The authors, from the Service and Central Laboratory of Hematology, Lausanne (Switzerland) University Hospital, also discussed the problems that might occur with regard to most standard forms of therapy. In particular, they addressed potential impacts of the pandemic on chemotherapy, bone marrow transplantation, maintenance treatments, supportive measures, and targeted therapies.
Of particular concern, “most patients may suffer from postponed chemotherapy, due to a shortage of isolation beds and blood products or the wish to avoid immunosuppressive treatments,” the authors noted, warning that “delay in chemotherapy initiation may negatively affect prognosis, [particularly in patients under age 60] with favorable- or intermediate-risk disease.”
With regard to stem cell transplantation, the authors detail the many potential difficulties with regard to procedures involving both donors and recipients, and warn that in some cases, delay in transplant could result in the reappearance of a significant minimal residual disease, which has a well-established negative impact on survival.
The authors also noted that blood product shortages have already begun in most affected countries, and how, in response, transfusion societies have called for conservative transfusion policies in strict adherence to evidence-based guidelines for patient’s blood management.
“COVID-19 will result in numerous casualties. Acute leukemia patients are at a higher risk of severe complications,” the authors stated. In particular, physicians should especially be aware of how treatment for acute leukemia may have “interactions with other drugs used to treat SARS-CoV-2–related infections/complications such as antibiotics, antiviral drugs, and various other drugs that prolong QTc or impact targeted-therapy pharmacokinetics,” they concluded.
The authors reported that they received no government or private funding for this research, and that they had no conflicts of interest.
SOURCE: Gavillet M et al. Leuk. Res. 2020. doi.org/10.1016/j.leukres.2020.106353.
The SARS-CoV-2 pandemic poses significant risks to leukemia patients and their providers, impacting every aspect of care from diagnosis through therapy, according to an editorial letter published online in Leukemia Research.
One key concern to be considered is the risk of missed or delayed diagnosis due to the pandemic conditions. An estimated 50%-75% of patients with acute leukemia are febrile at diagnosis and this puts them at high risk of a misdiagnosis of COVID-19 upon initial evaluation. As with other oncological conditions (primary mediastinal lymphoma or lung cancer, for example), which often present with a cough with or without fever, their symptoms “are likely to be considered trivial after a negative SARS-CoV-2 test,” with patients then being sent home without further assessment. In a rapidly progressing disease such as acute leukemia, this could lead to critical delays in therapeutic intervention.
The authors, from the Service and Central Laboratory of Hematology, Lausanne (Switzerland) University Hospital, also discussed the problems that might occur with regard to most standard forms of therapy. In particular, they addressed potential impacts of the pandemic on chemotherapy, bone marrow transplantation, maintenance treatments, supportive measures, and targeted therapies.
Of particular concern, “most patients may suffer from postponed chemotherapy, due to a shortage of isolation beds and blood products or the wish to avoid immunosuppressive treatments,” the authors noted, warning that “delay in chemotherapy initiation may negatively affect prognosis, [particularly in patients under age 60] with favorable- or intermediate-risk disease.”
With regard to stem cell transplantation, the authors detail the many potential difficulties with regard to procedures involving both donors and recipients, and warn that in some cases, delay in transplant could result in the reappearance of a significant minimal residual disease, which has a well-established negative impact on survival.
The authors also noted that blood product shortages have already begun in most affected countries, and how, in response, transfusion societies have called for conservative transfusion policies in strict adherence to evidence-based guidelines for patient’s blood management.
“COVID-19 will result in numerous casualties. Acute leukemia patients are at a higher risk of severe complications,” the authors stated. In particular, physicians should especially be aware of how treatment for acute leukemia may have “interactions with other drugs used to treat SARS-CoV-2–related infections/complications such as antibiotics, antiviral drugs, and various other drugs that prolong QTc or impact targeted-therapy pharmacokinetics,” they concluded.
The authors reported that they received no government or private funding for this research, and that they had no conflicts of interest.
SOURCE: Gavillet M et al. Leuk. Res. 2020. doi.org/10.1016/j.leukres.2020.106353.
The SARS-CoV-2 pandemic poses significant risks to leukemia patients and their providers, impacting every aspect of care from diagnosis through therapy, according to an editorial letter published online in Leukemia Research.
One key concern to be considered is the risk of missed or delayed diagnosis due to the pandemic conditions. An estimated 50%-75% of patients with acute leukemia are febrile at diagnosis and this puts them at high risk of a misdiagnosis of COVID-19 upon initial evaluation. As with other oncological conditions (primary mediastinal lymphoma or lung cancer, for example), which often present with a cough with or without fever, their symptoms “are likely to be considered trivial after a negative SARS-CoV-2 test,” with patients then being sent home without further assessment. In a rapidly progressing disease such as acute leukemia, this could lead to critical delays in therapeutic intervention.
The authors, from the Service and Central Laboratory of Hematology, Lausanne (Switzerland) University Hospital, also discussed the problems that might occur with regard to most standard forms of therapy. In particular, they addressed potential impacts of the pandemic on chemotherapy, bone marrow transplantation, maintenance treatments, supportive measures, and targeted therapies.
Of particular concern, “most patients may suffer from postponed chemotherapy, due to a shortage of isolation beds and blood products or the wish to avoid immunosuppressive treatments,” the authors noted, warning that “delay in chemotherapy initiation may negatively affect prognosis, [particularly in patients under age 60] with favorable- or intermediate-risk disease.”
With regard to stem cell transplantation, the authors detail the many potential difficulties with regard to procedures involving both donors and recipients, and warn that in some cases, delay in transplant could result in the reappearance of a significant minimal residual disease, which has a well-established negative impact on survival.
The authors also noted that blood product shortages have already begun in most affected countries, and how, in response, transfusion societies have called for conservative transfusion policies in strict adherence to evidence-based guidelines for patient’s blood management.
“COVID-19 will result in numerous casualties. Acute leukemia patients are at a higher risk of severe complications,” the authors stated. In particular, physicians should especially be aware of how treatment for acute leukemia may have “interactions with other drugs used to treat SARS-CoV-2–related infections/complications such as antibiotics, antiviral drugs, and various other drugs that prolong QTc or impact targeted-therapy pharmacokinetics,” they concluded.
The authors reported that they received no government or private funding for this research, and that they had no conflicts of interest.
SOURCE: Gavillet M et al. Leuk. Res. 2020. doi.org/10.1016/j.leukres.2020.106353.
FROM LEUKEMIA RESEARCH
COVID-19 experiences from the ob.gyn. front line
As the COVID-19 pandemic continues to spread across the United States, several members of the Ob.Gyn. News Editorial Advisory Board shared their experiences.
Catherine Cansino, MD, MPH, who is an associate clinical professor in the department of obstetrics and gynecology at the University of California, Davis, discussed the changes COVID-19 has had on local and regional practice in Sacramento and northern California.
There has been a dramatic increase in telehealth, using video, phone, and apps such as Zoom. Although ob.gyns. at the university are limiting outpatient appointments to essential visits only, we are continuing to offer telehealth to a few nonessential visits. This will be readdressed when the COVID-19 cases peak, Dr. Cansino said.
All patients admitted to labor & delivery undergo COVID-19 testing regardless of symptoms. For patients in the clinic who are expected to be induced or scheduled for cesarean delivery, we are screening them within 72 hours before admission.
In gynecology, only essential or urgent surgeries at UC Davis are being performed and include indications such as cancer, serious benign conditions unresponsive to conservative treatment (e.g., tubo-ovarian abscess, large symptomatic adnexal mass), and pregnancy termination. We are preserving access to abortion and reproductive health services since these are essential services.
We limit the number of providers involved in direct contact with inpatients to one or two, including a physician, nurse, and/or resident, Dr. Cansino said in an interview. Based on recent Liaison Committee on Medical Education policies related to concerns about educational experience during the pandemic, no medical students are allowed at the hospital at present. We also severely restrict the number of visitors in the inpatient and outpatient settings, including only two attendants (partner, doula, and such) during labor and delivery, and consider the impact on patients’ well-being when we restrict their visitors.
We are following University of California guidelines regarding face mask use, which have been in evolution over the last month. Face masks are used for patients and the health care providers primarily when patients either have known COVID-19 infection or are considered as patients under investigation or if the employee had a high-risk exposure. The use of face masks is becoming more permissive, rather than mandatory, to conserve personal protective equipment (PPE) for when the surge arrives.
Education is ongoing about caring for our families and ourselves if we get infected and need to isolate within our own homes. The department and health system is trying to balance the challenges of urgent patient care needs against the wellness concerns for the faculty, staff, and residents. Many physicians are also struggling with childcare problems, which add to our personal stress. There is anxiety among many physicians about exposure to asymptomatic carriers, including themselves, patients, and their families, Dr. Cansino said.
David Forstein, DO, dean and professor of obstetrics and gynecology at Touro College of Osteopathic Medicine, New York, said in an interview that the COVID-19 pandemic has “totally disrupted medical education. At almost all medical schools, didactics have moved completely online – ZOOM sessions abound, but labs become demonstrations, if at all, during the preclinical years. The clinical years have been put on hold, as well as student rotations suspended, out of caution for the students because hospitals needed to conserve PPE for the essential personnel and because administrators knew there would be less time for teaching. After initially requesting a pause, many hospitals now are asking students to come back because so many physicians, nurses, and residents have become ill with COVID-19 and either are quarantined or are patients in the hospital themselves.
“There has been a state-by-state call to consider graduating health professions students early, and press them into service, before their residencies actually begin. Some locations are looking for these new graduates to volunteer; some are willing to pay them a resident’s salary level. Medical schools are auditing their student records now to see which students would qualify to graduate early,” Dr. Forstein noted.
David M. Jaspan, DO, chairman of the department of obstetrics and gynecology at the Einstein Health Care Network in Philadelphia, described in an email interview how COVID-19 has changed practice.
To minimize the number of providers on the front line, we have developed a Monday to Friday rotating schedule of three teams of five members, he explained. There will be a hospital-based team, an office-based team, and a telehealth-based team who will provide their services from home. On-call responsibilities remain the same.
The hospital team, working 7 a.m. to 5 p.m., will rotate through assignments each day:
- One person will cover labor and delivery.
- One person will cover triage and help on labor and delivery.
- One person will be assigned to the resident office.
