Journal of Clinical Outcomes Management

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.

Anxiety and distress related to caring for a cancer patient who lives far away may be alleviated through an intervention that includes video-based coaching sessions with a nurse practitioner or social worker, a randomized study suggests.

AJ_Watt/E+

About 20% of long-distance caregivers had a significant reduction in anxiety and 25% had a significant reduction in distress when they received video coaching sessions, attended oncologist visits via video, and had access to a website specifically designed for their needs.

Adding the caregiver to oncologist office visits made the patients feel better supported and didn’t add a significant amount of time to the encounter, said Sara L. Douglas, PhD, RN, of Case Western Reserve University, Cleveland.

Taken together, these results suggest that fairly simple technologies can be leveraged to help caregivers cope with psychological strains related to supporting a patient who doesn’t live nearby, Dr. Douglas said.

Distance caregivers, defined as those who live an hour or more away from the patient, can experience high rates of distress and anxiety because they lack first-hand information or may have uncertainty about the patient’s current condition, according to Dr. Douglas and colleagues.

“Caregivers’ high rates of anxiety and distress have been found to have a negative impact not only upon their own health but upon their ability to provide high quality care to the patient,” Dr. Douglas said.

With this in mind, she and her colleagues conducted a 4-month study of distance caregivers. Dr. Douglas presented results from the study at the American Society of Clinical Oncology virtual scientific program during a press briefing in advance of the meeting. This year, ASCO’s annual meeting is split into two parts. The virtual scientific program will be presented online on May 29-31, and the virtual education program will be available Aug. 8-10.
 

Study details

The study enrolled 441 distance caregivers of cancer patients, and Dr. Douglas presented results in 311 of those caregivers. (Data in the presentation differ from the abstract.) The caregivers were, on average, 47 years of age. Most were female (72%), white (67%), the child of the patient (63%), currently employed (81%), and new to the distance caregiver role (89%).

The caregivers were randomized to one of three study arms.

One arm received the full intervention, which consisted of four video-coaching sessions with an advanced practice nurse or social worker, videoconference office visits with the physician and patient, and access to a website with information for cancer distance caregivers. A second arm received no video coaching but had access to the website and participated in video visits with the physician and patient. The third arm, which only received access to the website, served as the study’s control group.
 

Results

Dr. Douglas said that the full intervention had the biggest impact on caregivers’ distress and anxiety.

Among distance caregivers who received the full intervention, 19.2% had a significant reduction in anxiety (P = .03), as measured in online surveys before and after the intervention using the PROMIS Anxiety instrument. Furthermore, 24.8% of these caregivers had a significant reduction in distress (P = .02) from preintervention to post intervention, as measured by the National Comprehensive Cancer Network Distress Thermometer. Overall, distress and anxiety scores decreased in this arm.

Distance caregivers who only had physician-patient video visits and website access had a “moderate” reduction in distress and anxiety, Dr. Douglas said. Among these caregivers, 17.3% had an improvement in anxiety from baseline, and 19.8% had an improvement in distress. Overall, distress scores decreased, but anxiety scores increased slightly in this arm.

In the control arm, 13.1% of caregivers had an improvement in anxiety from baseline, and 18% had an improvement in distress. Overall, both anxiety and distress scores increased in this arm.

“While the full intervention yielded the best results for distance caregivers, we recognize that not all health care systems have the resources to provide individualized coaching sessions to distance caregivers,” Dr. Douglas said. “Therefore, it is worth noting that videoconference office visits alone are found to be of some benefit in improving distress and anxiety in this group of cancer caregivers.”

The study results suggest videoconferencing interventions can improve the emotional well-being of remote caregivers who provide “critical support” for cancer patients, said ASCO President Howard A. “Skip” Burris III, MD.

“As COVID-19 forces separation from loved ones and increases anxiety for people with cancer and their caregivers, providing emotional support virtually is more important than ever,” Dr. Burris said in a news release highlighting the study.

This study was funded by the National Institutes of Health and Case Comprehensive Cancer Center. Dr. Douglas reported having no disclosures. Other researchers involved in the study disclosed relationships with BridgeBio Pharma, Cardinal Health, Apexigen, Roche/Genentech, Seattle Genetics, Tesaro, Array BioPharma, Abbvie, Bristol-Myers Squibb, and Celgene. A full list of Dr. Burris’s financial disclosures is available on the ASCO website.

SOURCE: Douglas SL et al. ASCO 2020, Abstract 12123.

Anxiety and distress related to caring for a cancer patient who lives far away may be alleviated through an intervention that includes video-based coaching sessions with a nurse practitioner or social worker, a randomized study suggests.

AJ_Watt/E+

About 20% of long-distance caregivers had a significant reduction in anxiety and 25% had a significant reduction in distress when they received video coaching sessions, attended oncologist visits via video, and had access to a website specifically designed for their needs.

Adding the caregiver to oncologist office visits made the patients feel better supported and didn’t add a significant amount of time to the encounter, said Sara L. Douglas, PhD, RN, of Case Western Reserve University, Cleveland.

Taken together, these results suggest that fairly simple technologies can be leveraged to help caregivers cope with psychological strains related to supporting a patient who doesn’t live nearby, Dr. Douglas said.

Distance caregivers, defined as those who live an hour or more away from the patient, can experience high rates of distress and anxiety because they lack first-hand information or may have uncertainty about the patient’s current condition, according to Dr. Douglas and colleagues.

“Caregivers’ high rates of anxiety and distress have been found to have a negative impact not only upon their own health but upon their ability to provide high quality care to the patient,” Dr. Douglas said.

With this in mind, she and her colleagues conducted a 4-month study of distance caregivers. Dr. Douglas presented results from the study at the American Society of Clinical Oncology virtual scientific program during a press briefing in advance of the meeting. This year, ASCO’s annual meeting is split into two parts. The virtual scientific program will be presented online on May 29-31, and the virtual education program will be available Aug. 8-10.
 

Study details

The study enrolled 441 distance caregivers of cancer patients, and Dr. Douglas presented results in 311 of those caregivers. (Data in the presentation differ from the abstract.) The caregivers were, on average, 47 years of age. Most were female (72%), white (67%), the child of the patient (63%), currently employed (81%), and new to the distance caregiver role (89%).

The caregivers were randomized to one of three study arms.

One arm received the full intervention, which consisted of four video-coaching sessions with an advanced practice nurse or social worker, videoconference office visits with the physician and patient, and access to a website with information for cancer distance caregivers. A second arm received no video coaching but had access to the website and participated in video visits with the physician and patient. The third arm, which only received access to the website, served as the study’s control group.
 

Results

Dr. Douglas said that the full intervention had the biggest impact on caregivers’ distress and anxiety.

Among distance caregivers who received the full intervention, 19.2% had a significant reduction in anxiety (P = .03), as measured in online surveys before and after the intervention using the PROMIS Anxiety instrument. Furthermore, 24.8% of these caregivers had a significant reduction in distress (P = .02) from preintervention to post intervention, as measured by the National Comprehensive Cancer Network Distress Thermometer. Overall, distress and anxiety scores decreased in this arm.

Distance caregivers who only had physician-patient video visits and website access had a “moderate” reduction in distress and anxiety, Dr. Douglas said. Among these caregivers, 17.3% had an improvement in anxiety from baseline, and 19.8% had an improvement in distress. Overall, distress scores decreased, but anxiety scores increased slightly in this arm.

In the control arm, 13.1% of caregivers had an improvement in anxiety from baseline, and 18% had an improvement in distress. Overall, both anxiety and distress scores increased in this arm.

“While the full intervention yielded the best results for distance caregivers, we recognize that not all health care systems have the resources to provide individualized coaching sessions to distance caregivers,” Dr. Douglas said. “Therefore, it is worth noting that videoconference office visits alone are found to be of some benefit in improving distress and anxiety in this group of cancer caregivers.”

The study results suggest videoconferencing interventions can improve the emotional well-being of remote caregivers who provide “critical support” for cancer patients, said ASCO President Howard A. “Skip” Burris III, MD.

“As COVID-19 forces separation from loved ones and increases anxiety for people with cancer and their caregivers, providing emotional support virtually is more important than ever,” Dr. Burris said in a news release highlighting the study.

This study was funded by the National Institutes of Health and Case Comprehensive Cancer Center. Dr. Douglas reported having no disclosures. Other researchers involved in the study disclosed relationships with BridgeBio Pharma, Cardinal Health, Apexigen, Roche/Genentech, Seattle Genetics, Tesaro, Array BioPharma, Abbvie, Bristol-Myers Squibb, and Celgene. A full list of Dr. Burris’s financial disclosures is available on the ASCO website.

SOURCE: Douglas SL et al. ASCO 2020, Abstract 12123.

Anxiety and distress related to caring for a cancer patient who lives far away may be alleviated through an intervention that includes video-based coaching sessions with a nurse practitioner or social worker, a randomized study suggests.

AJ_Watt/E+

About 20% of long-distance caregivers had a significant reduction in anxiety and 25% had a significant reduction in distress when they received video coaching sessions, attended oncologist visits via video, and had access to a website specifically designed for their needs.

Adding the caregiver to oncologist office visits made the patients feel better supported and didn’t add a significant amount of time to the encounter, said Sara L. Douglas, PhD, RN, of Case Western Reserve University, Cleveland.

Taken together, these results suggest that fairly simple technologies can be leveraged to help caregivers cope with psychological strains related to supporting a patient who doesn’t live nearby, Dr. Douglas said.

Distance caregivers, defined as those who live an hour or more away from the patient, can experience high rates of distress and anxiety because they lack first-hand information or may have uncertainty about the patient’s current condition, according to Dr. Douglas and colleagues.

“Caregivers’ high rates of anxiety and distress have been found to have a negative impact not only upon their own health but upon their ability to provide high quality care to the patient,” Dr. Douglas said.

With this in mind, she and her colleagues conducted a 4-month study of distance caregivers. Dr. Douglas presented results from the study at the American Society of Clinical Oncology virtual scientific program during a press briefing in advance of the meeting. This year, ASCO’s annual meeting is split into two parts. The virtual scientific program will be presented online on May 29-31, and the virtual education program will be available Aug. 8-10.
 

Study details

The study enrolled 441 distance caregivers of cancer patients, and Dr. Douglas presented results in 311 of those caregivers. (Data in the presentation differ from the abstract.) The caregivers were, on average, 47 years of age. Most were female (72%), white (67%), the child of the patient (63%), currently employed (81%), and new to the distance caregiver role (89%).

The caregivers were randomized to one of three study arms.

One arm received the full intervention, which consisted of four video-coaching sessions with an advanced practice nurse or social worker, videoconference office visits with the physician and patient, and access to a website with information for cancer distance caregivers. A second arm received no video coaching but had access to the website and participated in video visits with the physician and patient. The third arm, which only received access to the website, served as the study’s control group.
 

Results

Dr. Douglas said that the full intervention had the biggest impact on caregivers’ distress and anxiety.

Among distance caregivers who received the full intervention, 19.2% had a significant reduction in anxiety (P = .03), as measured in online surveys before and after the intervention using the PROMIS Anxiety instrument. Furthermore, 24.8% of these caregivers had a significant reduction in distress (P = .02) from preintervention to post intervention, as measured by the National Comprehensive Cancer Network Distress Thermometer. Overall, distress and anxiety scores decreased in this arm.

Distance caregivers who only had physician-patient video visits and website access had a “moderate” reduction in distress and anxiety, Dr. Douglas said. Among these caregivers, 17.3% had an improvement in anxiety from baseline, and 19.8% had an improvement in distress. Overall, distress scores decreased, but anxiety scores increased slightly in this arm.

In the control arm, 13.1% of caregivers had an improvement in anxiety from baseline, and 18% had an improvement in distress. Overall, both anxiety and distress scores increased in this arm.