- One person will be assigned to cover the team of the post call attending (Sunday through Thursday call).
- One person will be assigned to gynecology coverage, consults, and postpartum rounds.
To further minimize the patient interactions, when possible, each patient should be seen by the attending physician with the resident. This is a change from usual practice, where the patient is first seen by the resident, who reports back to the attending, and then both physicians see the patient together.
The network’s offices now open from 9 a.m. (many offices had been offering early-morning hours starting at 7 a.m.), and the physicians and advanced practice providers will work through the last scheduled patient appointment, Dr. Jaspan explained. “The office-based team will preferentially see in-person visits.”
Several offices have been closed so that ob.gyns. and staff can be reassigned to telehealth. The remaining five offices generally have one attending physician and one advanced practice provider.
The remaining team of ob.gyns. provides telehealth with the help of staff members. This involves an initial call to the patient by staff letting them know the doctor will be calling, checking them in, verifying insurance, and collecting payment, followed by the actual telehealth visit. If follow-up is needed, the staff member schedules the follow-up.
Dr. Jaspan called the new approach to prenatal care because of COVID-19 a “cataclysmic change in how we care for our patients. We have decided to further limit our obstetrical in-person visits. It is our feeling that these changes will enable patients to remain outside of the office and in the safety of their homes, provide appropriate social distancing, and diminish potential exposures to the office staff providers and patients.”
In-person visits will occur at: the initial visit, between 24 and 28 weeks, at 32 weeks, and at 36 or 37 weeks; if the patient at 36/37 has a blood pressure cuff, they will not have additional scheduled in-patient visits. We have partnered with the insurance companies to provide more than 88% of obstetrical patients with home blood pressure cuffs.
Obstetrical visits via telehealth will continue at our standard intervals: monthly until 26 weeks; twice monthly during 26-36 weeks; and weekly from 37 weeks to delivery. These visits should use a video component such as Zoom, Doxy.me, or FaceTime.
“If the patient has concerns or problems, we will see them at any time. However, the new standard will be telehealth visits and the exception will be the in-person visit,” Dr. Jaspan said.
In addition, we have worked our division of maternal-fetal medicine to adjust the antenatal testing schedules, and we have curtailed the frequency of ultrasound, he noted.
He emphasized the importance of documenting telehealth interactions with obstetrical patients, in addition to “providing adequate teaching and education for patients regarding kick counts to ensure fetal well-being.” It also is key to “properly document conversations with patients regarding bleeding, rupture of membranes, fetal movement, headache, visual changes, fevers, cough, nausea and vomiting, diarrhea, fatigue, muscle aches, etc.”
The residents’ schedule also has been modified to diminish their exposure. Within our new paradigm, we have scheduled video conferences to enable our program to maintain our commitment to academics.
It is imperative that we keep our patients safe, and it is critical to protect our staff members. Those who provide women’s health cannot be replaced by other nurses or physicians.
Mark P. Trolice, MD, is director of Fertility CARE: the IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He related in an email interview that, on March 17, 2020, the American Society for Reproductive Medicine (ASRM) released “Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic.” This document serves as guidance on fertility care during the current crisis. Specifically, the recommendations include the following:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations, in vitro fertilization including retrievals and frozen embryo transfers, and nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
As a member of ASRM for more than 2 decades and a participant of several of their committees, my practice immediately ceased treatment cycles to comply with this guidance.
Then on March 20, 2020, the Florida governor’s executive order 20-72 was released, stating, “All hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices in the State of Florida are prohibited from providing any medically unnecessary, nonurgent or nonemergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.”
As a result, my practice has been limited to telemedicine consultations. While the ASRM guidance and the gubernatorial executive order pose a significant financial hardship on my center and all applicable medical clinics in my state, resulting in expected layoffs, salary reductions, and requests for government stimulus loans, the greater good takes priority and we pray for all the victims of this devastating pandemic.
The governor’s current executive order is set to expire on May 9, 2020, unless it is extended.
ASRM released an update of their guidance on March 30, 2020, offering no change from their prior recommendations. The organization plans to reevaluate the guidance at 2-week intervals.
Sangeeta Sinha, MD, an ob.gyn. in private practice at Stone Springs Hospital Center, Dulles, Va. said in an interview, “COVID 19 has put fear in all aspects of our daily activities which we are attempting to cope with.”
She related several changes made to her office and hospital environments. “In our office, we are now wearing a mask at all times, gloves to examine every patient. We have staggered physicians in the office to take televisits and in-office patients. We are screening all new patients on the phone to determine if they are sick, have traveled to high-risk, hot spot areas of the country, or have had contact with someone who tested positive for COVID-19. We are only seeing our pregnant women and have also pushed out their return appointments to 4 weeks if possible. There are several staff who are not working due to fear or are in self quarantine so we have shortage of staff in the office. At the hospital as well we are wearing a mask at all times, using personal protective equipment for deliveries and C-sections.
“We have had several scares, including a new transfer of an 18-year-old pregnant patient at 30 weeks with cough and sore throat, who later reported that her roommate is very sick and he works with someone who has tested positive for COVID-19. Thankfully she is healthy and well. We learned several lessons from this one.”
As the COVID-19 pandemic continues to spread across the United States, several members of the Ob.Gyn. News Editorial Advisory Board shared their experiences.
Catherine Cansino, MD, MPH, who is an associate clinical professor in the department of obstetrics and gynecology at the University of California, Davis, discussed the changes COVID-19 has had on local and regional practice in Sacramento and northern California.
There has been a dramatic increase in telehealth, using video, phone, and apps such as Zoom. Although ob.gyns. at the university are limiting outpatient appointments to essential visits only, we are continuing to offer telehealth to a few nonessential visits. This will be readdressed when the COVID-19 cases peak, Dr. Cansino said.
All patients admitted to labor & delivery undergo COVID-19 testing regardless of symptoms. For patients in the clinic who are expected to be induced or scheduled for cesarean delivery, we are screening them within 72 hours before admission.
In gynecology, only essential or urgent surgeries at UC Davis are being performed and include indications such as cancer, serious benign conditions unresponsive to conservative treatment (e.g., tubo-ovarian abscess, large symptomatic adnexal mass), and pregnancy termination. We are preserving access to abortion and reproductive health services since these are essential services.
We limit the number of providers involved in direct contact with inpatients to one or two, including a physician, nurse, and/or resident, Dr. Cansino said in an interview. Based on recent Liaison Committee on Medical Education policies related to concerns about educational experience during the pandemic, no medical students are allowed at the hospital at present. We also severely restrict the number of visitors in the inpatient and outpatient settings, including only two attendants (partner, doula, and such) during labor and delivery, and consider the impact on patients’ well-being when we restrict their visitors.
We are following University of California guidelines regarding face mask use, which have been in evolution over the last month. Face masks are used for patients and the health care providers primarily when patients either have known COVID-19 infection or are considered as patients under investigation or if the employee had a high-risk exposure. The use of face masks is becoming more permissive, rather than mandatory, to conserve personal protective equipment (PPE) for when the surge arrives.
Education is ongoing about caring for our families and ourselves if we get infected and need to isolate within our own homes. The department and health system is trying to balance the challenges of urgent patient care needs against the wellness concerns for the faculty, staff, and residents. Many physicians are also struggling with childcare problems, which add to our personal stress. There is anxiety among many physicians about exposure to asymptomatic carriers, including themselves, patients, and their families, Dr. Cansino said.
David Forstein, DO, dean and professor of obstetrics and gynecology at Touro College of Osteopathic Medicine, New York, said in an interview that the COVID-19 pandemic has “totally disrupted medical education. At almost all medical schools, didactics have moved completely online – ZOOM sessions abound, but labs become demonstrations, if at all, during the preclinical years. The clinical years have been put on hold, as well as student rotations suspended, out of caution for the students because hospitals needed to conserve PPE for the essential personnel and because administrators knew there would be less time for teaching. After initially requesting a pause, many hospitals now are asking students to come back because so many physicians, nurses, and residents have become ill with COVID-19 and either are quarantined or are patients in the hospital themselves.
“There has been a state-by-state call to consider graduating health professions students early, and press them into service, before their residencies actually begin. Some locations are looking for these new graduates to volunteer; some are willing to pay them a resident’s salary level. Medical schools are auditing their student records now to see which students would qualify to graduate early,” Dr. Forstein noted.
David M. Jaspan, DO, chairman of the department of obstetrics and gynecology at the Einstein Health Care Network in Philadelphia, described in an email interview how COVID-19 has changed practice.
To minimize the number of providers on the front line, we have developed a Monday to Friday rotating schedule of three teams of five members, he explained. There will be a hospital-based team, an office-based team, and a telehealth-based team who will provide their services from home. On-call responsibilities remain the same.
The hospital team, working 7 a.m. to 5 p.m., will rotate through assignments each day:
- One person will cover labor and delivery.
- One person will cover triage and help on labor and delivery.
- One person will be assigned to the resident office.
- One person will be assigned to cover the team of the post call attending (Sunday through Thursday call).
- One person will be assigned to gynecology coverage, consults, and postpartum rounds.
To further minimize the patient interactions, when possible, each patient should be seen by the attending physician with the resident. This is a change from usual practice, where the patient is first seen by the resident, who reports back to the attending, and then both physicians see the patient together.
The network’s offices now open from 9 a.m. (many offices had been offering early-morning hours starting at 7 a.m.), and the physicians and advanced practice providers will work through the last scheduled patient appointment, Dr. Jaspan explained. “The office-based team will preferentially see in-person visits.”
Several offices have been closed so that ob.gyns. and staff can be reassigned to telehealth. The remaining five offices generally have one attending physician and one advanced practice provider.
The remaining team of ob.gyns. provides telehealth with the help of staff members. This involves an initial call to the patient by staff letting them know the doctor will be calling, checking them in, verifying insurance, and collecting payment, followed by the actual telehealth visit. If follow-up is needed, the staff member schedules the follow-up.
Dr. Jaspan called the new approach to prenatal care because of COVID-19 a “cataclysmic change in how we care for our patients. We have decided to further limit our obstetrical in-person visits. It is our feeling that these changes will enable patients to remain outside of the office and in the safety of their homes, provide appropriate social distancing, and diminish potential exposures to the office staff providers and patients.”
In-person visits will occur at: the initial visit, between 24 and 28 weeks, at 32 weeks, and at 36 or 37 weeks; if the patient at 36/37 has a blood pressure cuff, they will not have additional scheduled in-patient visits. We have partnered with the insurance companies to provide more than 88% of obstetrical patients with home blood pressure cuffs.
Obstetrical visits via telehealth will continue at our standard intervals: monthly until 26 weeks; twice monthly during 26-36 weeks; and weekly from 37 weeks to delivery. These visits should use a video component such as Zoom, Doxy.me, or FaceTime.
“If the patient has concerns or problems, we will see them at any time. However, the new standard will be telehealth visits and the exception will be the in-person visit,” Dr. Jaspan said.
In addition, we have worked our division of maternal-fetal medicine to adjust the antenatal testing schedules, and we have curtailed the frequency of ultrasound, he noted.
He emphasized the importance of documenting telehealth interactions with obstetrical patients, in addition to “providing adequate teaching and education for patients regarding kick counts to ensure fetal well-being.” It also is key to “properly document conversations with patients regarding bleeding, rupture of membranes, fetal movement, headache, visual changes, fevers, cough, nausea and vomiting, diarrhea, fatigue, muscle aches, etc.”
The residents’ schedule also has been modified to diminish their exposure. Within our new paradigm, we have scheduled video conferences to enable our program to maintain our commitment to academics.
It is imperative that we keep our patients safe, and it is critical to protect our staff members. Those who provide women’s health cannot be replaced by other nurses or physicians.
Mark P. Trolice, MD, is director of Fertility CARE: the IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He related in an email interview that, on March 17, 2020, the American Society for Reproductive Medicine (ASRM) released “Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic.” This document serves as guidance on fertility care during the current crisis. Specifically, the recommendations include the following:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations, in vitro fertilization including retrievals and frozen embryo transfers, and nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
As a member of ASRM for more than 2 decades and a participant of several of their committees, my practice immediately ceased treatment cycles to comply with this guidance.
Then on March 20, 2020, the Florida governor’s executive order 20-72 was released, stating, “All hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices in the State of Florida are prohibited from providing any medically unnecessary, nonurgent or nonemergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.”
As a result, my practice has been limited to telemedicine consultations. While the ASRM guidance and the gubernatorial executive order pose a significant financial hardship on my center and all applicable medical clinics in my state, resulting in expected layoffs, salary reductions, and requests for government stimulus loans, the greater good takes priority and we pray for all the victims of this devastating pandemic.
The governor’s current executive order is set to expire on May 9, 2020, unless it is extended.
ASRM released an update of their guidance on March 30, 2020, offering no change from their prior recommendations. The organization plans to reevaluate the guidance at 2-week intervals.
Sangeeta Sinha, MD, an ob.gyn. in private practice at Stone Springs Hospital Center, Dulles, Va. said in an interview, “COVID 19 has put fear in all aspects of our daily activities which we are attempting to cope with.”
She related several changes made to her office and hospital environments. “In our office, we are now wearing a mask at all times, gloves to examine every patient. We have staggered physicians in the office to take televisits and in-office patients. We are screening all new patients on the phone to determine if they are sick, have traveled to high-risk, hot spot areas of the country, or have had contact with someone who tested positive for COVID-19. We are only seeing our pregnant women and have also pushed out their return appointments to 4 weeks if possible. There are several staff who are not working due to fear or are in self quarantine so we have shortage of staff in the office. At the hospital as well we are wearing a mask at all times, using personal protective equipment for deliveries and C-sections.
“We have had several scares, including a new transfer of an 18-year-old pregnant patient at 30 weeks with cough and sore throat, who later reported that her roommate is very sick and he works with someone who has tested positive for COVID-19. Thankfully she is healthy and well. We learned several lessons from this one.”
As the COVID-19 pandemic continues to spread across the United States, several members of the Ob.Gyn. News Editorial Advisory Board shared their experiences.
Catherine Cansino, MD, MPH, who is an associate clinical professor in the department of obstetrics and gynecology at the University of California, Davis, discussed the changes COVID-19 has had on local and regional practice in Sacramento and northern California.
There has been a dramatic increase in telehealth, using video, phone, and apps such as Zoom. Although ob.gyns. at the university are limiting outpatient appointments to essential visits only, we are continuing to offer telehealth to a few nonessential visits. This will be readdressed when the COVID-19 cases peak, Dr. Cansino said.
All patients admitted to labor & delivery undergo COVID-19 testing regardless of symptoms. For patients in the clinic who are expected to be induced or scheduled for cesarean delivery, we are screening them within 72 hours before admission.
In gynecology, only essential or urgent surgeries at UC Davis are being performed and include indications such as cancer, serious benign conditions unresponsive to conservative treatment (e.g., tubo-ovarian abscess, large symptomatic adnexal mass), and pregnancy termination. We are preserving access to abortion and reproductive health services since these are essential services.
We limit the number of providers involved in direct contact with inpatients to one or two, including a physician, nurse, and/or resident, Dr. Cansino said in an interview. Based on recent Liaison Committee on Medical Education policies related to concerns about educational experience during the pandemic, no medical students are allowed at the hospital at present. We also severely restrict the number of visitors in the inpatient and outpatient settings, including only two attendants (partner, doula, and such) during labor and delivery, and consider the impact on patients’ well-being when we restrict their visitors.
We are following University of California guidelines regarding face mask use, which have been in evolution over the last month. Face masks are used for patients and the health care providers primarily when patients either have known COVID-19 infection or are considered as patients under investigation or if the employee had a high-risk exposure. The use of face masks is becoming more permissive, rather than mandatory, to conserve personal protective equipment (PPE) for when the surge arrives.
Education is ongoing about caring for our families and ourselves if we get infected and need to isolate within our own homes. The department and health system is trying to balance the challenges of urgent patient care needs against the wellness concerns for the faculty, staff, and residents. Many physicians are also struggling with childcare problems, which add to our personal stress. There is anxiety among many physicians about exposure to asymptomatic carriers, including themselves, patients, and their families, Dr. Cansino said.
David Forstein, DO, dean and professor of obstetrics and gynecology at Touro College of Osteopathic Medicine, New York, said in an interview that the COVID-19 pandemic has “totally disrupted medical education. At almost all medical schools, didactics have moved completely online – ZOOM sessions abound, but labs become demonstrations, if at all, during the preclinical years. The clinical years have been put on hold, as well as student rotations suspended, out of caution for the students because hospitals needed to conserve PPE for the essential personnel and because administrators knew there would be less time for teaching. After initially requesting a pause, many hospitals now are asking students to come back because so many physicians, nurses, and residents have become ill with COVID-19 and either are quarantined or are patients in the hospital themselves.
“There has been a state-by-state call to consider graduating health professions students early, and press them into service, before their residencies actually begin. Some locations are looking for these new graduates to volunteer; some are willing to pay them a resident’s salary level. Medical schools are auditing their student records now to see which students would qualify to graduate early,” Dr. Forstein noted.
David M. Jaspan, DO, chairman of the department of obstetrics and gynecology at the Einstein Health Care Network in Philadelphia, described in an email interview how COVID-19 has changed practice.
To minimize the number of providers on the front line, we have developed a Monday to Friday rotating schedule of three teams of five members, he explained. There will be a hospital-based team, an office-based team, and a telehealth-based team who will provide their services from home. On-call responsibilities remain the same.
The hospital team, working 7 a.m. to 5 p.m., will rotate through assignments each day:
- One person will cover labor and delivery.
- One person will cover triage and help on labor and delivery.
- One person will be assigned to the resident office.
- One person will be assigned to cover the team of the post call attending (Sunday through Thursday call).
- One person will be assigned to gynecology coverage, consults, and postpartum rounds.
To further minimize the patient interactions, when possible, each patient should be seen by the attending physician with the resident. This is a change from usual practice, where the patient is first seen by the resident, who reports back to the attending, and then both physicians see the patient together.
The network’s offices now open from 9 a.m. (many offices had been offering early-morning hours starting at 7 a.m.), and the physicians and advanced practice providers will work through the last scheduled patient appointment, Dr. Jaspan explained. “The office-based team will preferentially see in-person visits.”
Several offices have been closed so that ob.gyns. and staff can be reassigned to telehealth. The remaining five offices generally have one attending physician and one advanced practice provider.
The remaining team of ob.gyns. provides telehealth with the help of staff members. This involves an initial call to the patient by staff letting them know the doctor will be calling, checking them in, verifying insurance, and collecting payment, followed by the actual telehealth visit. If follow-up is needed, the staff member schedules the follow-up.
Dr. Jaspan called the new approach to prenatal care because of COVID-19 a “cataclysmic change in how we care for our patients. We have decided to further limit our obstetrical in-person visits. It is our feeling that these changes will enable patients to remain outside of the office and in the safety of their homes, provide appropriate social distancing, and diminish potential exposures to the office staff providers and patients.”
In-person visits will occur at: the initial visit, between 24 and 28 weeks, at 32 weeks, and at 36 or 37 weeks; if the patient at 36/37 has a blood pressure cuff, they will not have additional scheduled in-patient visits. We have partnered with the insurance companies to provide more than 88% of obstetrical patients with home blood pressure cuffs.
Obstetrical visits via telehealth will continue at our standard intervals: monthly until 26 weeks; twice monthly during 26-36 weeks; and weekly from 37 weeks to delivery. These visits should use a video component such as Zoom, Doxy.me, or FaceTime.
“If the patient has concerns or problems, we will see them at any time. However, the new standard will be telehealth visits and the exception will be the in-person visit,” Dr. Jaspan said.
In addition, we have worked our division of maternal-fetal medicine to adjust the antenatal testing schedules, and we have curtailed the frequency of ultrasound, he noted.
He emphasized the importance of documenting telehealth interactions with obstetrical patients, in addition to “providing adequate teaching and education for patients regarding kick counts to ensure fetal well-being.” It also is key to “properly document conversations with patients regarding bleeding, rupture of membranes, fetal movement, headache, visual changes, fevers, cough, nausea and vomiting, diarrhea, fatigue, muscle aches, etc.”
The residents’ schedule also has been modified to diminish their exposure. Within our new paradigm, we have scheduled video conferences to enable our program to maintain our commitment to academics.
It is imperative that we keep our patients safe, and it is critical to protect our staff members. Those who provide women’s health cannot be replaced by other nurses or physicians.