“While the full intervention yielded the best results for distance caregivers, we recognize that not all health care systems have the resources to provide individualized coaching sessions to distance caregivers,” Dr. Douglas said. “Therefore, it is worth noting that videoconference office visits alone are found to be of some benefit in improving distress and anxiety in this group of cancer caregivers.”

The study results suggest videoconferencing interventions can improve the emotional well-being of remote caregivers who provide “critical support” for cancer patients, said ASCO President Howard A. “Skip” Burris III, MD.

“As COVID-19 forces separation from loved ones and increases anxiety for people with cancer and their caregivers, providing emotional support virtually is more important than ever,” Dr. Burris said in a news release highlighting the study.

This study was funded by the National Institutes of Health and Case Comprehensive Cancer Center. Dr. Douglas reported having no disclosures. Other researchers involved in the study disclosed relationships with BridgeBio Pharma, Cardinal Health, Apexigen, Roche/Genentech, Seattle Genetics, Tesaro, Array BioPharma, Abbvie, Bristol-Myers Squibb, and Celgene. A full list of Dr. Burris’s financial disclosures is available on the ASCO website.

SOURCE: Douglas SL et al. ASCO 2020, Abstract 12123.

A 21-year-old young adult presented to the ED with a 1-week history of high fever, vomiting, diarrhea, and abdominal pain. His mother was SARS-CoV-2 positive by polymerase chain reaction approximately 3 weeks prior; his PCR was negative for SARS-CoV-2.

EyeMark/thinkstockphotos.com

Following admission, he became hypotensive and tachycardic with evidence of myocarditis. His chest x-ray was normal and his O₂ saturation was 100% on room air. His clinical presentation was initially suggestive of toxic shock syndrome without a rash, but despite aggressive fluid resuscitation and broad-spectrum antibiotics, he continued to clinically deteriorate with persistent high fever and increasing cardiac stress. Echocardiography revealed biventricular dysfunction. His laboratory abnormalities included rising inflammatory markers and troponin I and B-type natriuretic peptide (BNP). A repeat PCR for SARS-CoV-2 was negative on day 2 of illness. He was diagnosed as likely having macrophage-activation syndrome (MAS) despite the atypical features (myocarditis), and he received Anakinra with no apparent response. He also was given intravenous immunoglobulin (IVIg) for his myocarditis and subsequently high-dose steroids. He became afebrile, his blood pressure stabilized, his inflammatory markers declined, and over several days he returned to normal. His COVID-19 antibody test IgG was positive on day 4 of illness.

This case challenged us for several reasons. First, the PCR from his nasopharynx was negative on two occasions, which raises the issue of how sensitive and accurate these PCR tests are for SARS-CoV-2 or are patients with COVID-19–associated hyperinflammatory syndrome still PCR positive? Second, although we have seen many adult cases with a cytokine storm picture similar to this patient, nearly all of the prior cases had chest x-ray abnormalities and hypoxia. Third, the severity of the myocardial dysfunction and rising troponin and BNP also was unusual in our experience with COVID-19 infection. Lastly, the use of antibody detection to SARS-CoV-2 enabled us to confirm recent COIVD-19 disease and see his illness as part of the likely spectrum of clinical syndromes seen with this virus.

The Lancet reported eight children, aged 4-14 years, with a hyperinflammatory shock-like syndrome in early May.¹ The cases had features similar to atypical Kawasaki disease, KD shock syndrome, and toxic shock syndrome. Each case had high fever for multiple days; diarrhea and abdominal pain was present in even children; elevated ferritin, C-reactive protein, d-dimer, increased troponins, and ventricular dysfunction also was present in seven. Most patients had no pulmonary involvement, and most tested negative for SARS-CoV-2 despite four of the eight having direct contact with a COVID-positive family member. All received IVIg and antibiotics; six received aspirin. Seven of the eight made a full recovery; one child died from a large cerebrovascular infarct.

Also in early May, the New York Times described a “mysterious” hyperinflammatory syndrome in children thought to be linked to COVID-19. A total of 76 suspected cases in children had been reported in New York state, three of whom died. The syndrome has been given the name pediatric multisystem inflammatory syndrome. The syndrome can resemble KD shock syndrome with rash; fever; conjunctivitis; hypotension; and redness in the lips, tongue and mucous membranes . It also can resemble toxic shock syndrome with abdominal pain, vomiting, and diarrhea. However, the degree of cardiac inflammation and dysfunction is substantial in many cases and usually beyond that seen in KD or toxic shock.

The syndrome is not limited to the United States. The Royal College of Pediatrics and Child Health has created a case definition:²

• A child presenting with persistent fever, inflammation (elevated C-reactive protein, neutrophilia, and lymphopenia) and evidence of single or multiorgan dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurologic) with additional features.
• Exclusion of any other microbial causes such as bacterial sepsis or staphylococcal or streptococcal shock syndromes, infections known to be associated with myocarditis (such as enterovirus).
• SARS-CoV-2 testing may or may not be positive.

As with our young adult, treatment is supportive, nonspecific, and aimed at quieting the inflammatory response. The current thinking is the syndrome is seen as antibody to SARS-CoV-2 appears and frequently the nasopharyngeal PCR is negative. It is hypothesized that the syndrome occurs in genetically predisposed hosts and potentially is a late-onset inflammatory process or potentially an antibody-triggered inflammatory process. The negative PCR from nasopharyngeal specimens reflects that the onset is later in the course of disease; whether fecal samples would be COVID positive is unknown. As with our case, antibody testing for IgG against SARS-CoV-2 is appropriate to confirm COVID-19 disease and may be positive as early as day 7.

The approach needs to be team oriented and include cardiology, rheumatology, infectious diseases, and intensive care specialists working collaboratively. Such cases should be considered COVID positive despite negative PCR tests, and full personal protective equipment should be used as we do not as yet know if live virus could be found in stool. We initiated treatment with Anakinra (an interleukin-1 type-1 receptor inhibitor) as part of our treatment protocol for MAS; we did not appreciate a response. He then received IVIg and high-dose steroids, and he recovered over several days with improved cardiac function and stable blood pressure.

Clearly, we have a steep learning curve about the multisystem hyperinflammatory syndrome emerging in association with SARS-CoV-2 infection. What is the pathogenesis? Is SARS-CoV-2 causative or just an associated finding? Who are the at-risk children, adolescents, and adults? Is there a genetic predisposition? What therapies work best? The eight cases described in London all received IVIg, as did our case, and all but one improved and survived. In adults we have seen substantial inflammation with elevated C-reactive protein (often as high as 300), ferritin, lactate dehydrogenase, triglycerides, fibrinogen, and d-dimers, but nearly all have extensive pulmonary disease, hypoxia, and are SARS-CoV-2 positive by PCR. Influenza is also associated with a cytokine storm syndrome in adolescents and young adults.³ The mechanisms influenza virus uses to initiate a cytokine storm and strategies for immunomodulatory treatment may provide insights into COVID-19–associated multisystem hyperinflammatory syndrome.

Dr. Pelton is professor of pediatrics and epidemiology at Boston University and public health and senior attending physician in pediatric infectious diseases at Boston Medical Center. Dr. Camelo is a senior fellow in pediatric infectious diseases at Boston Medical Center. They have no relevant financial disclosures. Email them at [email protected].

References

1. Riphagen S et al. Lancet. 2020 May 6. doi: 10.1016/S0140-6736(20)31094-1.

2. Royal College of Paediatrics and Child Health Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19.

3. Liu Q et al.Cell Mol Immunol. 2016 Jan;13(1):3-10.

A 21-year-old young adult presented to the ED with a 1-week history of high fever, vomiting, diarrhea, and abdominal pain. His mother was SARS-CoV-2 positive by polymerase chain reaction approximately 3 weeks prior; his PCR was negative for SARS-CoV-2.

EyeMark/thinkstockphotos.com

Following admission, he became hypotensive and tachycardic with evidence of myocarditis. His chest x-ray was normal and his O₂ saturation was 100% on room air. His clinical presentation was initially suggestive of toxic shock syndrome without a rash, but despite aggressive fluid resuscitation and broad-spectrum antibiotics, he continued to clinically deteriorate with persistent high fever and increasing cardiac stress. Echocardiography revealed biventricular dysfunction. His laboratory abnormalities included rising inflammatory markers and troponin I and B-type natriuretic peptide (BNP). A repeat PCR for SARS-CoV-2 was negative on day 2 of illness. He was diagnosed as likely having macrophage-activation syndrome (MAS) despite the atypical features (myocarditis), and he received Anakinra with no apparent response. He also was given intravenous immunoglobulin (IVIg) for his myocarditis and subsequently high-dose steroids. He became afebrile, his blood pressure stabilized, his inflammatory markers declined, and over several days he returned to normal. His COVID-19 antibody test IgG was positive on day 4 of illness.

This case challenged us for several reasons. First, the PCR from his nasopharynx was negative on two occasions, which raises the issue of how sensitive and accurate these PCR tests are for SARS-CoV-2 or are patients with COVID-19–associated hyperinflammatory syndrome still PCR positive? Second, although we have seen many adult cases with a cytokine storm picture similar to this patient, nearly all of the prior cases had chest x-ray abnormalities and hypoxia. Third, the severity of the myocardial dysfunction and rising troponin and BNP also was unusual in our experience with COVID-19 infection. Lastly, the use of antibody detection to SARS-CoV-2 enabled us to confirm recent COIVD-19 disease and see his illness as part of the likely spectrum of clinical syndromes seen with this virus.

The Lancet reported eight children, aged 4-14 years, with a hyperinflammatory shock-like syndrome in early May.¹ The cases had features similar to atypical Kawasaki disease, KD shock syndrome, and toxic shock syndrome. Each case had high fever for multiple days; diarrhea and abdominal pain was present in even children; elevated ferritin, C-reactive protein, d-dimer, increased troponins, and ventricular dysfunction also was present in seven. Most patients had no pulmonary involvement, and most tested negative for SARS-CoV-2 despite four of the eight having direct contact with a COVID-positive family member. All received IVIg and antibiotics; six received aspirin. Seven of the eight made a full recovery; one child died from a large cerebrovascular infarct.

Also in early May, the New York Times described a “mysterious” hyperinflammatory syndrome in children thought to be linked to COVID-19. A total of 76 suspected cases in children had been reported in New York state, three of whom died. The syndrome has been given the name pediatric multisystem inflammatory syndrome. The syndrome can resemble KD shock syndrome with rash; fever; conjunctivitis; hypotension; and redness in the lips, tongue and mucous membranes . It also can resemble toxic shock syndrome with abdominal pain, vomiting, and diarrhea. However, the degree of cardiac inflammation and dysfunction is substantial in many cases and usually beyond that seen in KD or toxic shock.

The syndrome is not limited to the United States. The Royal College of Pediatrics and Child Health has created a case definition:²

• A child presenting with persistent fever, inflammation (elevated C-reactive protein, neutrophilia, and lymphopenia) and evidence of single or multiorgan dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurologic) with additional features.
• Exclusion of any other microbial causes such as bacterial sepsis or staphylococcal or streptococcal shock syndromes, infections known to be associated with myocarditis (such as enterovirus).
• SARS-CoV-2 testing may or may not be positive.

As with our young adult, treatment is supportive, nonspecific, and aimed at quieting the inflammatory response. The current thinking is the syndrome is seen as antibody to SARS-CoV-2 appears and frequently the nasopharyngeal PCR is negative. It is hypothesized that the syndrome occurs in genetically predisposed hosts and potentially is a late-onset inflammatory process or potentially an antibody-triggered inflammatory process. The negative PCR from nasopharyngeal specimens reflects that the onset is later in the course of disease; whether fecal samples would be COVID positive is unknown. As with our case, antibody testing for IgG against SARS-CoV-2 is appropriate to confirm COVID-19 disease and may be positive as early as day 7.