Mark P. Trolice, MD, is director of Fertility CARE: the IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He related in an email interview that, on March 17, 2020, the American Society for Reproductive Medicine (ASRM) released “Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic.” This document serves as guidance on fertility care during the current crisis. Specifically, the recommendations include the following:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations, in vitro fertilization including retrievals and frozen embryo transfers, and nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
As a member of ASRM for more than 2 decades and a participant of several of their committees, my practice immediately ceased treatment cycles to comply with this guidance.
Then on March 20, 2020, the Florida governor’s executive order 20-72 was released, stating, “All hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices in the State of Florida are prohibited from providing any medically unnecessary, nonurgent or nonemergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.”
As a result, my practice has been limited to telemedicine consultations. While the ASRM guidance and the gubernatorial executive order pose a significant financial hardship on my center and all applicable medical clinics in my state, resulting in expected layoffs, salary reductions, and requests for government stimulus loans, the greater good takes priority and we pray for all the victims of this devastating pandemic.
The governor’s current executive order is set to expire on May 9, 2020, unless it is extended.
ASRM released an update of their guidance on March 30, 2020, offering no change from their prior recommendations. The organization plans to reevaluate the guidance at 2-week intervals.
Sangeeta Sinha, MD, an ob.gyn. in private practice at Stone Springs Hospital Center, Dulles, Va. said in an interview, “COVID 19 has put fear in all aspects of our daily activities which we are attempting to cope with.”
She related several changes made to her office and hospital environments. “In our office, we are now wearing a mask at all times, gloves to examine every patient. We have staggered physicians in the office to take televisits and in-office patients. We are screening all new patients on the phone to determine if they are sick, have traveled to high-risk, hot spot areas of the country, or have had contact with someone who tested positive for COVID-19. We are only seeing our pregnant women and have also pushed out their return appointments to 4 weeks if possible. There are several staff who are not working due to fear or are in self quarantine so we have shortage of staff in the office. At the hospital as well we are wearing a mask at all times, using personal protective equipment for deliveries and C-sections.
“We have had several scares, including a new transfer of an 18-year-old pregnant patient at 30 weeks with cough and sore throat, who later reported that her roommate is very sick and he works with someone who has tested positive for COVID-19. Thankfully she is healthy and well. We learned several lessons from this one.”
Maintaining cancer care in the face of COVID-19
Medical oncologist Anne Chiang, MD, PhD, is scrambling to maintain cancer care in New Haven, Connecticut, while COVID-19 advances unrelentingly. As deputy chief medical officer of the Smilow Cancer Network, the largest cancer care delivery system in Connecticut and Rhode Island, she has no illusions about dodging what’s unfolding just 2 hours down the road in New York City.
“They’re trying their best to continue active cancer treatment but it’s getting harder,” she says of her colleagues in the thick of the pandemic. “We have to be prepared for it here.”
In anticipation of what’s coming, her team has just emptied the top three floors of the Smilow Cancer Hospital, moving 60 patients by ambulance and other medical transport to a different hospital nearby.
The move frees the Smilow Cancer hospital’s negative-pressure wards for the anticipated wave of COVID-19 patients. It will keep the virus sealed off from the rest of the hospital. But in other locations it’s harder to shield patients with cancer from the infection.
Around the state, Smilow Cancer Network’s affiliated hospitals are already treating a growing number of COVID-19 patients, especially at Greenwich Hospital, right on the border with New York state.
To protect patients with cancer, who are among the most vulnerable to the virus, oncologists are embracing telemedicine to allow most patients to stay home.
“We’re really concentrating on decreasing the risk to these patients, with a widespread massive-scale conversion to telehealth,” said Chiang. “This is something that, in the space of about a week, has transformed the care of our patients — it’s a really amazing transformation.”
If anything good comes out of the COVID-19 pandemic, it will be this global adoption of virtual healthcare.
Across the US border in Canada, the medical director of Toronto’s Princess Margaret Cancer Centre is directing a similar transformation.
“We have converted probably about 70% to 80% of our clinic visits to virtual visits,” says radiation oncologist Mary Gospodarowicz, MD.
“We have three priorities: number one, to keep our patients safe; number two, to keep our staff safe, because if staff are sick we won’t be treating anybody; and number three, to treat as many patients with cancer as possible.”
Gospodarowicz woke up last week to a local headline about a woman whose mastectomy had been canceled “because of the coronavirus.” The story exposed the many layers of the COVID-19 crisis. “A lot of hospitals have canceled elective surgeries,” she acknowledged. “For patients who have treatment or surgery deferred, we have a database and we’ll make sure we look after those patients eventually. We have a priority system, so low-risk prostate cancer, very low-risk breast cancer patients are waiting. All the urgent head and neck, breast, and other higher priority surgeries are still being done, but it just depends how it goes. The situation changes every day.”
It’s similar in Los Angeles, at the University of Southern California, says Elizabeth David, MD, a cardiothoracic surgeon with Keck Medicine.
“For thoracic, we just had a conference call with about 30 surgeons around the country going through really nitty-gritty specifics to help with our decision making about what could wait without detriment to the patient – hopefully – and what should be done now,” she told Medscape Medical News.
“There are some hospitals where they are not doing anything but life and death emergency operations, whereas we are still doing our emergent cancer operations in our institution, but we all know – and patients know – that could change from one day to the next. They may think they’re having surgery tomorrow but may get a call saying we can’t do it,” David said.
Many of David’s patients have non–small cell lung cancer, putting them at particular risk with a pulmonary infection like COVID-19. For now, she says delivery of postsurgical chemotherapy and radiotherapy has not been impacted in her area, but her videoconference discussions with patients are much longer – and harder – these days.
“I’ve been in practice a while now and I’ve had numerous conversations with patients this week that I never trained for, and I’ve never known anyone else who has. It’s really hard as a provider to know what to say,” she said.
In cardiothoracic surgery, David said guidance on clinical decision making is coming from the American College of Surgeons, Society of Thoracic Surgery, and American Association of Thoracic Surgeons. Yet, she says each patient is being assessed – and reassessed – individually.
“You have to balance the risk of delaying the intervention with supply issues, hospital exposure issues, the danger to the patient of being in the hospital environment – there’s just so many factors. We’re spending so much time talking through cases, and a lot of times we’re talking about cases we already talked about, but we’re just making sure that based on today’s numbers we should still be moving forward,” she commented.
In Connecticut, Chiang said treatment decisions are also mostly on a case-by-case basis at the moment, although more standardized guidelines are being worked out.
“Our disease teams have been really proactive in terms of offering alternative solutions to patients, creative ways to basically keep them out of the hospital and also reduce the immunosuppressive regimens that we give them,” she said.
Examples include offering endocrine therapy to patients who can’t get breast cancer surgery, or offering alternative drug regimens and dosing schedules. “At this point we haven’t needed to ration actual treatment – patients are continuing to get active therapy if that’s appropriate – it’s more about how can we protect them,” she said. “It’s a complex puzzle of moving pieces.”
In Toronto, Gospodarowicz says newly published medical and radiation oncology guidelines from France are the backbone of her hospital’s policy discussions about treating cancer and protecting patients from COVID-19.
While patients’ concerns are understandable, she says even in the current hot spots of infection, it’s encouraging to know that cancer patients are not being forgotten.
“I recently had email communication with a radiation oncologist in Brescia, one of the worst-affected areas in Italy, and he told me the radiotherapy department has been 60% to 70% capacity, so they still treat 70% these patients, just taking precautions and separating the COVID-positive and negative ones. When we read the stats it looks horrible, but life still goes on and people are still being treated,” she said.
Although telemedicine offers meaningful solutions to the COVID-19 crisis in North America, it may not be possible in other parts of the world.
Web consultations were only just approved in Brazil this week. “We are still discussing how to make it official and reimbursed,” says Rachel Riechelmann, MD, head of clinical oncology at AC Camargo Cancer Center in São Paulo.
To minimize infection risk for patients, Riechelmann says her hospital is doing the following: postponing surgeries in cases where there is good evidence of neoadjuvant treatment, such as total neoadjuvant therapy for rectal cancer; avoiding adjuvant chemo for stage 2 colon cancer; moving to hypofractionated radiotherapy if possible; adopting watchful waiting in grade 1 nonfunctional neuroendocrine tumors; and postponing follow-up visits.
“We do our best,” she wrote in an email. “We keep treating cancer if treatment cannot wait.”
Riechelmann’s center has just launched a trial of hydroxychloroquine and tocilizumab therapy in patients with cancer who have severe COVID-19 and acute respiratory distress syndrome (ARDS).
Meanwhile in New Haven, Chiang says for patients with cancer who are infected with COVID-19, her team is also prognosticating about the fair allocation of limited resources such as ventilators.
“If it ever gets to the point where somebody has to choose between a cancer patient and a noncancer patient in providing life support, it’s really important that people understand that cancer patients are doing very well nowadays and even with a diagnosis of cancer they can potentially live for many years, so that shouldn’t necessarily be a decision-point,” she emphasized.
This article first appeared on Medscape.com.
Medical oncologist Anne Chiang, MD, PhD, is scrambling to maintain cancer care in New Haven, Connecticut, while COVID-19 advances unrelentingly. As deputy chief medical officer of the Smilow Cancer Network, the largest cancer care delivery system in Connecticut and Rhode Island, she has no illusions about dodging what’s unfolding just 2 hours down the road in New York City.
“They’re trying their best to continue active cancer treatment but it’s getting harder,” she says of her colleagues in the thick of the pandemic. “We have to be prepared for it here.”
In anticipation of what’s coming, her team has just emptied the top three floors of the Smilow Cancer Hospital, moving 60 patients by ambulance and other medical transport to a different hospital nearby.
The move frees the Smilow Cancer hospital’s negative-pressure wards for the anticipated wave of COVID-19 patients. It will keep the virus sealed off from the rest of the hospital. But in other locations it’s harder to shield patients with cancer from the infection.
Around the state, Smilow Cancer Network’s affiliated hospitals are already treating a growing number of COVID-19 patients, especially at Greenwich Hospital, right on the border with New York state.
To protect patients with cancer, who are among the most vulnerable to the virus, oncologists are embracing telemedicine to allow most patients to stay home.