The approach needs to be team oriented and include cardiology, rheumatology, infectious diseases, and intensive care specialists working collaboratively. Such cases should be considered COVID positive despite negative PCR tests, and full personal protective equipment should be used as we do not as yet know if live virus could be found in stool. We initiated treatment with Anakinra (an interleukin-1 type-1 receptor inhibitor) as part of our treatment protocol for MAS; we did not appreciate a response. He then received IVIg and high-dose steroids, and he recovered over several days with improved cardiac function and stable blood pressure.

Clearly, we have a steep learning curve about the multisystem hyperinflammatory syndrome emerging in association with SARS-CoV-2 infection. What is the pathogenesis? Is SARS-CoV-2 causative or just an associated finding? Who are the at-risk children, adolescents, and adults? Is there a genetic predisposition? What therapies work best? The eight cases described in London all received IVIg, as did our case, and all but one improved and survived. In adults we have seen substantial inflammation with elevated C-reactive protein (often as high as 300), ferritin, lactate dehydrogenase, triglycerides, fibrinogen, and d-dimers, but nearly all have extensive pulmonary disease, hypoxia, and are SARS-CoV-2 positive by PCR. Influenza is also associated with a cytokine storm syndrome in adolescents and young adults.³ The mechanisms influenza virus uses to initiate a cytokine storm and strategies for immunomodulatory treatment may provide insights into COVID-19–associated multisystem hyperinflammatory syndrome.

Dr. Pelton is professor of pediatrics and epidemiology at Boston University and public health and senior attending physician in pediatric infectious diseases at Boston Medical Center. Dr. Camelo is a senior fellow in pediatric infectious diseases at Boston Medical Center. They have no relevant financial disclosures. Email them at [email protected].

References

1. Riphagen S et al. Lancet. 2020 May 6. doi: 10.1016/S0140-6736(20)31094-1.

2. Royal College of Paediatrics and Child Health Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19.

3. Liu Q et al.Cell Mol Immunol. 2016 Jan;13(1):3-10.

A 21-year-old young adult presented to the ED with a 1-week history of high fever, vomiting, diarrhea, and abdominal pain. His mother was SARS-CoV-2 positive by polymerase chain reaction approximately 3 weeks prior; his PCR was negative for SARS-CoV-2.

EyeMark/thinkstockphotos.com

Following admission, he became hypotensive and tachycardic with evidence of myocarditis. His chest x-ray was normal and his O₂ saturation was 100% on room air. His clinical presentation was initially suggestive of toxic shock syndrome without a rash, but despite aggressive fluid resuscitation and broad-spectrum antibiotics, he continued to clinically deteriorate with persistent high fever and increasing cardiac stress. Echocardiography revealed biventricular dysfunction. His laboratory abnormalities included rising inflammatory markers and troponin I and B-type natriuretic peptide (BNP). A repeat PCR for SARS-CoV-2 was negative on day 2 of illness. He was diagnosed as likely having macrophage-activation syndrome (MAS) despite the atypical features (myocarditis), and he received Anakinra with no apparent response. He also was given intravenous immunoglobulin (IVIg) for his myocarditis and subsequently high-dose steroids. He became afebrile, his blood pressure stabilized, his inflammatory markers declined, and over several days he returned to normal. His COVID-19 antibody test IgG was positive on day 4 of illness.

This case challenged us for several reasons. First, the PCR from his nasopharynx was negative on two occasions, which raises the issue of how sensitive and accurate these PCR tests are for SARS-CoV-2 or are patients with COVID-19–associated hyperinflammatory syndrome still PCR positive? Second, although we have seen many adult cases with a cytokine storm picture similar to this patient, nearly all of the prior cases had chest x-ray abnormalities and hypoxia. Third, the severity of the myocardial dysfunction and rising troponin and BNP also was unusual in our experience with COVID-19 infection. Lastly, the use of antibody detection to SARS-CoV-2 enabled us to confirm recent COIVD-19 disease and see his illness as part of the likely spectrum of clinical syndromes seen with this virus.

The Lancet reported eight children, aged 4-14 years, with a hyperinflammatory shock-like syndrome in early May.¹ The cases had features similar to atypical Kawasaki disease, KD shock syndrome, and toxic shock syndrome. Each case had high fever for multiple days; diarrhea and abdominal pain was present in even children; elevated ferritin, C-reactive protein, d-dimer, increased troponins, and ventricular dysfunction also was present in seven. Most patients had no pulmonary involvement, and most tested negative for SARS-CoV-2 despite four of the eight having direct contact with a COVID-positive family member. All received IVIg and antibiotics; six received aspirin. Seven of the eight made a full recovery; one child died from a large cerebrovascular infarct.

Also in early May, the New York Times described a “mysterious” hyperinflammatory syndrome in children thought to be linked to COVID-19. A total of 76 suspected cases in children had been reported in New York state, three of whom died. The syndrome has been given the name pediatric multisystem inflammatory syndrome. The syndrome can resemble KD shock syndrome with rash; fever; conjunctivitis; hypotension; and redness in the lips, tongue and mucous membranes . It also can resemble toxic shock syndrome with abdominal pain, vomiting, and diarrhea. However, the degree of cardiac inflammation and dysfunction is substantial in many cases and usually beyond that seen in KD or toxic shock.

The syndrome is not limited to the United States. The Royal College of Pediatrics and Child Health has created a case definition:²

• A child presenting with persistent fever, inflammation (elevated C-reactive protein, neutrophilia, and lymphopenia) and evidence of single or multiorgan dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurologic) with additional features.
• Exclusion of any other microbial causes such as bacterial sepsis or staphylococcal or streptococcal shock syndromes, infections known to be associated with myocarditis (such as enterovirus).
• SARS-CoV-2 testing may or may not be positive.

As with our young adult, treatment is supportive, nonspecific, and aimed at quieting the inflammatory response. The current thinking is the syndrome is seen as antibody to SARS-CoV-2 appears and frequently the nasopharyngeal PCR is negative. It is hypothesized that the syndrome occurs in genetically predisposed hosts and potentially is a late-onset inflammatory process or potentially an antibody-triggered inflammatory process. The negative PCR from nasopharyngeal specimens reflects that the onset is later in the course of disease; whether fecal samples would be COVID positive is unknown. As with our case, antibody testing for IgG against SARS-CoV-2 is appropriate to confirm COVID-19 disease and may be positive as early as day 7.

The approach needs to be team oriented and include cardiology, rheumatology, infectious diseases, and intensive care specialists working collaboratively. Such cases should be considered COVID positive despite negative PCR tests, and full personal protective equipment should be used as we do not as yet know if live virus could be found in stool. We initiated treatment with Anakinra (an interleukin-1 type-1 receptor inhibitor) as part of our treatment protocol for MAS; we did not appreciate a response. He then received IVIg and high-dose steroids, and he recovered over several days with improved cardiac function and stable blood pressure.

Clearly, we have a steep learning curve about the multisystem hyperinflammatory syndrome emerging in association with SARS-CoV-2 infection. What is the pathogenesis? Is SARS-CoV-2 causative or just an associated finding? Who are the at-risk children, adolescents, and adults? Is there a genetic predisposition? What therapies work best? The eight cases described in London all received IVIg, as did our case, and all but one improved and survived. In adults we have seen substantial inflammation with elevated C-reactive protein (often as high as 300), ferritin, lactate dehydrogenase, triglycerides, fibrinogen, and d-dimers, but nearly all have extensive pulmonary disease, hypoxia, and are SARS-CoV-2 positive by PCR. Influenza is also associated with a cytokine storm syndrome in adolescents and young adults.³ The mechanisms influenza virus uses to initiate a cytokine storm and strategies for immunomodulatory treatment may provide insights into COVID-19–associated multisystem hyperinflammatory syndrome.

Dr. Pelton is professor of pediatrics and epidemiology at Boston University and public health and senior attending physician in pediatric infectious diseases at Boston Medical Center. Dr. Camelo is a senior fellow in pediatric infectious diseases at Boston Medical Center. They have no relevant financial disclosures. Email them at [email protected].

References

1. Riphagen S et al. Lancet. 2020 May 6. doi: 10.1016/S0140-6736(20)31094-1.

2. Royal College of Paediatrics and Child Health Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19.

3. Liu Q et al.Cell Mol Immunol. 2016 Jan;13(1):3-10.

The social distancing and sheltering in place mandated because of the COVID-19 pandemic are keeping parents and kids out of their doctors’ offices, and that has prompted a steep decline in recommended routine vaccinations for U.S. children, according to Centers for Disease Control and Prevention researchers.

Pediatric vaccinations dropped sharply after the national emergency was declared on March 13, suggesting that some children may be at increased risk for other serious infectious diseases, such as measles.

The researchers compared weekly orders for federally funded vaccines from Jan. 6 to April 19, 2020, with those during the same period in 2019.

They noted that, by the end of the study period, there was a cumulative COVID-19–related decline of 2.5 million doses in orders for routine noninfluenza pediatric childhood vaccines recommended by the Advisory Committee on Immunization Practices, as well as a cumulative decline in orders of 250,000 doses of measles vaccines.

Although the overall decrease in vaccinations during the study period was larger, according to CDC spokesperson Richard Quartarone, the above figures represent declines clearly associated with the pandemic.

The weekly number of measles vaccines ordered for children aged 24 months or older fell dramatically to about 500 during the week beginning March 16, 2020, and fell further to approximately 250 during the week beginning March 23. It stayed at that level until the week beginning April 13. By comparison, more than 2,500 were ordered during the week starting March 2, before the emergency was declared.

The decline was notably less for children younger than 2 years. For those children, orders dropped to about 750 during the week starting March 23 and climbed slightly for 3 weeks. By comparison, during the week of March 2, about 2,000 vaccines were ordered.

The findings, which were published in the CDC’s Morbidity and Mortality Weekly Report, stem from an analysis of ordering data from the federal Vaccines for Children (VFC) Program, as well as from vaccine administration data from the CDC’s Vaccine Tracking System and the collaborative Vaccine Safety Datalink (VSD).

The VFC provides federally purchased vaccines at no cost to about half of persons aged 18 years or younger. The VSD collaborates on vaccine coverage with the CDC’s Immunization Safety Office and eight large health care organizations across the country. Vaccination coverage is the usual metric for assessing vaccine usage; providers’ orders and the number of doses administered are two proxy measures, the authors explained.

“The substantial reduction in VFC-funded pediatric vaccine ordering after the COVID-19 emergency declaration is consistent with changes in vaccine administration among children in the VSD population receiving care through eight large U.S. health care organizations,” wrote Jeanne M. Santoli, MD, and colleagues, of the immunization services division at the National Center for Immunization and Respiratory Diseases. “The smaller decline in measles-containing vaccine administration among children aged ≤24 months suggests that system-level strategies to prioritize well child care and immunization for this age group are being implemented.”

Dr. Santoli, who is an Atlanta-based pediatrician, and associates stressed the importance of maintaining regular vaccinations during the pandemic. “The identified declines in routine pediatric vaccine ordering and doses administered might indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” they wrote. “Parental concerns about potentially exposing their children to COVID-19 during well child visits might contribute to the declines observed.” Parents should therefore be reminded of the necessity of protecting their children against vaccine-preventable diseases.

In 2019, a Gallup survey reported that overall support for vaccination continued to decline in the United States.

The researchers predicted that, as social distancing relaxes, unvaccinated children will be more susceptible to other serious diseases. “In response, continued coordinated efforts between health care providers and public health officials at the local, state, and federal levels will be necessary to achieve rapid catch-up vaccination,” they concluded.

The authors disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The social distancing and sheltering in place mandated because of the COVID-19 pandemic are keeping parents and kids out of their doctors’ offices, and that has prompted a steep decline in recommended routine vaccinations for U.S. children, according to Centers for Disease Control and Prevention researchers.

Pediatric vaccinations dropped sharply after the national emergency was declared on March 13, suggesting that some children may be at increased risk for other serious infectious diseases, such as measles.

The researchers compared weekly orders for federally funded vaccines from Jan. 6 to April 19, 2020, with those during the same period in 2019.

They noted that, by the end of the study period, there was a cumulative COVID-19–related decline of 2.5 million doses in orders for routine noninfluenza pediatric childhood vaccines recommended by the Advisory Committee on Immunization Practices, as well as a cumulative decline in orders of 250,000 doses of measles vaccines.

Although the overall decrease in vaccinations during the study period was larger, according to CDC spokesperson Richard Quartarone, the above figures represent declines clearly associated with the pandemic.

The weekly number of measles vaccines ordered for children aged 24 months or older fell dramatically to about 500 during the week beginning March 16, 2020, and fell further to approximately 250 during the week beginning March 23. It stayed at that level until the week beginning April 13. By comparison, more than 2,500 were ordered during the week starting March 2, before the emergency was declared.

The decline was notably less for children younger than 2 years. For those children, orders dropped to about 750 during the week starting March 23 and climbed slightly for 3 weeks. By comparison, during the week of March 2, about 2,000 vaccines were ordered.

The findings, which were published in the CDC’s Morbidity and Mortality Weekly Report, stem from an analysis of ordering data from the federal Vaccines for Children (VFC) Program, as well as from vaccine administration data from the CDC’s Vaccine Tracking System and the collaborative Vaccine Safety Datalink (VSD).

The VFC provides federally purchased vaccines at no cost to about half of persons aged 18 years or younger. The VSD collaborates on vaccine coverage with the CDC’s Immunization Safety Office and eight large health care organizations across the country. Vaccination coverage is the usual metric for assessing vaccine usage; providers’ orders and the number of doses administered are two proxy measures, the authors explained.

“The substantial reduction in VFC-funded pediatric vaccine ordering after the COVID-19 emergency declaration is consistent with changes in vaccine administration among children in the VSD population receiving care through eight large U.S. health care organizations,” wrote Jeanne M. Santoli, MD, and colleagues, of the immunization services division at the National Center for Immunization and Respiratory Diseases. “The smaller decline in measles-containing vaccine administration among children aged ≤24 months suggests that system-level strategies to prioritize well child care and immunization for this age group are being implemented.”

Dr. Santoli, who is an Atlanta-based pediatrician, and associates stressed the importance of maintaining regular vaccinations during the pandemic. “The identified declines in routine pediatric vaccine ordering and doses administered might indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” they wrote. “Parental concerns about potentially exposing their children to COVID-19 during well child visits might contribute to the declines observed.” Parents should therefore be reminded of the necessity of protecting their children against vaccine-preventable diseases.

In 2019, a Gallup survey reported that overall support for vaccination continued to decline in the United States.

The researchers predicted that, as social distancing relaxes, unvaccinated children will be more susceptible to other serious diseases. “In response, continued coordinated efforts between health care providers and public health officials at the local, state, and federal levels will be necessary to achieve rapid catch-up vaccination,” they concluded.

The authors disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The social distancing and sheltering in place mandated because of the COVID-19 pandemic are keeping parents and kids out of their doctors’ offices, and that has prompted a steep decline in recommended routine vaccinations for U.S. children, according to Centers for Disease Control and Prevention researchers.

Pediatric vaccinations dropped sharply after the national emergency was declared on March 13, suggesting that some children may be at increased risk for other serious infectious diseases, such as measles.

The researchers compared weekly orders for federally funded vaccines from Jan. 6 to April 19, 2020, with those during the same period in 2019.

They noted that, by the end of the study period, there was a cumulative COVID-19–related decline of 2.5 million doses in orders for routine noninfluenza pediatric childhood vaccines recommended by the Advisory Committee on Immunization Practices, as well as a cumulative decline in orders of 250,000 doses of measles vaccines.

Although the overall decrease in vaccinations during the study period was larger, according to CDC spokesperson Richard Quartarone, the above figures represent declines clearly associated with the pandemic.

The weekly number of measles vaccines ordered for children aged 24 months or older fell dramatically to about 500 during the week beginning March 16, 2020, and fell further to approximately 250 during the week beginning March 23. It stayed at that level until the week beginning April 13. By comparison, more than 2,500 were ordered during the week starting March 2, before the emergency was declared.

The decline was notably less for children younger than 2 years. For those children, orders dropped to about 750 during the week starting March 23 and climbed slightly for 3 weeks. By comparison, during the week of March 2, about 2,000 vaccines were ordered.

The findings, which were published in the CDC’s Morbidity and Mortality Weekly Report, stem from an analysis of ordering data from the federal Vaccines for Children (VFC) Program, as well as from vaccine administration data from the CDC’s Vaccine Tracking System and the collaborative Vaccine Safety Datalink (VSD).

The VFC provides federally purchased vaccines at no cost to about half of persons aged 18 years or younger. The VSD collaborates on vaccine coverage with the CDC’s Immunization Safety Office and eight large health care organizations across the country. Vaccination coverage is the usual metric for assessing vaccine usage; providers’ orders and the number of doses administered are two proxy measures, the authors explained.

“The substantial reduction in VFC-funded pediatric vaccine ordering after the COVID-19 emergency declaration is consistent with changes in vaccine administration among children in the VSD population receiving care through eight large U.S. health care organizations,” wrote Jeanne M. Santoli, MD, and colleagues, of the immunization services division at the National Center for Immunization and Respiratory Diseases. “The smaller decline in measles-containing vaccine administration among children aged ≤24 months suggests that system-level strategies to prioritize well child care and immunization for this age group are being implemented.”

Dr. Santoli, who is an Atlanta-based pediatrician, and associates stressed the importance of maintaining regular vaccinations during the pandemic. “The identified declines in routine pediatric vaccine ordering and doses administered might indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” they wrote. “Parental concerns about potentially exposing their children to COVID-19 during well child visits might contribute to the declines observed.” Parents should therefore be reminded of the necessity of protecting their children against vaccine-preventable diseases.

In 2019, a Gallup survey reported that overall support for vaccination continued to decline in the United States.

The researchers predicted that, as social distancing relaxes, unvaccinated children will be more susceptible to other serious diseases. “In response, continued coordinated efforts between health care providers and public health officials at the local, state, and federal levels will be necessary to achieve rapid catch-up vaccination,” they concluded.

The authors disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

In recent weeks, physicians have gotten the first hints of how much income they could lose in the COVID-19 crisis.

“At a combined system and hospital board meeting yesterday, there was a financial presentation,” said a cardiologist in Minnesota, who declined to be named. “We have ‘salary support’ through May 16, which means we will be receiving base pay at our 2019 level. After May 16, I think it’s fairly certain salaries will be decreased.”

A general internist in the same area added: “The system has decided to pay physicians and other employees for 8 weeks, until May 15, and they are borrowing about $150 million to do this. We don’t know what will happen after May 15, but we are supposed to have an update in early May.”

Physician income is of huge interest, and many aspects of it are discussed in Medscape’s Physician Compensation Report 2020, just released.

The worst may be yet to come

Of all the categories of physicians, “I am worried about private practices the most,” said Travis Singleton, senior vice president at Merritt Hawkins, a physician search firm. “They don’t have a financial cushion, and will start seeing big drops in revenue at the end of May.”

“A lot of the A/R [accounts receivables] for practices come within 30 days, and very little comes in after 90 days,” said Terrence R. McWilliams, MD, chief clinical consultant at HSG Advisors, a consultancy for not-for-profit hospitals and their employed physician networks around the country. “So private practices are reaching the point where prior A/R will start to dwindle and they will start feeling the decline in new claims submissions.”

Large practices may have a bigger financial cushion, but in many cases, they also have more liabilities. “We don’t know the financial loss yet, but I think it’s been devastating,” said Paul M. Yonover, MD, a urologist at UroPartners, a large single-specialty practice in Chicago with 62 urologists. “In fact, the financial loss may well be larger than our loss in volume, because we have to support our own surgery center, pathology lab, radiation center, and other in-house services.”

Employed physicians in limbo

In contrast to physicians in private practices, many employed physicians at hospitals and health systems have been shielded from the impact of COVID-19 – at least for now.

“The experiences of employed physicians are very mixed,” said Mr. Singleton at Merritt Hawkins. “Some health systems have reduced physicians’ pay by 20%, but other systems have been putting off any reductions.”

Hospitals and health systems are struggling. “Stopping elective surgeries deeply affected hospitals,” said Ryan Inman, founder of Physician Wealth Services in San Diego. “With fewer elective surgeries, they have much less income coming in. Some big hospitals that are pillars of their community are under great financial stress.”

“Hospitals’ patient volumes have fallen by 50%-90%,” Mr. McWilliams reported. “Lower volume means lower pay for employed physicians, who are paid by straight productivity or other models that require high volumes. However, some health systems have intervened to make sure these physicians get some money.” 

Base pay is often safe for now, but quarterly bonuses are on the chopping block. “Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” said Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., a state mecca for physician employment. “They’ve been told that they will continue to get their base salary but forget about the quarterly bonuses. This amounts to salary reductions of 10%-30%.”

Ensuring payment for these doctors means lowering their productivity benchmarks, but the benchmarks might still be too high for these times. An internist at a large health system in Minneapolis–St. Paul reports that, at a lunch meeting, employed doctors learned that payment benchmarks will be reduced to 70% of their 2019 monthly average.

“I am seeing nowhere near 70% of what I was seeing last year,” he said in an interview, asking that his name not be used. “Given how slow things have been, I am probably closer to 30%, but have not been given any data on this, so I am guessing at this point.”

Adapting to a brave new world

Even as they face a dark financial future, physicians have had to completely revamp the way they practice medicine – a cumbersome process that, in itself, incurred some financial losses. They had to obtain masks and other PPE, reposition or even close down their waiting rooms, cut back on unneeded staff, and adapt to telemedicine.

“It’s been an incredibly challenging time,” said Dr. Yonover, the Chicago urologist. “As a doctor. I cannot avoid contact, and it’s not totally clear yet how the virus spreads. But I don’t have the option of closing the door. As a practice owner, you’re responsible for the health and well-being of employees, patients, and the business.”

“A practice’s daily routine is somewhat slower and costlier,” said David N. Gans, MSHA, senior fellow at the Medical Group Management Association (MGMA), which represents group practices. “Between each patient, you have to clean a lot more than previously, and you have to stock up on PPE such as masks and gowns. PPE used to be limited to infectious patients, but now it’s universal.”

At PA Clinical Network, a clinically integrated network in Pennsylvania, volume fell 40%-50% and income fell 30%-50% from late March to late April, according to Jaan Sidorov, MD, an internist who is CEO of the network, which has 158 physicians in a variety of specialties working in 54 practices around the state.

“Revenue went down but it didn’t crash,” he said. “And our physicians pivoted very quickly. They adapted to telehealth and applied for the federal loan programs. They didn’t use waiting rooms. In some cases, staff was out in the parking lot, putting stethoscopes through patients’ windows.”

“None of the practices closed, not even temporarily,” Dr. Sidorov said. “But clearly this cannot go forever without having serious consequences.”

How much can telemedicine help?

Telemedicine has been a lifeline for many struggling practices. “As much as 20%-40% of a practice’s losses can be recouped through telemedicine, depending on variables like patients’ attitudes,” said Mr. Singleton at Merritt Hawkins.

The rise in telemedicine was made possible by a temporary relaxation of the limits on telemedicine payments by Medicare and many private payers. Medicare is currently paying the same rates for telemedicine as it does for in-office visits.

In a recent MGMA Stat survey, 97% of practices reported that they had taken up telemedicine, according to Mr. Gans. He estimates that 80% of primary care could be converted to telemedicine, including medication refills, ongoing care of chronic patients, and recording patients’ vital signs from home.

Some primary care physicians are now using telemedicine for 100% of their visits. “I voluntarily closed my practice weeks ago except for virtual visits due to the risk of exposure for my patients,” a doctor in South Carolina told the Primary Care Collaborative in mid-April. “I continue to pay my staff out of pocket but have reduced hours and am not receiving any income myself.”