“We’re really concentrating on decreasing the risk to these patients, with a widespread massive-scale conversion to telehealth,” said Chiang. “This is something that, in the space of about a week, has transformed the care of our patients — it’s a really amazing transformation.”
If anything good comes out of the COVID-19 pandemic, it will be this global adoption of virtual healthcare.
Across the US border in Canada, the medical director of Toronto’s Princess Margaret Cancer Centre is directing a similar transformation.
“We have converted probably about 70% to 80% of our clinic visits to virtual visits,” says radiation oncologist Mary Gospodarowicz, MD.
“We have three priorities: number one, to keep our patients safe; number two, to keep our staff safe, because if staff are sick we won’t be treating anybody; and number three, to treat as many patients with cancer as possible.”
Gospodarowicz woke up last week to a local headline about a woman whose mastectomy had been canceled “because of the coronavirus.” The story exposed the many layers of the COVID-19 crisis. “A lot of hospitals have canceled elective surgeries,” she acknowledged. “For patients who have treatment or surgery deferred, we have a database and we’ll make sure we look after those patients eventually. We have a priority system, so low-risk prostate cancer, very low-risk breast cancer patients are waiting. All the urgent head and neck, breast, and other higher priority surgeries are still being done, but it just depends how it goes. The situation changes every day.”
It’s similar in Los Angeles, at the University of Southern California, says Elizabeth David, MD, a cardiothoracic surgeon with Keck Medicine.
“For thoracic, we just had a conference call with about 30 surgeons around the country going through really nitty-gritty specifics to help with our decision making about what could wait without detriment to the patient – hopefully – and what should be done now,” she told Medscape Medical News.
“There are some hospitals where they are not doing anything but life and death emergency operations, whereas we are still doing our emergent cancer operations in our institution, but we all know – and patients know – that could change from one day to the next. They may think they’re having surgery tomorrow but may get a call saying we can’t do it,” David said.
Many of David’s patients have non–small cell lung cancer, putting them at particular risk with a pulmonary infection like COVID-19. For now, she says delivery of postsurgical chemotherapy and radiotherapy has not been impacted in her area, but her videoconference discussions with patients are much longer – and harder – these days.
“I’ve been in practice a while now and I’ve had numerous conversations with patients this week that I never trained for, and I’ve never known anyone else who has. It’s really hard as a provider to know what to say,” she said.
In cardiothoracic surgery, David said guidance on clinical decision making is coming from the American College of Surgeons, Society of Thoracic Surgery, and American Association of Thoracic Surgeons. Yet, she says each patient is being assessed – and reassessed – individually.
“You have to balance the risk of delaying the intervention with supply issues, hospital exposure issues, the danger to the patient of being in the hospital environment – there’s just so many factors. We’re spending so much time talking through cases, and a lot of times we’re talking about cases we already talked about, but we’re just making sure that based on today’s numbers we should still be moving forward,” she commented.
In Connecticut, Chiang said treatment decisions are also mostly on a case-by-case basis at the moment, although more standardized guidelines are being worked out.
“Our disease teams have been really proactive in terms of offering alternative solutions to patients, creative ways to basically keep them out of the hospital and also reduce the immunosuppressive regimens that we give them,” she said.
Examples include offering endocrine therapy to patients who can’t get breast cancer surgery, or offering alternative drug regimens and dosing schedules. “At this point we haven’t needed to ration actual treatment – patients are continuing to get active therapy if that’s appropriate – it’s more about how can we protect them,” she said. “It’s a complex puzzle of moving pieces.”
In Toronto, Gospodarowicz says newly published medical and radiation oncology guidelines from France are the backbone of her hospital’s policy discussions about treating cancer and protecting patients from COVID-19.
While patients’ concerns are understandable, she says even in the current hot spots of infection, it’s encouraging to know that cancer patients are not being forgotten.
“I recently had email communication with a radiation oncologist in Brescia, one of the worst-affected areas in Italy, and he told me the radiotherapy department has been 60% to 70% capacity, so they still treat 70% these patients, just taking precautions and separating the COVID-positive and negative ones. When we read the stats it looks horrible, but life still goes on and people are still being treated,” she said.
Although telemedicine offers meaningful solutions to the COVID-19 crisis in North America, it may not be possible in other parts of the world.
Web consultations were only just approved in Brazil this week. “We are still discussing how to make it official and reimbursed,” says Rachel Riechelmann, MD, head of clinical oncology at AC Camargo Cancer Center in São Paulo.
To minimize infection risk for patients, Riechelmann says her hospital is doing the following: postponing surgeries in cases where there is good evidence of neoadjuvant treatment, such as total neoadjuvant therapy for rectal cancer; avoiding adjuvant chemo for stage 2 colon cancer; moving to hypofractionated radiotherapy if possible; adopting watchful waiting in grade 1 nonfunctional neuroendocrine tumors; and postponing follow-up visits.
“We do our best,” she wrote in an email. “We keep treating cancer if treatment cannot wait.”
Riechelmann’s center has just launched a trial of hydroxychloroquine and tocilizumab therapy in patients with cancer who have severe COVID-19 and acute respiratory distress syndrome (ARDS).
Meanwhile in New Haven, Chiang says for patients with cancer who are infected with COVID-19, her team is also prognosticating about the fair allocation of limited resources such as ventilators.
“If it ever gets to the point where somebody has to choose between a cancer patient and a noncancer patient in providing life support, it’s really important that people understand that cancer patients are doing very well nowadays and even with a diagnosis of cancer they can potentially live for many years, so that shouldn’t necessarily be a decision-point,” she emphasized.
This article first appeared on Medscape.com.
Medical oncologist Anne Chiang, MD, PhD, is scrambling to maintain cancer care in New Haven, Connecticut, while COVID-19 advances unrelentingly. As deputy chief medical officer of the Smilow Cancer Network, the largest cancer care delivery system in Connecticut and Rhode Island, she has no illusions about dodging what’s unfolding just 2 hours down the road in New York City.
“They’re trying their best to continue active cancer treatment but it’s getting harder,” she says of her colleagues in the thick of the pandemic. “We have to be prepared for it here.”
In anticipation of what’s coming, her team has just emptied the top three floors of the Smilow Cancer Hospital, moving 60 patients by ambulance and other medical transport to a different hospital nearby.
The move frees the Smilow Cancer hospital’s negative-pressure wards for the anticipated wave of COVID-19 patients. It will keep the virus sealed off from the rest of the hospital. But in other locations it’s harder to shield patients with cancer from the infection.
Around the state, Smilow Cancer Network’s affiliated hospitals are already treating a growing number of COVID-19 patients, especially at Greenwich Hospital, right on the border with New York state.
To protect patients with cancer, who are among the most vulnerable to the virus, oncologists are embracing telemedicine to allow most patients to stay home.
“We’re really concentrating on decreasing the risk to these patients, with a widespread massive-scale conversion to telehealth,” said Chiang. “This is something that, in the space of about a week, has transformed the care of our patients — it’s a really amazing transformation.”
If anything good comes out of the COVID-19 pandemic, it will be this global adoption of virtual healthcare.
Across the US border in Canada, the medical director of Toronto’s Princess Margaret Cancer Centre is directing a similar transformation.
“We have converted probably about 70% to 80% of our clinic visits to virtual visits,” says radiation oncologist Mary Gospodarowicz, MD.
“We have three priorities: number one, to keep our patients safe; number two, to keep our staff safe, because if staff are sick we won’t be treating anybody; and number three, to treat as many patients with cancer as possible.”
Gospodarowicz woke up last week to a local headline about a woman whose mastectomy had been canceled “because of the coronavirus.” The story exposed the many layers of the COVID-19 crisis. “A lot of hospitals have canceled elective surgeries,” she acknowledged. “For patients who have treatment or surgery deferred, we have a database and we’ll make sure we look after those patients eventually. We have a priority system, so low-risk prostate cancer, very low-risk breast cancer patients are waiting. All the urgent head and neck, breast, and other higher priority surgeries are still being done, but it just depends how it goes. The situation changes every day.”
It’s similar in Los Angeles, at the University of Southern California, says Elizabeth David, MD, a cardiothoracic surgeon with Keck Medicine.
“For thoracic, we just had a conference call with about 30 surgeons around the country going through really nitty-gritty specifics to help with our decision making about what could wait without detriment to the patient – hopefully – and what should be done now,” she told Medscape Medical News.
“There are some hospitals where they are not doing anything but life and death emergency operations, whereas we are still doing our emergent cancer operations in our institution, but we all know – and patients know – that could change from one day to the next. They may think they’re having surgery tomorrow but may get a call saying we can’t do it,” David said.
Many of David’s patients have non–small cell lung cancer, putting them at particular risk with a pulmonary infection like COVID-19. For now, she says delivery of postsurgical chemotherapy and radiotherapy has not been impacted in her area, but her videoconference discussions with patients are much longer – and harder – these days.
“I’ve been in practice a while now and I’ve had numerous conversations with patients this week that I never trained for, and I’ve never known anyone else who has. It’s really hard as a provider to know what to say,” she said.
In cardiothoracic surgery, David said guidance on clinical decision making is coming from the American College of Surgeons, Society of Thoracic Surgery, and American Association of Thoracic Surgeons. Yet, she says each patient is being assessed – and reassessed – individually.
“You have to balance the risk of delaying the intervention with supply issues, hospital exposure issues, the danger to the patient of being in the hospital environment – there’s just so many factors. We’re spending so much time talking through cases, and a lot of times we’re talking about cases we already talked about, but we’re just making sure that based on today’s numbers we should still be moving forward,” she commented.
In Connecticut, Chiang said treatment decisions are also mostly on a case-by-case basis at the moment, although more standardized guidelines are being worked out.
“Our disease teams have been really proactive in terms of offering alternative solutions to patients, creative ways to basically keep them out of the hospital and also reduce the immunosuppressive regimens that we give them,” she said.
Examples include offering endocrine therapy to patients who can’t get breast cancer surgery, or offering alternative drug regimens and dosing schedules. “At this point we haven’t needed to ration actual treatment – patients are continuing to get active therapy if that’s appropriate – it’s more about how can we protect them,” she said. “It’s a complex puzzle of moving pieces.”
In Toronto, Gospodarowicz says newly published medical and radiation oncology guidelines from France are the backbone of her hospital’s policy discussions about treating cancer and protecting patients from COVID-19.