However, Mr. Inman of Physician Wealth Services said family medicine clients using telemedicine for all of their patients are earning less per visit, even though the Medicare reimbursement is the same as for an office visit. “They earn less because they cannot charge for any ancillaries, such as labs or imaging,” he said.

“Telemedicine has its limits,” Mr. Singleton said. It cannot replace elective surgeries, and even in primary care practices, “there is a lot of work for which patients have to come in, such as physicals or providing vaccines,” he said. “I know of one doctor who has refrigerator full of vaccines to give out. That pays his bills.”

In many cases, “telemedicine” simply means using the phone, with no video. Many patients can only use the phone, and Medicare now reimburses for some kinds of phone visits. In a mid-April survey of primary care providers, 44% were using the telephone for the majority of their visits, and 14% were not using video at all. Medicare recently decided to pay physicians the same amount for telephone visits as in-person visits.

Financial boosts will run out soon

Many private practices are surviving only because they have managed to tap into new federal programs that can finance them for the short-term. Here are the main examples:

Receiving advance Medicare payments. Through the Medicare Accelerated and Advance Payment Program, physicians can be paid up to 3 months of their average Medicare reimbursement in advance. However, repayment starts 120 days after receiving the money and must be completed within 210 days.

Obtaining a federal loan. Under the Paycheck Protection Program (PPP), which is available to all kinds of small businesses, practices can apply for up to 2.5 times their average monthly payroll costs.

PPP money can be used for payroll, rent, mortgage interest, or utility payments for up to 8 weeks. The loan will be entirely forgiven as long as the rules are followed. For example, three quarters of the money must go to payroll, and laid-off employees must be rehired by June 30.

There was such a rush for the first round of PPP loans that many physicians failed to get the loan. “Many of my physician clients applied for the loan as soon as they could, but none of them got it,” said Mr. Inman, the San Diego financial adviser. “We are hoping that the next round of funding will provide them some relief.” The second round started on April 27.

Physicians who have already obtained the PPP loan are very relieved. “This loan made it possible for us to pay our employees,” said George W. Monks, MD, a dermatologist in Tulsa, Okla., and president of the Oklahoma Medical Association.

Staff benefiting from higher unemployment payments. Many practices and hospitals are laying off their staff so that they can collect unemployment benefits. This is a good time to do that because the federal government has boosted unemployment payments by $600 a week, creating a total benefit that is greater than many people earned at their regular jobs.

This extra boost ends in July, but practices with PPP loans will have to rehire their laid-off workers a month before that. Getting laid-off staffers to come back in is going to be critical, and some practices are already having a hard time convincing them to come back, said Michael La Penna, a physician practice manager in Grand Rapids, Mich.

“They are finding that those people don’t want to come back in yet,” he said. “In many cases they have to care for children at home or have been getting generous unemployment checks.”

The problem with all these temporary financial boosts is that they will disappear within weeks or months from now. Mr. La Penna is concerned that the sudden loss of this support could send some practices spinning into bankruptcy. “Unless volume gets better very soon, time is running out for a lot of practices,” he said.

Hospitals, which also have been depending on federal assistance, may run out of money, too. Daniel Wrenne, a financial planner for physicians in Lexington, Ky., said smaller hospitals are particularly vulnerable because they lack the capital. He said a friend who is an attorney for hospitals predicted that 25% of small regional hospitals “won’t make it through this.”

Such financial turmoil might prompt many physicians to retire or find a new job, said Gary Price, MD, a plastic surgeon in New Haven, Conn., and president of the Physicians Foundation, an advocacy group for the profession. In a survey of doctors by the Physicians Foundation and Merritt Hawkins, released on April 21, 18% planned to retire, temporarily close their practices, or opt out of patient care, and another 14%, presumably employed physicians, planned to change jobs.

Is recovery around the corner?

In early May, practices in many parts of the country were seeing the possibility of a return to normal business – or at least what could pass for normal in these unusual times.

“From mid-March to mid-April, hospitals and practices were in panic mode,” said MGMA’s Mr. Gans. “They were focusing on the here and now. But from mid-April to mid-May, they could begin looking at the big picture and decide how they will get back into business.”

Surgeons devastated by bans on elective surgeries might see a bounce in cases, as the backlog of patients comes back in. By late April, 10 states reinstituted elective surgeries, including California, Arizona, Georgia, Indiana, Colorado, and Oklahoma, and New York has reinstituted elective surgeries for some counties.

Dr. Price said he hopes to reopen his plastic surgery practice by the end of June. “If it takes longer than that, I’m not sure that the practice will survive.” His PPP loan would have run out and he would have to lay off his staff. “At that point, ongoing viability of practice would become a real question.”

Dr. Monks said he hopes a lot more patients will come to his dermatology practice. As of the end of April, “we’re starting to see an uptick in the number of patients wanting to come in,” he said. “They seem to be more comfortable with the new world we’re living in.

“Viewing the backlog of cases that haven’t been attended to,” Dr. Monks added, “I think we’ll be really busy for a while.”

But Mr. La Penna said he thinks the expected backlog of elective patients will be more like a trickle than a flood. “Many patients aren’t going to want to return that fast,” he said. “They may have a condition that makes exposure to COVID-19 more risky, like diabetes or high blood pressure, or they’re elderly, or they live in a household with one of these risk groups.”

Andrew Musbach, cofounder of MD Wealth Management in Chelsea, Mich., said he expects a slow recovery for primary care physicians as well. “Even when the lockdowns are over, not everyone is going to feel comfortable coming to a hospital or visiting a doctor’s office unless it’s absolutely necessary,” he said.

Getting back to normal patient volumes will involve finding better ways to protect patients and staff from COVID-19, Dr. Yonover said. At his urology practice, “we take all the usual precautions, but nothing yet has made it dramatically easier to protect patients and staff,” he said. “Rapid, accurate testing for COVID-19 would change the landscape, but I have no idea when that will come.”

Mr. Wrenne advises his physician clients that a financial recovery will take months. “I tell them to plan for 6 months, until October, before income returns to pre–COVID-19 levels. Reimbursement lags appointments by as much as 3 months, plus it will probably take the economy 2-3 months more to get back to normal.”

“We are facing a recession, and how long it will last is anyone’s guess,” said Alex Kilian, a physician wealth manager at Aldrich Wealth in San Diego. “The federal government’s efforts to stimulate the economy is keeping it from crashing, but there are no real signs that it will actually pick up. It may take years for the travel and entertainment industries to come back.”

A recession means patients will have less spending power, and health care sectors like laser eye surgery may be damaged for years to come, said John B. Pinto, an ophthalmology practice management consultant in San Diego. “[That kind of surgery] is purely elective and relatively costly,” he said. “When people get back to work, they are going to be building up their savings and avoiding new debt. They won’t be having [laser eye surgery].”

“There won’t be any quick return to normal for me,” said Dr. Price, the Connecticut plastic surgeon. “The damage this time will probably be worse than in the Great Recession. Back then, plastic surgery was off by 20%, but this time you have the extra problem of patients reluctant to come into medical offices.”

“To get patients to come in, facilities are going to have to convince patients that they are safe,” Mr. Singleton said. “That may mean undertaking some marketing and promotion, and hospitals tend to be much better at that than practices.”

What a new wave of COVID-19 would mean

Some states have begun reopening public places, which could signal patients to return to doctors’ offices even though doctors’ offices were never officially closed. Oklahoma, for example, reopened restaurants, movie theaters, and sports venues on May 1.

Dr. Monks, president of the Oklahoma Medical Association, said his group opposes states reopening. “The governor’s order is too hasty and overly ambitious,” he said. “Oklahoma has seen an ongoing growth in the number of cases, hospitalizations, and deaths in the past week alone [in late April].”  

The concern is that opening up public places too soon would create a new wave of COVID-19, which would not only be a public health disaster, but also a financial disaster for physicians. Doctors would be back where they were in March, but unlike in March, they would not benefit from revenues from previously busy times.

Mr. Pinto said the number of COVID-19 cases will rise and fall in the next 2 years, forcing states to reenact new bans on public gatherings and on elective surgeries until the numbers subside again.

Mr. Pinto said authorities in Singapore have successfully handled such waves of the disease through short bans that are tantamount to tapping the brakes of a car. “As the car gathers speed down the hill, you tap the brake,” he said. “I suspect we’ll be seeing a lot of brake-tapping until a vaccine can be developed and distributed.” 

Gary LeRoy, MD, president of the American Academy of Family Physicians, recalled the worldwide Spanish Flu pandemic a century ago. “People were allowed out of their houses after 2 months, and the flu spiked up again,” he said. “I hope we don’t make that mistake this time.”

Dr. LeRoy said it’s not possible to predict how the COVID-19 crisis will play out. “What will the future be like? I don’t know the answer,” he said. “The information we learn in next hours, days, or months will probably change everything.”

A version of this article originally appeared on Medscape.com.

In recent weeks, physicians have gotten the first hints of how much income they could lose in the COVID-19 crisis.

“At a combined system and hospital board meeting yesterday, there was a financial presentation,” said a cardiologist in Minnesota, who declined to be named. “We have ‘salary support’ through May 16, which means we will be receiving base pay at our 2019 level. After May 16, I think it’s fairly certain salaries will be decreased.”

A general internist in the same area added: “The system has decided to pay physicians and other employees for 8 weeks, until May 15, and they are borrowing about $150 million to do this. We don’t know what will happen after May 15, but we are supposed to have an update in early May.”

Physician income is of huge interest, and many aspects of it are discussed in Medscape’s Physician Compensation Report 2020, just released.

The worst may be yet to come

Of all the categories of physicians, “I am worried about private practices the most,” said Travis Singleton, senior vice president at Merritt Hawkins, a physician search firm. “They don’t have a financial cushion, and will start seeing big drops in revenue at the end of May.”

“A lot of the A/R [accounts receivables] for practices come within 30 days, and very little comes in after 90 days,” said Terrence R. McWilliams, MD, chief clinical consultant at HSG Advisors, a consultancy for not-for-profit hospitals and their employed physician networks around the country. “So private practices are reaching the point where prior A/R will start to dwindle and they will start feeling the decline in new claims submissions.”

Large practices may have a bigger financial cushion, but in many cases, they also have more liabilities. “We don’t know the financial loss yet, but I think it’s been devastating,” said Paul M. Yonover, MD, a urologist at UroPartners, a large single-specialty practice in Chicago with 62 urologists. “In fact, the financial loss may well be larger than our loss in volume, because we have to support our own surgery center, pathology lab, radiation center, and other in-house services.”

Employed physicians in limbo

In contrast to physicians in private practices, many employed physicians at hospitals and health systems have been shielded from the impact of COVID-19 – at least for now.

“The experiences of employed physicians are very mixed,” said Mr. Singleton at Merritt Hawkins. “Some health systems have reduced physicians’ pay by 20%, but other systems have been putting off any reductions.”

Hospitals and health systems are struggling. “Stopping elective surgeries deeply affected hospitals,” said Ryan Inman, founder of Physician Wealth Services in San Diego. “With fewer elective surgeries, they have much less income coming in. Some big hospitals that are pillars of their community are under great financial stress.”

“Hospitals’ patient volumes have fallen by 50%-90%,” Mr. McWilliams reported. “Lower volume means lower pay for employed physicians, who are paid by straight productivity or other models that require high volumes. However, some health systems have intervened to make sure these physicians get some money.” 

Base pay is often safe for now, but quarterly bonuses are on the chopping block. “Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” said Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., a state mecca for physician employment. “They’ve been told that they will continue to get their base salary but forget about the quarterly bonuses. This amounts to salary reductions of 10%-30%.”

Ensuring payment for these doctors means lowering their productivity benchmarks, but the benchmarks might still be too high for these times. An internist at a large health system in Minneapolis–St. Paul reports that, at a lunch meeting, employed doctors learned that payment benchmarks will be reduced to 70% of their 2019 monthly average.