While patients’ concerns are understandable, she says even in the current hot spots of infection, it’s encouraging to know that cancer patients are not being forgotten.
“I recently had email communication with a radiation oncologist in Brescia, one of the worst-affected areas in Italy, and he told me the radiotherapy department has been 60% to 70% capacity, so they still treat 70% these patients, just taking precautions and separating the COVID-positive and negative ones. When we read the stats it looks horrible, but life still goes on and people are still being treated,” she said.
Although telemedicine offers meaningful solutions to the COVID-19 crisis in North America, it may not be possible in other parts of the world.
Web consultations were only just approved in Brazil this week. “We are still discussing how to make it official and reimbursed,” says Rachel Riechelmann, MD, head of clinical oncology at AC Camargo Cancer Center in São Paulo.
To minimize infection risk for patients, Riechelmann says her hospital is doing the following: postponing surgeries in cases where there is good evidence of neoadjuvant treatment, such as total neoadjuvant therapy for rectal cancer; avoiding adjuvant chemo for stage 2 colon cancer; moving to hypofractionated radiotherapy if possible; adopting watchful waiting in grade 1 nonfunctional neuroendocrine tumors; and postponing follow-up visits.
“We do our best,” she wrote in an email. “We keep treating cancer if treatment cannot wait.”
Riechelmann’s center has just launched a trial of hydroxychloroquine and tocilizumab therapy in patients with cancer who have severe COVID-19 and acute respiratory distress syndrome (ARDS).
Meanwhile in New Haven, Chiang says for patients with cancer who are infected with COVID-19, her team is also prognosticating about the fair allocation of limited resources such as ventilators.
“If it ever gets to the point where somebody has to choose between a cancer patient and a noncancer patient in providing life support, it’s really important that people understand that cancer patients are doing very well nowadays and even with a diagnosis of cancer they can potentially live for many years, so that shouldn’t necessarily be a decision-point,” she emphasized.
This article first appeared on Medscape.com.
Close your practice temporarily ... or longer? Your decision during COVID-19
On March 19, 2020, Gene Dorio, MD, a geriatrician at a two-physician practice in Santa Clarita, Calif., called his staff together to decide whether to stay open in the face of the COVID-19 pandemic.
“We have seven people, and I did not want to put any of them at risk,” he said. “We don’t want to put patients at risk, either.” The practice had been operating successfully for many years.
The practice’s finances were being threatened by an abrupt and very significant decline in patient visits. “People have been canceling all the time,” he said. “They’re canceling out of fear. I saw 5 patients today, and I usually see 10-14 patients a day.”
After much discussion, “we decided to stay open,” he said. “That’s the most important thing we can do for our patients and this community.”
The staff will meet again in a few weeks to reassess their future. “This is a fluid situation,” Dr. Dorio said. If things do not improve financially, he does not rule out the possibility of having to close.
At medical practices across the country, the COVID-19 pandemic is threatening not only the lives of staff and patients but also the economic well-being of the practices themselves, and many are contemplating closing.
Many patients are not showing up for appointments. In addition, practices such as Dr. Dorio’s are advising older patients, who are at higher risk for mortality, not to come in, and they are canceling nonurgent visits. “Financially speaking, we are shooting ourselves in the foot,” Dr. Dorio said.
In addition, many hospitals are canceling elective procedures, which are an important source of income for a wide array of specialists, including gastroenterologists, orthopedic surgeons, and cardiologists. The thinking is that elective surgeries would take away important resources from COVID-19 patients and that elective-surgery patients would be put at risk of getting the virus.
The financial pain for practices came abruptly, says Steve Messinger, president of ECG Management Consultants in Washington, D.C. “The first half of March was somewhat normal for practices. In the second half of March, things escalated dramatically.”
In the past few weeks, “there has been a significant drop-off in the number of claims at health insurers,” Mr. Messinger said. “This loss of volume is reminiscent of what we saw during the Great Recession of 2008-2009.”
Hoping to stay open: Here’s what to try first
“Most doctors are hoping that this will be a temporary slowdown of their practices,” said A. Michael La Penna, a practice management advisor in Grand Rapids, Mich. “It’s human nature to assume that relative normalcy will return fairly soon, so just hang in there.”
Some physicians who are putting off closing may be hoping for some kind of financial rescue. On March 19, the American Medical Association and several other major physician groups asked Congressional leaders to take several actions, including providing “dedicated financial support to all physicians and their practices who are experiencing adverse economic impact on their practices from suspending elective visits and procedures.”
Practices that have decided to stay open are radically changing their operations.
Phil Boucher, MD, a pediatrician in Lincoln, Neb., is trying to keep his office open by strategically reorganizing the way he schedules patient visits and by seeing patients via telemedicine.
Practices have also been separating well patients from sick ones. Dr. Boucher has started conducting well visits, such as seeing babies who are brought in for vaccination, in the morning and sick visits in the afternoon.
Dr. Boucher also says he has postponed physical examinations for the next school year until the summer, so that children are not put at risk for exposure at the practice. “Usually we like to space out the physicals so we won’t get overwhelmed in the summer, but we have no choice.”
“The concern is that you don’t want a lot of patients in your office at any one time,” said Gregory Mertz, a physician practice manager in Virginia Beach.
A group of urologists in Fredericksburg, Va., who are Mr. Mertz’s clients, have limited their practice to urgent visits, and patients are screened before coming in for an appointment. “When patients call, someone talks to the patient over the phone and determine whether they should come in,” said Mr. Mertz.
Telemedicine can help doctors keep seeing patients
Many practices have started using telemedicine as a way to distance staff from patients and avoid transmission of the virus. Medicare payment restrictions have been temporarily waived so that telemedicine can be provided throughout the country and can originate in patients’ homes.
Medicare is also temporarily allowing telemedicine visits via patients’ smartphones if they have a video connection such as Skype or FaceTime, and they must ensure patient privacy. In addition, Medicare has allowed practices to waive collecting copays for telemedicine. Reportedly, some private insurers have followed suit.
Dr. Boucher just started using telemedicine. “A couple of weeks ago I would have told you I could only use telemedicine on 5% of my patients, but now I think it’s more like 30%-40%,” he said. “It works for patients on medications, children with rashes, and parents with some sick children. You can eyeball the patient and say, ‘Let’s wait and see how things go.’ ”
But Dr. Dorio finds it less useful. “It would be nice if all the patients knew how to use FaceTime or Skype, but many seniors do not,” he said.
The sad decision to cut staff
Now that practices are seeing fewer patients, they are forced to consider reducing staff. “Staff is largest expense other than real estate, so practices have to closely manage their staffing,” Mr. Mertz said. “On a weekly or even daily basis, the practice has to match staffing to patient demand.”
Some staff may seek time off to take care of children who are now released from school. Others may be quarantined if they are suspected of having been infected by the virus. And some staff may be repurposed for other work, such as phone triaging or wiping down surfaces.
“The practice may decide: ‘I don’t need you this month,’ ” Mr. Mertz said. “Then the staff member can get unemployment as long are they have exhausted the paid leave they had coming to them.”
Many doctors want to keep all their staff on board. “In that case, the practice could impose shorter work weeks for existing staff,” said Elizabeth Woodcock, a practice management consultant in Atlanta. “Many people might have to work on a temporary basis.”
Trying to make the closure temporary
Most practices are still receiving income from past billing, since the reduction in volume started recently, so they have a few weeks or longer to decide what to do next, Mr. La Penna says. He suggests that they use the time to plan for the future.
“You need to have a plan for what you will do if this situation continues. When the risk is unknown, as is the case with this pandemic, people tend to plan for the best and fear the worst,” he said. “But it makes more sense to plan for the worst and hope for the best.”
Mr. La Penna advises practices to thoroughly analyze their operations. That analysis should include defining ongoing expenses and deciding how to handle them, developing a time-off policy for employees, and holding off on new hires and purchases.
He advises being transparent about your plans. “Be very public and forthcoming about the measures the practice is taking to avoid a complete shutdown, but keep your options open. Communicate with referral sources at every stage so that they stay in the loop.”
Procedure-oriented practices should follow the rules on elective procedures, Mr. La Penna says. “Conform to your association’s national guidelines on performing elective surgery or procedures,” he said. “If you do not follow those guidelines, you may be liable if your patient develops the virus.”
The AMA has compiled a list of actions to help keep your practice open. Here are some highlights:
- Determine the minimal cash flow you’d need. Develop a contingency plan based on estimates of minimum cash flow to stay afloat.
- Track your losses and expenses. You’ll need a record to make a claim through your business insurance policy. The policy may or may not cover COVID-19-related liabilities. Contact your broker to find out.
- Keep track of impending defaults. Review existing loan documents and financial covenants to determine whether a slowdown of business or collections could trigger a default.
- Negotiate with lenders. Contact vendors, landlords, and creditors to discuss reasonable accommodations for cash-flow disruptions. Consider asking them for forbearance, forgiveness, or a standstill, and agree to establish a process for keeping them informed over time.
- Get a low-interest loan. The Small Business Administration has begun to administer low-interest loans funded by numerous states, counties, and municipalities.
- Keep up with policy changes. State, local, and federal laws and regulations that affect practices are changing rapidly. Assign a staff member to follow these changes in the news and on government websites.
Closing your office may be the only option
Still, many practices may have to close – hopefully, most closures will be temporary, but some could end up being permanent.
“If you want to close your practice temporarily, you can get a short-term loan, try to defer payments, and wait for circumstances to improve,” Mr. La Penna said. “You’ll need to spend a few weeks winding down your practice, and you’ll want to make sure employees and patients don’t drift off.”
However, many practices may have no choice but to go permanently out of business, Mr. La Penna says.
The problem for many practices is that they typically distribute income among partners and have not retained earnings to cushion them from a financial disaster, Mr. Messinger says. “Some higher-performing practices have a cash surplus of perhaps 2 months, if that. They could take out loans and use lines of credit, but some of them already have outstanding loans for equipment or accounts receivables.”
Older physicians who were planning retirement may decide to retire early. “Anecdotally, there are a number of doctors who are ready to call it quits,” said Louis Weinstein, MD, chair of the AMA Senior Physicians Section. “This virus is the last straw. Their thought is: ‘Get out before you get sick.’ One colleague was going to close in a year from now but decided to speed it up.”