“I am seeing nowhere near 70% of what I was seeing last year,” he said in an interview, asking that his name not be used. “Given how slow things have been, I am probably closer to 30%, but have not been given any data on this, so I am guessing at this point.”

Adapting to a brave new world

Even as they face a dark financial future, physicians have had to completely revamp the way they practice medicine – a cumbersome process that, in itself, incurred some financial losses. They had to obtain masks and other PPE, reposition or even close down their waiting rooms, cut back on unneeded staff, and adapt to telemedicine.

“It’s been an incredibly challenging time,” said Dr. Yonover, the Chicago urologist. “As a doctor. I cannot avoid contact, and it’s not totally clear yet how the virus spreads. But I don’t have the option of closing the door. As a practice owner, you’re responsible for the health and well-being of employees, patients, and the business.”

“A practice’s daily routine is somewhat slower and costlier,” said David N. Gans, MSHA, senior fellow at the Medical Group Management Association (MGMA), which represents group practices. “Between each patient, you have to clean a lot more than previously, and you have to stock up on PPE such as masks and gowns. PPE used to be limited to infectious patients, but now it’s universal.”

At PA Clinical Network, a clinically integrated network in Pennsylvania, volume fell 40%-50% and income fell 30%-50% from late March to late April, according to Jaan Sidorov, MD, an internist who is CEO of the network, which has 158 physicians in a variety of specialties working in 54 practices around the state.

“Revenue went down but it didn’t crash,” he said. “And our physicians pivoted very quickly. They adapted to telehealth and applied for the federal loan programs. They didn’t use waiting rooms. In some cases, staff was out in the parking lot, putting stethoscopes through patients’ windows.”

“None of the practices closed, not even temporarily,” Dr. Sidorov said. “But clearly this cannot go forever without having serious consequences.”

How much can telemedicine help?

Telemedicine has been a lifeline for many struggling practices. “As much as 20%-40% of a practice’s losses can be recouped through telemedicine, depending on variables like patients’ attitudes,” said Mr. Singleton at Merritt Hawkins.

The rise in telemedicine was made possible by a temporary relaxation of the limits on telemedicine payments by Medicare and many private payers. Medicare is currently paying the same rates for telemedicine as it does for in-office visits.

In a recent MGMA Stat survey, 97% of practices reported that they had taken up telemedicine, according to Mr. Gans. He estimates that 80% of primary care could be converted to telemedicine, including medication refills, ongoing care of chronic patients, and recording patients’ vital signs from home.

Some primary care physicians are now using telemedicine for 100% of their visits. “I voluntarily closed my practice weeks ago except for virtual visits due to the risk of exposure for my patients,” a doctor in South Carolina told the Primary Care Collaborative in mid-April. “I continue to pay my staff out of pocket but have reduced hours and am not receiving any income myself.”

However, Mr. Inman of Physician Wealth Services said family medicine clients using telemedicine for all of their patients are earning less per visit, even though the Medicare reimbursement is the same as for an office visit. “They earn less because they cannot charge for any ancillaries, such as labs or imaging,” he said.

“Telemedicine has its limits,” Mr. Singleton said. It cannot replace elective surgeries, and even in primary care practices, “there is a lot of work for which patients have to come in, such as physicals or providing vaccines,” he said. “I know of one doctor who has refrigerator full of vaccines to give out. That pays his bills.”

In many cases, “telemedicine” simply means using the phone, with no video. Many patients can only use the phone, and Medicare now reimburses for some kinds of phone visits. In a mid-April survey of primary care providers, 44% were using the telephone for the majority of their visits, and 14% were not using video at all. Medicare recently decided to pay physicians the same amount for telephone visits as in-person visits.

Financial boosts will run out soon

Many private practices are surviving only because they have managed to tap into new federal programs that can finance them for the short-term. Here are the main examples:

Receiving advance Medicare payments. Through the Medicare Accelerated and Advance Payment Program, physicians can be paid up to 3 months of their average Medicare reimbursement in advance. However, repayment starts 120 days after receiving the money and must be completed within 210 days.

Obtaining a federal loan. Under the Paycheck Protection Program (PPP), which is available to all kinds of small businesses, practices can apply for up to 2.5 times their average monthly payroll costs.

PPP money can be used for payroll, rent, mortgage interest, or utility payments for up to 8 weeks. The loan will be entirely forgiven as long as the rules are followed. For example, three quarters of the money must go to payroll, and laid-off employees must be rehired by June 30.

There was such a rush for the first round of PPP loans that many physicians failed to get the loan. “Many of my physician clients applied for the loan as soon as they could, but none of them got it,” said Mr. Inman, the San Diego financial adviser. “We are hoping that the next round of funding will provide them some relief.” The second round started on April 27.

Physicians who have already obtained the PPP loan are very relieved. “This loan made it possible for us to pay our employees,” said George W. Monks, MD, a dermatologist in Tulsa, Okla., and president of the Oklahoma Medical Association.

Staff benefiting from higher unemployment payments. Many practices and hospitals are laying off their staff so that they can collect unemployment benefits. This is a good time to do that because the federal government has boosted unemployment payments by $600 a week, creating a total benefit that is greater than many people earned at their regular jobs.

This extra boost ends in July, but practices with PPP loans will have to rehire their laid-off workers a month before that. Getting laid-off staffers to come back in is going to be critical, and some practices are already having a hard time convincing them to come back, said Michael La Penna, a physician practice manager in Grand Rapids, Mich.

“They are finding that those people don’t want to come back in yet,” he said. “In many cases they have to care for children at home or have been getting generous unemployment checks.”

The problem with all these temporary financial boosts is that they will disappear within weeks or months from now. Mr. La Penna is concerned that the sudden loss of this support could send some practices spinning into bankruptcy. “Unless volume gets better very soon, time is running out for a lot of practices,” he said.

Hospitals, which also have been depending on federal assistance, may run out of money, too. Daniel Wrenne, a financial planner for physicians in Lexington, Ky., said smaller hospitals are particularly vulnerable because they lack the capital. He said a friend who is an attorney for hospitals predicted that 25% of small regional hospitals “won’t make it through this.”

Such financial turmoil might prompt many physicians to retire or find a new job, said Gary Price, MD, a plastic surgeon in New Haven, Conn., and president of the Physicians Foundation, an advocacy group for the profession. In a survey of doctors by the Physicians Foundation and Merritt Hawkins, released on April 21, 18% planned to retire, temporarily close their practices, or opt out of patient care, and another 14%, presumably employed physicians, planned to change jobs.

Is recovery around the corner?

In early May, practices in many parts of the country were seeing the possibility of a return to normal business – or at least what could pass for normal in these unusual times.

“From mid-March to mid-April, hospitals and practices were in panic mode,” said MGMA’s Mr. Gans. “They were focusing on the here and now. But from mid-April to mid-May, they could begin looking at the big picture and decide how they will get back into business.”

Surgeons devastated by bans on elective surgeries might see a bounce in cases, as the backlog of patients comes back in. By late April, 10 states reinstituted elective surgeries, including California, Arizona, Georgia, Indiana, Colorado, and Oklahoma, and New York has reinstituted elective surgeries for some counties.

Dr. Price said he hopes to reopen his plastic surgery practice by the end of June. “If it takes longer than that, I’m not sure that the practice will survive.” His PPP loan would have run out and he would have to lay off his staff. “At that point, ongoing viability of practice would become a real question.”

Dr. Monks said he hopes a lot more patients will come to his dermatology practice. As of the end of April, “we’re starting to see an uptick in the number of patients wanting to come in,” he said. “They seem to be more comfortable with the new world we’re living in.

“Viewing the backlog of cases that haven’t been attended to,” Dr. Monks added, “I think we’ll be really busy for a while.”

But Mr. La Penna said he thinks the expected backlog of elective patients will be more like a trickle than a flood. “Many patients aren’t going to want to return that fast,” he said. “They may have a condition that makes exposure to COVID-19 more risky, like diabetes or high blood pressure, or they’re elderly, or they live in a household with one of these risk groups.”

Andrew Musbach, cofounder of MD Wealth Management in Chelsea, Mich., said he expects a slow recovery for primary care physicians as well. “Even when the lockdowns are over, not everyone is going to feel comfortable coming to a hospital or visiting a doctor’s office unless it’s absolutely necessary,” he said.

Getting back to normal patient volumes will involve finding better ways to protect patients and staff from COVID-19, Dr. Yonover said. At his urology practice, “we take all the usual precautions, but nothing yet has made it dramatically easier to protect patients and staff,” he said. “Rapid, accurate testing for COVID-19 would change the landscape, but I have no idea when that will come.”

Mr. Wrenne advises his physician clients that a financial recovery will take months. “I tell them to plan for 6 months, until October, before income returns to pre–COVID-19 levels. Reimbursement lags appointments by as much as 3 months, plus it will probably take the economy 2-3 months more to get back to normal.”

“We are facing a recession, and how long it will last is anyone’s guess,” said Alex Kilian, a physician wealth manager at Aldrich Wealth in San Diego. “The federal government’s efforts to stimulate the economy is keeping it from crashing, but there are no real signs that it will actually pick up. It may take years for the travel and entertainment industries to come back.”

A recession means patients will have less spending power, and health care sectors like laser eye surgery may be damaged for years to come, said John B. Pinto, an ophthalmology practice management consultant in San Diego. “[That kind of surgery] is purely elective and relatively costly,” he said. “When people get back to work, they are going to be building up their savings and avoiding new debt. They won’t be having [laser eye surgery].”

“There won’t be any quick return to normal for me,” said Dr. Price, the Connecticut plastic surgeon. “The damage this time will probably be worse than in the Great Recession. Back then, plastic surgery was off by 20%, but this time you have the extra problem of patients reluctant to come into medical offices.”

“To get patients to come in, facilities are going to have to convince patients that they are safe,” Mr. Singleton said. “That may mean undertaking some marketing and promotion, and hospitals tend to be much better at that than practices.”

What a new wave of COVID-19 would mean

Some states have begun reopening public places, which could signal patients to return to doctors’ offices even though doctors’ offices were never officially closed. Oklahoma, for example, reopened restaurants, movie theaters, and sports venues on May 1.

Dr. Monks, president of the Oklahoma Medical Association, said his group opposes states reopening. “The governor’s order is too hasty and overly ambitious,” he said. “Oklahoma has seen an ongoing growth in the number of cases, hospitalizations, and deaths in the past week alone [in late April].”  

The concern is that opening up public places too soon would create a new wave of COVID-19, which would not only be a public health disaster, but also a financial disaster for physicians. Doctors would be back where they were in March, but unlike in March, they would not benefit from revenues from previously busy times.

Mr. Pinto said the number of COVID-19 cases will rise and fall in the next 2 years, forcing states to reenact new bans on public gatherings and on elective surgeries until the numbers subside again.

Mr. Pinto said authorities in Singapore have successfully handled such waves of the disease through short bans that are tantamount to tapping the brakes of a car. “As the car gathers speed down the hill, you tap the brake,” he said. “I suspect we’ll be seeing a lot of brake-tapping until a vaccine can be developed and distributed.” 

Gary LeRoy, MD, president of the American Academy of Family Physicians, recalled the worldwide Spanish Flu pandemic a century ago. “People were allowed out of their houses after 2 months, and the flu spiked up again,” he said. “I hope we don’t make that mistake this time.”

Dr. LeRoy said it’s not possible to predict how the COVID-19 crisis will play out. “What will the future be like? I don’t know the answer,” he said. “The information we learn in next hours, days, or months will probably change everything.”

A version of this article originally appeared on Medscape.com.

In recent weeks, physicians have gotten the first hints of how much income they could lose in the COVID-19 crisis.

“At a combined system and hospital board meeting yesterday, there was a financial presentation,” said a cardiologist in Minnesota, who declined to be named. “We have ‘salary support’ through May 16, which means we will be receiving base pay at our 2019 level. After May 16, I think it’s fairly certain salaries will be decreased.”