To find the specific steps needed to shut down a practice, check with physician organizations, practice managers, and health care attorneys. For example, the American Association of Family Physicians provides a Closing Your Practice Checklist, which specifies what you should do 60-90 days and 30-60 days before closing.
Employed physicians’ concerns
While private practices wrestle with staying open, there are potentially some grim or unhappy prospects for employed physicians too.
Many hospitals are in difficult economic straits and may not be able to afford paying doctors who aren’t working. But some experts are more optimistic.
“In many cases, I think the hospital will pay their salary even though their volume is down,” Mr. Mertz said. And Mr. Messinger said: “Hospitals may put employed physicians with low volume on an ‘RVU [relative value unit] holiday’ for a while. They don’t want to have a destabilized workforce.”
“When employed surgeons can’t do elective procedures, suddenly they can’t meet their productivity targets to get bonuses,” Mr. La Penna said. Productivity measures are typically based on RVUs. Mr. La Penna says he is working with a 100-physician practice where RVU payments that had been projected for the remainder of the year are expected to fall by half.
Some employed physicians have a guaranteed base pay that is not affected by RVUs, but in many cases, pay is based purely on productivity, says Andrew Hajde, assistant director of association content at the Medical Group Management Association. “If their volume goes down, they are in danger of not getting paid,” he said.
A version of this article originally appeared on Medscape.com.
On March 19, 2020, Gene Dorio, MD, a geriatrician at a two-physician practice in Santa Clarita, Calif., called his staff together to decide whether to stay open in the face of the COVID-19 pandemic.
“We have seven people, and I did not want to put any of them at risk,” he said. “We don’t want to put patients at risk, either.” The practice had been operating successfully for many years.
The practice’s finances were being threatened by an abrupt and very significant decline in patient visits. “People have been canceling all the time,” he said. “They’re canceling out of fear. I saw 5 patients today, and I usually see 10-14 patients a day.”
After much discussion, “we decided to stay open,” he said. “That’s the most important thing we can do for our patients and this community.”
The staff will meet again in a few weeks to reassess their future. “This is a fluid situation,” Dr. Dorio said. If things do not improve financially, he does not rule out the possibility of having to close.
At medical practices across the country, the COVID-19 pandemic is threatening not only the lives of staff and patients but also the economic well-being of the practices themselves, and many are contemplating closing.
Many patients are not showing up for appointments. In addition, practices such as Dr. Dorio’s are advising older patients, who are at higher risk for mortality, not to come in, and they are canceling nonurgent visits. “Financially speaking, we are shooting ourselves in the foot,” Dr. Dorio said.
In addition, many hospitals are canceling elective procedures, which are an important source of income for a wide array of specialists, including gastroenterologists, orthopedic surgeons, and cardiologists. The thinking is that elective surgeries would take away important resources from COVID-19 patients and that elective-surgery patients would be put at risk of getting the virus.
The financial pain for practices came abruptly, says Steve Messinger, president of ECG Management Consultants in Washington, D.C. “The first half of March was somewhat normal for practices. In the second half of March, things escalated dramatically.”
In the past few weeks, “there has been a significant drop-off in the number of claims at health insurers,” Mr. Messinger said. “This loss of volume is reminiscent of what we saw during the Great Recession of 2008-2009.”
Hoping to stay open: Here’s what to try first
“Most doctors are hoping that this will be a temporary slowdown of their practices,” said A. Michael La Penna, a practice management advisor in Grand Rapids, Mich. “It’s human nature to assume that relative normalcy will return fairly soon, so just hang in there.”
Some physicians who are putting off closing may be hoping for some kind of financial rescue. On March 19, the American Medical Association and several other major physician groups asked Congressional leaders to take several actions, including providing “dedicated financial support to all physicians and their practices who are experiencing adverse economic impact on their practices from suspending elective visits and procedures.”
Practices that have decided to stay open are radically changing their operations.
Phil Boucher, MD, a pediatrician in Lincoln, Neb., is trying to keep his office open by strategically reorganizing the way he schedules patient visits and by seeing patients via telemedicine.
Practices have also been separating well patients from sick ones. Dr. Boucher has started conducting well visits, such as seeing babies who are brought in for vaccination, in the morning and sick visits in the afternoon.
Dr. Boucher also says he has postponed physical examinations for the next school year until the summer, so that children are not put at risk for exposure at the practice. “Usually we like to space out the physicals so we won’t get overwhelmed in the summer, but we have no choice.”
“The concern is that you don’t want a lot of patients in your office at any one time,” said Gregory Mertz, a physician practice manager in Virginia Beach.
A group of urologists in Fredericksburg, Va., who are Mr. Mertz’s clients, have limited their practice to urgent visits, and patients are screened before coming in for an appointment. “When patients call, someone talks to the patient over the phone and determine whether they should come in,” said Mr. Mertz.
Telemedicine can help doctors keep seeing patients
Many practices have started using telemedicine as a way to distance staff from patients and avoid transmission of the virus. Medicare payment restrictions have been temporarily waived so that telemedicine can be provided throughout the country and can originate in patients’ homes.
Medicare is also temporarily allowing telemedicine visits via patients’ smartphones if they have a video connection such as Skype or FaceTime, and they must ensure patient privacy. In addition, Medicare has allowed practices to waive collecting copays for telemedicine. Reportedly, some private insurers have followed suit.
Dr. Boucher just started using telemedicine. “A couple of weeks ago I would have told you I could only use telemedicine on 5% of my patients, but now I think it’s more like 30%-40%,” he said. “It works for patients on medications, children with rashes, and parents with some sick children. You can eyeball the patient and say, ‘Let’s wait and see how things go.’ ”
But Dr. Dorio finds it less useful. “It would be nice if all the patients knew how to use FaceTime or Skype, but many seniors do not,” he said.
The sad decision to cut staff
Now that practices are seeing fewer patients, they are forced to consider reducing staff. “Staff is largest expense other than real estate, so practices have to closely manage their staffing,” Mr. Mertz said. “On a weekly or even daily basis, the practice has to match staffing to patient demand.”
Some staff may seek time off to take care of children who are now released from school. Others may be quarantined if they are suspected of having been infected by the virus. And some staff may be repurposed for other work, such as phone triaging or wiping down surfaces.
“The practice may decide: ‘I don’t need you this month,’ ” Mr. Mertz said. “Then the staff member can get unemployment as long are they have exhausted the paid leave they had coming to them.”
Many doctors want to keep all their staff on board. “In that case, the practice could impose shorter work weeks for existing staff,” said Elizabeth Woodcock, a practice management consultant in Atlanta. “Many people might have to work on a temporary basis.”
Trying to make the closure temporary
Most practices are still receiving income from past billing, since the reduction in volume started recently, so they have a few weeks or longer to decide what to do next, Mr. La Penna says. He suggests that they use the time to plan for the future.
“You need to have a plan for what you will do if this situation continues. When the risk is unknown, as is the case with this pandemic, people tend to plan for the best and fear the worst,” he said. “But it makes more sense to plan for the worst and hope for the best.”
Mr. La Penna advises practices to thoroughly analyze their operations. That analysis should include defining ongoing expenses and deciding how to handle them, developing a time-off policy for employees, and holding off on new hires and purchases.
He advises being transparent about your plans. “Be very public and forthcoming about the measures the practice is taking to avoid a complete shutdown, but keep your options open. Communicate with referral sources at every stage so that they stay in the loop.”
Procedure-oriented practices should follow the rules on elective procedures, Mr. La Penna says. “Conform to your association’s national guidelines on performing elective surgery or procedures,” he said. “If you do not follow those guidelines, you may be liable if your patient develops the virus.”
The AMA has compiled a list of actions to help keep your practice open. Here are some highlights:
- Determine the minimal cash flow you’d need. Develop a contingency plan based on estimates of minimum cash flow to stay afloat.
- Track your losses and expenses. You’ll need a record to make a claim through your business insurance policy. The policy may or may not cover COVID-19-related liabilities. Contact your broker to find out.
- Keep track of impending defaults. Review existing loan documents and financial covenants to determine whether a slowdown of business or collections could trigger a default.
- Negotiate with lenders. Contact vendors, landlords, and creditors to discuss reasonable accommodations for cash-flow disruptions. Consider asking them for forbearance, forgiveness, or a standstill, and agree to establish a process for keeping them informed over time.
- Get a low-interest loan. The Small Business Administration has begun to administer low-interest loans funded by numerous states, counties, and municipalities.
- Keep up with policy changes. State, local, and federal laws and regulations that affect practices are changing rapidly. Assign a staff member to follow these changes in the news and on government websites.
Closing your office may be the only option
Still, many practices may have to close – hopefully, most closures will be temporary, but some could end up being permanent.
“If you want to close your practice temporarily, you can get a short-term loan, try to defer payments, and wait for circumstances to improve,” Mr. La Penna said. “You’ll need to spend a few weeks winding down your practice, and you’ll want to make sure employees and patients don’t drift off.”
However, many practices may have no choice but to go permanently out of business, Mr. La Penna says.
The problem for many practices is that they typically distribute income among partners and have not retained earnings to cushion them from a financial disaster, Mr. Messinger says. “Some higher-performing practices have a cash surplus of perhaps 2 months, if that. They could take out loans and use lines of credit, but some of them already have outstanding loans for equipment or accounts receivables.”
Older physicians who were planning retirement may decide to retire early. “Anecdotally, there are a number of doctors who are ready to call it quits,” said Louis Weinstein, MD, chair of the AMA Senior Physicians Section. “This virus is the last straw. Their thought is: ‘Get out before you get sick.’ One colleague was going to close in a year from now but decided to speed it up.”
To find the specific steps needed to shut down a practice, check with physician organizations, practice managers, and health care attorneys. For example, the American Association of Family Physicians provides a Closing Your Practice Checklist, which specifies what you should do 60-90 days and 30-60 days before closing.
Employed physicians’ concerns
While private practices wrestle with staying open, there are potentially some grim or unhappy prospects for employed physicians too.
Many hospitals are in difficult economic straits and may not be able to afford paying doctors who aren’t working. But some experts are more optimistic.
“In many cases, I think the hospital will pay their salary even though their volume is down,” Mr. Mertz said. And Mr. Messinger said: “Hospitals may put employed physicians with low volume on an ‘RVU [relative value unit] holiday’ for a while. They don’t want to have a destabilized workforce.”