A general internist in the same area added: “The system has decided to pay physicians and other employees for 8 weeks, until May 15, and they are borrowing about $150 million to do this. We don’t know what will happen after May 15, but we are supposed to have an update in early May.”

Physician income is of huge interest, and many aspects of it are discussed in Medscape’s Physician Compensation Report 2020, just released.

The worst may be yet to come

Of all the categories of physicians, “I am worried about private practices the most,” said Travis Singleton, senior vice president at Merritt Hawkins, a physician search firm. “They don’t have a financial cushion, and will start seeing big drops in revenue at the end of May.”

“A lot of the A/R [accounts receivables] for practices come within 30 days, and very little comes in after 90 days,” said Terrence R. McWilliams, MD, chief clinical consultant at HSG Advisors, a consultancy for not-for-profit hospitals and their employed physician networks around the country. “So private practices are reaching the point where prior A/R will start to dwindle and they will start feeling the decline in new claims submissions.”

Large practices may have a bigger financial cushion, but in many cases, they also have more liabilities. “We don’t know the financial loss yet, but I think it’s been devastating,” said Paul M. Yonover, MD, a urologist at UroPartners, a large single-specialty practice in Chicago with 62 urologists. “In fact, the financial loss may well be larger than our loss in volume, because we have to support our own surgery center, pathology lab, radiation center, and other in-house services.”

Employed physicians in limbo

In contrast to physicians in private practices, many employed physicians at hospitals and health systems have been shielded from the impact of COVID-19 – at least for now.

“The experiences of employed physicians are very mixed,” said Mr. Singleton at Merritt Hawkins. “Some health systems have reduced physicians’ pay by 20%, but other systems have been putting off any reductions.”

Hospitals and health systems are struggling. “Stopping elective surgeries deeply affected hospitals,” said Ryan Inman, founder of Physician Wealth Services in San Diego. “With fewer elective surgeries, they have much less income coming in. Some big hospitals that are pillars of their community are under great financial stress.”

“Hospitals’ patient volumes have fallen by 50%-90%,” Mr. McWilliams reported. “Lower volume means lower pay for employed physicians, who are paid by straight productivity or other models that require high volumes. However, some health systems have intervened to make sure these physicians get some money.” 

Base pay is often safe for now, but quarterly bonuses are on the chopping block. “Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” said Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., a state mecca for physician employment. “They’ve been told that they will continue to get their base salary but forget about the quarterly bonuses. This amounts to salary reductions of 10%-30%.”

Ensuring payment for these doctors means lowering their productivity benchmarks, but the benchmarks might still be too high for these times. An internist at a large health system in Minneapolis–St. Paul reports that, at a lunch meeting, employed doctors learned that payment benchmarks will be reduced to 70% of their 2019 monthly average.

“I am seeing nowhere near 70% of what I was seeing last year,” he said in an interview, asking that his name not be used. “Given how slow things have been, I am probably closer to 30%, but have not been given any data on this, so I am guessing at this point.”

Adapting to a brave new world

Even as they face a dark financial future, physicians have had to completely revamp the way they practice medicine – a cumbersome process that, in itself, incurred some financial losses. They had to obtain masks and other PPE, reposition or even close down their waiting rooms, cut back on unneeded staff, and adapt to telemedicine.

“It’s been an incredibly challenging time,” said Dr. Yonover, the Chicago urologist. “As a doctor. I cannot avoid contact, and it’s not totally clear yet how the virus spreads. But I don’t have the option of closing the door. As a practice owner, you’re responsible for the health and well-being of employees, patients, and the business.”

“A practice’s daily routine is somewhat slower and costlier,” said David N. Gans, MSHA, senior fellow at the Medical Group Management Association (MGMA), which represents group practices. “Between each patient, you have to clean a lot more than previously, and you have to stock up on PPE such as masks and gowns. PPE used to be limited to infectious patients, but now it’s universal.”

At PA Clinical Network, a clinically integrated network in Pennsylvania, volume fell 40%-50% and income fell 30%-50% from late March to late April, according to Jaan Sidorov, MD, an internist who is CEO of the network, which has 158 physicians in a variety of specialties working in 54 practices around the state.

“Revenue went down but it didn’t crash,” he said. “And our physicians pivoted very quickly. They adapted to telehealth and applied for the federal loan programs. They didn’t use waiting rooms. In some cases, staff was out in the parking lot, putting stethoscopes through patients’ windows.”

“None of the practices closed, not even temporarily,” Dr. Sidorov said. “But clearly this cannot go forever without having serious consequences.”

How much can telemedicine help?

Telemedicine has been a lifeline for many struggling practices. “As much as 20%-40% of a practice’s losses can be recouped through telemedicine, depending on variables like patients’ attitudes,” said Mr. Singleton at Merritt Hawkins.

The rise in telemedicine was made possible by a temporary relaxation of the limits on telemedicine payments by Medicare and many private payers. Medicare is currently paying the same rates for telemedicine as it does for in-office visits.

In a recent MGMA Stat survey, 97% of practices reported that they had taken up telemedicine, according to Mr. Gans. He estimates that 80% of primary care could be converted to telemedicine, including medication refills, ongoing care of chronic patients, and recording patients’ vital signs from home.

Some primary care physicians are now using telemedicine for 100% of their visits. “I voluntarily closed my practice weeks ago except for virtual visits due to the risk of exposure for my patients,” a doctor in South Carolina told the Primary Care Collaborative in mid-April. “I continue to pay my staff out of pocket but have reduced hours and am not receiving any income myself.”

However, Mr. Inman of Physician Wealth Services said family medicine clients using telemedicine for all of their patients are earning less per visit, even though the Medicare reimbursement is the same as for an office visit. “They earn less because they cannot charge for any ancillaries, such as labs or imaging,” he said.

“Telemedicine has its limits,” Mr. Singleton said. It cannot replace elective surgeries, and even in primary care practices, “there is a lot of work for which patients have to come in, such as physicals or providing vaccines,” he said. “I know of one doctor who has refrigerator full of vaccines to give out. That pays his bills.”

In many cases, “telemedicine” simply means using the phone, with no video. Many patients can only use the phone, and Medicare now reimburses for some kinds of phone visits. In a mid-April survey of primary care providers, 44% were using the telephone for the majority of their visits, and 14% were not using video at all. Medicare recently decided to pay physicians the same amount for telephone visits as in-person visits.

Financial boosts will run out soon

Many private practices are surviving only because they have managed to tap into new federal programs that can finance them for the short-term. Here are the main examples:

Receiving advance Medicare payments. Through the Medicare Accelerated and Advance Payment Program, physicians can be paid up to 3 months of their average Medicare reimbursement in advance. However, repayment starts 120 days after receiving the money and must be completed within 210 days.

Obtaining a federal loan. Under the Paycheck Protection Program (PPP), which is available to all kinds of small businesses, practices can apply for up to 2.5 times their average monthly payroll costs.

PPP money can be used for payroll, rent, mortgage interest, or utility payments for up to 8 weeks. The loan will be entirely forgiven as long as the rules are followed. For example, three quarters of the money must go to payroll, and laid-off employees must be rehired by June 30.

There was such a rush for the first round of PPP loans that many physicians failed to get the loan. “Many of my physician clients applied for the loan as soon as they could, but none of them got it,” said Mr. Inman, the San Diego financial adviser. “We are hoping that the next round of funding will provide them some relief.” The second round started on April 27.

Physicians who have already obtained the PPP loan are very relieved. “This loan made it possible for us to pay our employees,” said George W. Monks, MD, a dermatologist in Tulsa, Okla., and president of the Oklahoma Medical Association.

Staff benefiting from higher unemployment payments. Many practices and hospitals are laying off their staff so that they can collect unemployment benefits. This is a good time to do that because the federal government has boosted unemployment payments by $600 a week, creating a total benefit that is greater than many people earned at their regular jobs.

This extra boost ends in July, but practices with PPP loans will have to rehire their laid-off workers a month before that. Getting laid-off staffers to come back in is going to be critical, and some practices are already having a hard time convincing them to come back, said Michael La Penna, a physician practice manager in Grand Rapids, Mich.

“They are finding that those people don’t want to come back in yet,” he said. “In many cases they have to care for children at home or have been getting generous unemployment checks.”

The problem with all these temporary financial boosts is that they will disappear within weeks or months from now. Mr. La Penna is concerned that the sudden loss of this support could send some practices spinning into bankruptcy. “Unless volume gets better very soon, time is running out for a lot of practices,” he said.

Hospitals, which also have been depending on federal assistance, may run out of money, too. Daniel Wrenne, a financial planner for physicians in Lexington, Ky., said smaller hospitals are particularly vulnerable because they lack the capital. He said a friend who is an attorney for hospitals predicted that 25% of small regional hospitals “won’t make it through this.”

Such financial turmoil might prompt many physicians to retire or find a new job, said Gary Price, MD, a plastic surgeon in New Haven, Conn., and president of the Physicians Foundation, an advocacy group for the profession. In a survey of doctors by the Physicians Foundation and Merritt Hawkins, released on April 21, 18% planned to retire, temporarily close their practices, or opt out of patient care, and another 14%, presumably employed physicians, planned to change jobs.

Is recovery around the corner?

In early May, practices in many parts of the country were seeing the possibility of a return to normal business – or at least what could pass for normal in these unusual times.

“From mid-March to mid-April, hospitals and practices were in panic mode,” said MGMA’s Mr. Gans. “They were focusing on the here and now. But from mid-April to mid-May, they could begin looking at the big picture and decide how they will get back into business.”

Surgeons devastated by bans on elective surgeries might see a bounce in cases, as the backlog of patients comes back in. By late April, 10 states reinstituted elective surgeries, including California, Arizona, Georgia, Indiana, Colorado, and Oklahoma, and New York has reinstituted elective surgeries for some counties.

Dr. Price said he hopes to reopen his plastic surgery practice by the end of June. “If it takes longer than that, I’m not sure that the practice will survive.” His PPP loan would have run out and he would have to lay off his staff. “At that point, ongoing viability of practice would become a real question.”

Dr. Monks said he hopes a lot more patients will come to his dermatology practice. As of the end of April, “we’re starting to see an uptick in the number of patients wanting to come in,” he said. “They seem to be more comfortable with the new world we’re living in.

“Viewing the backlog of cases that haven’t been attended to,” Dr. Monks added, “I think we’ll be really busy for a while.”

But Mr. La Penna said he thinks the expected backlog of elective patients will be more like a trickle than a flood. “Many patients aren’t going to want to return that fast,” he said. “They may have a condition that makes exposure to COVID-19 more risky, like diabetes or high blood pressure, or they’re elderly, or they live in a household with one of these risk groups.”

Andrew Musbach, cofounder of MD Wealth Management in Chelsea, Mich., said he expects a slow recovery for primary care physicians as well. “Even when the lockdowns are over, not everyone is going to feel comfortable coming to a hospital or visiting a doctor’s office unless it’s absolutely necessary,” he said.

Getting back to normal patient volumes will involve finding better ways to protect patients and staff from COVID-19, Dr. Yonover said. At his urology practice, “we take all the usual precautions, but nothing yet has made it dramatically easier to protect patients and staff,” he said. “Rapid, accurate testing for COVID-19 would change the landscape, but I have no idea when that will come.”

Mr. Wrenne advises his physician clients that a financial recovery will take months. “I tell them to plan for 6 months, until October, before income returns to pre–COVID-19 levels. Reimbursement lags appointments by as much as 3 months, plus it will probably take the economy 2-3 months more to get back to normal.”

“We are facing a recession, and how long it will last is anyone’s guess,” said Alex Kilian, a physician wealth manager at Aldrich Wealth in San Diego. “The federal government’s efforts to stimulate the economy is keeping it from crashing, but there are no real signs that it will actually pick up. It may take years for the travel and entertainment industries to come back.”