“When employed surgeons can’t do elective procedures, suddenly they can’t meet their productivity targets to get bonuses,” Mr. La Penna said. Productivity measures are typically based on RVUs. Mr. La Penna says he is working with a 100-physician practice where RVU payments that had been projected for the remainder of the year are expected to fall by half.
Some employed physicians have a guaranteed base pay that is not affected by RVUs, but in many cases, pay is based purely on productivity, says Andrew Hajde, assistant director of association content at the Medical Group Management Association. “If their volume goes down, they are in danger of not getting paid,” he said.
A version of this article originally appeared on Medscape.com.
On March 19, 2020, Gene Dorio, MD, a geriatrician at a two-physician practice in Santa Clarita, Calif., called his staff together to decide whether to stay open in the face of the COVID-19 pandemic.
“We have seven people, and I did not want to put any of them at risk,” he said. “We don’t want to put patients at risk, either.” The practice had been operating successfully for many years.
The practice’s finances were being threatened by an abrupt and very significant decline in patient visits. “People have been canceling all the time,” he said. “They’re canceling out of fear. I saw 5 patients today, and I usually see 10-14 patients a day.”
After much discussion, “we decided to stay open,” he said. “That’s the most important thing we can do for our patients and this community.”
The staff will meet again in a few weeks to reassess their future. “This is a fluid situation,” Dr. Dorio said. If things do not improve financially, he does not rule out the possibility of having to close.
At medical practices across the country, the COVID-19 pandemic is threatening not only the lives of staff and patients but also the economic well-being of the practices themselves, and many are contemplating closing.
Many patients are not showing up for appointments. In addition, practices such as Dr. Dorio’s are advising older patients, who are at higher risk for mortality, not to come in, and they are canceling nonurgent visits. “Financially speaking, we are shooting ourselves in the foot,” Dr. Dorio said.
In addition, many hospitals are canceling elective procedures, which are an important source of income for a wide array of specialists, including gastroenterologists, orthopedic surgeons, and cardiologists. The thinking is that elective surgeries would take away important resources from COVID-19 patients and that elective-surgery patients would be put at risk of getting the virus.
The financial pain for practices came abruptly, says Steve Messinger, president of ECG Management Consultants in Washington, D.C. “The first half of March was somewhat normal for practices. In the second half of March, things escalated dramatically.”
In the past few weeks, “there has been a significant drop-off in the number of claims at health insurers,” Mr. Messinger said. “This loss of volume is reminiscent of what we saw during the Great Recession of 2008-2009.”
Hoping to stay open: Here’s what to try first
“Most doctors are hoping that this will be a temporary slowdown of their practices,” said A. Michael La Penna, a practice management advisor in Grand Rapids, Mich. “It’s human nature to assume that relative normalcy will return fairly soon, so just hang in there.”
Some physicians who are putting off closing may be hoping for some kind of financial rescue. On March 19, the American Medical Association and several other major physician groups asked Congressional leaders to take several actions, including providing “dedicated financial support to all physicians and their practices who are experiencing adverse economic impact on their practices from suspending elective visits and procedures.”
Practices that have decided to stay open are radically changing their operations.
Phil Boucher, MD, a pediatrician in Lincoln, Neb., is trying to keep his office open by strategically reorganizing the way he schedules patient visits and by seeing patients via telemedicine.
Practices have also been separating well patients from sick ones. Dr. Boucher has started conducting well visits, such as seeing babies who are brought in for vaccination, in the morning and sick visits in the afternoon.
Dr. Boucher also says he has postponed physical examinations for the next school year until the summer, so that children are not put at risk for exposure at the practice. “Usually we like to space out the physicals so we won’t get overwhelmed in the summer, but we have no choice.”
“The concern is that you don’t want a lot of patients in your office at any one time,” said Gregory Mertz, a physician practice manager in Virginia Beach.
A group of urologists in Fredericksburg, Va., who are Mr. Mertz’s clients, have limited their practice to urgent visits, and patients are screened before coming in for an appointment. “When patients call, someone talks to the patient over the phone and determine whether they should come in,” said Mr. Mertz.
Telemedicine can help doctors keep seeing patients
Many practices have started using telemedicine as a way to distance staff from patients and avoid transmission of the virus. Medicare payment restrictions have been temporarily waived so that telemedicine can be provided throughout the country and can originate in patients’ homes.
Medicare is also temporarily allowing telemedicine visits via patients’ smartphones if they have a video connection such as Skype or FaceTime, and they must ensure patient privacy. In addition, Medicare has allowed practices to waive collecting copays for telemedicine. Reportedly, some private insurers have followed suit.
Dr. Boucher just started using telemedicine. “A couple of weeks ago I would have told you I could only use telemedicine on 5% of my patients, but now I think it’s more like 30%-40%,” he said. “It works for patients on medications, children with rashes, and parents with some sick children. You can eyeball the patient and say, ‘Let’s wait and see how things go.’ ”
But Dr. Dorio finds it less useful. “It would be nice if all the patients knew how to use FaceTime or Skype, but many seniors do not,” he said.
The sad decision to cut staff
Now that practices are seeing fewer patients, they are forced to consider reducing staff. “Staff is largest expense other than real estate, so practices have to closely manage their staffing,” Mr. Mertz said. “On a weekly or even daily basis, the practice has to match staffing to patient demand.”
Some staff may seek time off to take care of children who are now released from school. Others may be quarantined if they are suspected of having been infected by the virus. And some staff may be repurposed for other work, such as phone triaging or wiping down surfaces.
“The practice may decide: ‘I don’t need you this month,’ ” Mr. Mertz said. “Then the staff member can get unemployment as long are they have exhausted the paid leave they had coming to them.”
Many doctors want to keep all their staff on board. “In that case, the practice could impose shorter work weeks for existing staff,” said Elizabeth Woodcock, a practice management consultant in Atlanta. “Many people might have to work on a temporary basis.”
Trying to make the closure temporary
Most practices are still receiving income from past billing, since the reduction in volume started recently, so they have a few weeks or longer to decide what to do next, Mr. La Penna says. He suggests that they use the time to plan for the future.
“You need to have a plan for what you will do if this situation continues. When the risk is unknown, as is the case with this pandemic, people tend to plan for the best and fear the worst,” he said. “But it makes more sense to plan for the worst and hope for the best.”
Mr. La Penna advises practices to thoroughly analyze their operations. That analysis should include defining ongoing expenses and deciding how to handle them, developing a time-off policy for employees, and holding off on new hires and purchases.
He advises being transparent about your plans. “Be very public and forthcoming about the measures the practice is taking to avoid a complete shutdown, but keep your options open. Communicate with referral sources at every stage so that they stay in the loop.”
Procedure-oriented practices should follow the rules on elective procedures, Mr. La Penna says. “Conform to your association’s national guidelines on performing elective surgery or procedures,” he said. “If you do not follow those guidelines, you may be liable if your patient develops the virus.”
The AMA has compiled a list of actions to help keep your practice open. Here are some highlights:
- Determine the minimal cash flow you’d need. Develop a contingency plan based on estimates of minimum cash flow to stay afloat.
- Track your losses and expenses. You’ll need a record to make a claim through your business insurance policy. The policy may or may not cover COVID-19-related liabilities. Contact your broker to find out.
- Keep track of impending defaults. Review existing loan documents and financial covenants to determine whether a slowdown of business or collections could trigger a default.
- Negotiate with lenders. Contact vendors, landlords, and creditors to discuss reasonable accommodations for cash-flow disruptions. Consider asking them for forbearance, forgiveness, or a standstill, and agree to establish a process for keeping them informed over time.
- Get a low-interest loan. The Small Business Administration has begun to administer low-interest loans funded by numerous states, counties, and municipalities.
- Keep up with policy changes. State, local, and federal laws and regulations that affect practices are changing rapidly. Assign a staff member to follow these changes in the news and on government websites.
Closing your office may be the only option
Still, many practices may have to close – hopefully, most closures will be temporary, but some could end up being permanent.
“If you want to close your practice temporarily, you can get a short-term loan, try to defer payments, and wait for circumstances to improve,” Mr. La Penna said. “You’ll need to spend a few weeks winding down your practice, and you’ll want to make sure employees and patients don’t drift off.”
However, many practices may have no choice but to go permanently out of business, Mr. La Penna says.
The problem for many practices is that they typically distribute income among partners and have not retained earnings to cushion them from a financial disaster, Mr. Messinger says. “Some higher-performing practices have a cash surplus of perhaps 2 months, if that. They could take out loans and use lines of credit, but some of them already have outstanding loans for equipment or accounts receivables.”
Older physicians who were planning retirement may decide to retire early. “Anecdotally, there are a number of doctors who are ready to call it quits,” said Louis Weinstein, MD, chair of the AMA Senior Physicians Section. “This virus is the last straw. Their thought is: ‘Get out before you get sick.’ One colleague was going to close in a year from now but decided to speed it up.”
To find the specific steps needed to shut down a practice, check with physician organizations, practice managers, and health care attorneys. For example, the American Association of Family Physicians provides a Closing Your Practice Checklist, which specifies what you should do 60-90 days and 30-60 days before closing.
Employed physicians’ concerns
While private practices wrestle with staying open, there are potentially some grim or unhappy prospects for employed physicians too.
Many hospitals are in difficult economic straits and may not be able to afford paying doctors who aren’t working. But some experts are more optimistic.
“In many cases, I think the hospital will pay their salary even though their volume is down,” Mr. Mertz said. And Mr. Messinger said: “Hospitals may put employed physicians with low volume on an ‘RVU [relative value unit] holiday’ for a while. They don’t want to have a destabilized workforce.”
“When employed surgeons can’t do elective procedures, suddenly they can’t meet their productivity targets to get bonuses,” Mr. La Penna said. Productivity measures are typically based on RVUs. Mr. La Penna says he is working with a 100-physician practice where RVU payments that had been projected for the remainder of the year are expected to fall by half.
Some employed physicians have a guaranteed base pay that is not affected by RVUs, but in many cases, pay is based purely on productivity, says Andrew Hajde, assistant director of association content at the Medical Group Management Association. “If their volume goes down, they are in danger of not getting paid,” he said.
A version of this article originally appeared on Medscape.com.