A recession means patients will have less spending power, and health care sectors like laser eye surgery may be damaged for years to come, said John B. Pinto, an ophthalmology practice management consultant in San Diego. “[That kind of surgery] is purely elective and relatively costly,” he said. “When people get back to work, they are going to be building up their savings and avoiding new debt. They won’t be having [laser eye surgery].”

“There won’t be any quick return to normal for me,” said Dr. Price, the Connecticut plastic surgeon. “The damage this time will probably be worse than in the Great Recession. Back then, plastic surgery was off by 20%, but this time you have the extra problem of patients reluctant to come into medical offices.”

“To get patients to come in, facilities are going to have to convince patients that they are safe,” Mr. Singleton said. “That may mean undertaking some marketing and promotion, and hospitals tend to be much better at that than practices.”

What a new wave of COVID-19 would mean

Some states have begun reopening public places, which could signal patients to return to doctors’ offices even though doctors’ offices were never officially closed. Oklahoma, for example, reopened restaurants, movie theaters, and sports venues on May 1.

Dr. Monks, president of the Oklahoma Medical Association, said his group opposes states reopening. “The governor’s order is too hasty and overly ambitious,” he said. “Oklahoma has seen an ongoing growth in the number of cases, hospitalizations, and deaths in the past week alone [in late April].”  

The concern is that opening up public places too soon would create a new wave of COVID-19, which would not only be a public health disaster, but also a financial disaster for physicians. Doctors would be back where they were in March, but unlike in March, they would not benefit from revenues from previously busy times.

Mr. Pinto said the number of COVID-19 cases will rise and fall in the next 2 years, forcing states to reenact new bans on public gatherings and on elective surgeries until the numbers subside again.

Mr. Pinto said authorities in Singapore have successfully handled such waves of the disease through short bans that are tantamount to tapping the brakes of a car. “As the car gathers speed down the hill, you tap the brake,” he said. “I suspect we’ll be seeing a lot of brake-tapping until a vaccine can be developed and distributed.” 

Gary LeRoy, MD, president of the American Academy of Family Physicians, recalled the worldwide Spanish Flu pandemic a century ago. “People were allowed out of their houses after 2 months, and the flu spiked up again,” he said. “I hope we don’t make that mistake this time.”

Dr. LeRoy said it’s not possible to predict how the COVID-19 crisis will play out. “What will the future be like? I don’t know the answer,” he said. “The information we learn in next hours, days, or months will probably change everything.”

A version of this article originally appeared on Medscape.com.

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

Minimal residual disease (MRD) surveillance after surgery can detect relapse in advance of imaging in patients with early-stage non–small cell lung cancer (NSCLC), according to findings from the TRACERx study.

The findings pave the way for clinical trials of MRD-driven treatment escalation, Chris Abbosh, MD, of University College London, reported during a presentation at the AACR virtual meeting I. Data in the presentation were updated from the abstract.

Dr. Abbosh and colleagues used phylogenetic circulating tumor DNA (ctDNA) profiling to assess MRD and predict relapse in patients from the TRACERx study who underwent surgery for stage I-III NSCLC.

“The approach we take is technically termed a ‘tumor-informed, personalized cell-free DNA-enrichment approach,’” Dr. Abbosh explained. “We take out the primary tumor from the patient, we multiregion sample that tumor, and submit each region for deep whole-exome sequencing.”

The researchers prioritize variants for MRD tracking based on clonality/subclonality, high copy number status, and low background sequencing noise. The researchers then construct an anchored-multiplex PCR panel against the positions of interest, which is applied to cell-free DNA in the pre- and postoperative setting.

“We’ve developed an MRD caller to go alongside this chemistry,” Dr. Abbosh said. “The main premise behind the MRD caller is that it can calculate intralibrary error rates to inform the MRD pool.”
 

Sensitivity and specificity

To validate their approach, Dr. Abbosh and colleagues tested the assay with low DNA input (5 ng, 10 ng) and high DNA input (30 ng, 60 ng). They found the assay to be more sensitive with higher DNA input, and variant fractions were detected down to 0.003%.

The researchers also assessed how sensitivity and specificity scale with an increasing number of variants – 50, 100, or 200 variants. When tracking 200 variants, the assay was powered to detect lower ctDNA fractions than when tracking 50 variants. On the other hand, specificity was higher with 50 variants (99.8%) than with 200 variants (99.4%).

Next, Dr. Abbosh and colleagues analyzed postoperative cell-free DNA collected at 271 time points from 37 NSCLC patients who did not relapse. This included 11 patients who developed proven second primary malignancies.

Of the 271 time points when MRD negativity was expected, MRD was not detected at 269 time points, which translates to 99.3% specificity for the assay.
 

Shedding, relapse, and disease-free survival

Dr. Abbosh and colleagues also found that non-adenocarcinoma histology is associated with preoperative ctDNA shedding in NSCLC. The researchers analyzed 88 early-stage preoperative samples from NSCLC patients. ctDNA was detected preoperatively in 49% of lung adenocarcinomas and 100% of lung squamous cell carcinomas.

“This finding is important when it comes to interpreting our non–small cell lung cancer relapse data from 53 TRACERx patients,” Dr. Abbosh said.

Of the 53 patients who relapsed, 42 had ctDNA detected prior to surgery and were thus considered shedders, while 11 were nonshedders. ctDNA was detectable at or before relapse in 91% (38/42) of shedders and 64% (7/11) of nonshedders.

The median time from ctDNA detection to clinical relapse was 164 days in shedders and 22 days in nonshedders. The median disease-free survival was 362 days and 640 days, respectively.

“So what these data suggest is that preoperative ctDNA detection status will be a proxy of the potential utility of ctDNA as an MRD biomarker in a clinical setting,” Dr. Abbosh explained.

Standard-of-care imaging findings in the 53 patients who relapsed further demonstrated the utility of ctDNA in this setting, Dr. Abbosh said.

All scans were divided into three categories: those showing unequivocal relapse, those with a new equivocal change (relapse, inflammation, or a nonspecific finding), and those with no evidence of relapse. Each was further categorized by preimaging MRD status.

Relapse occurred in 9 of 10 patients who were MRD positive but had a scan showing no evidence of relapse. Relapse occurred in 15 of 16 patients who were MRD positive and had scans showing new equivocal changes.

Patients with unequivocal evidence of relapse who were MRD negative at or before the scan were more likely to have a second primary cancer than to have NSCLC relapse (52% vs. 48%), which is a reflection of the specificity of the MRD assay to the primary tumor, Dr. Abbosh said.
 

Implications of the findings

The researchers’ findings are important because establishing an MRD-driven approach to treating early-stage NSCLC would facilitate escalation of standard-of-care treatment only for those patients at high risk for relapse, thereby overcoming a key challenge in conventional adjuvant drug-trial design, Dr. Abbosh said.

“If we take a patient population with high-risk early-stage disease who have undergone potentially curative resection of their cancer and we offer these patients adjuvant chemotherapy or adjuvant chemoradiation therapy, then we can improve 5-year survival outcomes in this population,” Dr. Abbosh said. “This is striking because, if we give the same treatment in the metastatic setting, we only see a progression-free survival benefit of a short number of months.”

This suggests a potential “vulnerability of low-burden residual cancer to systemic treatment following surgery,” he added. “So if we want to improve outcomes further in non–small cell lung cancer, we really need to focus on innovation in the early-stage space.”

Dr. Abbosh said he and colleagues demonstrated that “personalized cell-free DNA enrichment can detect low-frequency variant DNA in an accurate manner.

“We’ve shown that preoperative ctDNA shedding is associated with utility of ctDNA as an MRD biomarker and that MRD surveillance can lead to detection of relapse in advance of standard-of-care-imaging,” he said. “We feel that the field is now ready for MRD-driven adjuvant trials.”
 

Questions to be answered

Invited discussant Corey J. Langer, MD, of Penn Medicine in Philadelphia, outlined “fundamental questions” raised by the findings.

“We need more information on the staging and demographics of those who were MRD positive versus MRD negative,” he said.

Dr. Langer also asked about the findings for shedders versus nonshedders.

“Does this mean nonshedders fare better? This needs to addressed formally,” he said.

Another question is whether the assay “simply enables us to detect relapse sooner and increase anxiety,” or if the trajectory and outcomes in those who prove MRD positive ahead of radiographic manifestations can actually be altered.

A study comparing standard observation with early immunotherapy or chemoimmunotherapy in patients with MRD-positive radiographically occult relapse or progression – using progression-free and overall survival, along with time without symptoms of disease or relapse – would be useful, Dr. Langer said.

“A hazard ratio of 0.8 or less would be meaningful,” he added. “In this regard, there are trials looking at enhanced adjuvant treatment both in colorectal and breast cancer, and trials planned in advanced non–small cell [lung cancer].”

Dr. Langer also said it would be interesting to know if the assay can be used as an adjunct to diagnosis in frailer patients with inaccessible tumors or equivocal biopsy results or to avoid invasive procedures in patients who are stereotactic radiation candidates.

“The jury is still out on this,” he said.

TRACERx is funded by University College London in collaboration with Cancer Research UK. Dr. Abbosh disclosed relationships with AstraZeneca, Novartis, Roche Diagnostics, Bristol Myers Squibb, Achilles Therapeutics, and Archer Diagnostics. Dr. Langer reported grant/research support and/or scientific advisory work for multiple companies.

[email protected]

SOURCE: Abbosh C et al. AACR 2020, Abstract CT023.

Minimal residual disease (MRD) surveillance after surgery can detect relapse in advance of imaging in patients with early-stage non–small cell lung cancer (NSCLC), according to findings from the TRACERx study.

The findings pave the way for clinical trials of MRD-driven treatment escalation, Chris Abbosh, MD, of University College London, reported during a presentation at the AACR virtual meeting I. Data in the presentation were updated from the abstract.

Dr. Abbosh and colleagues used phylogenetic circulating tumor DNA (ctDNA) profiling to assess MRD and predict relapse in patients from the TRACERx study who underwent surgery for stage I-III NSCLC.

“The approach we take is technically termed a ‘tumor-informed, personalized cell-free DNA-enrichment approach,’” Dr. Abbosh explained. “We take out the primary tumor from the patient, we multiregion sample that tumor, and submit each region for deep whole-exome sequencing.”

The researchers prioritize variants for MRD tracking based on clonality/subclonality, high copy number status, and low background sequencing noise. The researchers then construct an anchored-multiplex PCR panel against the positions of interest, which is applied to cell-free DNA in the pre- and postoperative setting.

“We’ve developed an MRD caller to go alongside this chemistry,” Dr. Abbosh said. “The main premise behind the MRD caller is that it can calculate intralibrary error rates to inform the MRD pool.”
 

Sensitivity and specificity

To validate their approach, Dr. Abbosh and colleagues tested the assay with low DNA input (5 ng, 10 ng) and high DNA input (30 ng, 60 ng). They found the assay to be more sensitive with higher DNA input, and variant fractions were detected down to 0.003%.

The researchers also assessed how sensitivity and specificity scale with an increasing number of variants – 50, 100, or 200 variants. When tracking 200 variants, the assay was powered to detect lower ctDNA fractions than when tracking 50 variants. On the other hand, specificity was higher with 50 variants (99.8%) than with 200 variants (99.4%).

Next, Dr. Abbosh and colleagues analyzed postoperative cell-free DNA collected at 271 time points from 37 NSCLC patients who did not relapse. This included 11 patients who developed proven second primary malignancies.

Of the 271 time points when MRD negativity was expected, MRD was not detected at 269 time points, which translates to 99.3% specificity for the assay.
 

Shedding, relapse, and disease-free survival

Dr. Abbosh and colleagues also found that non-adenocarcinoma histology is associated with preoperative ctDNA shedding in NSCLC. The researchers analyzed 88 early-stage preoperative samples from NSCLC patients. ctDNA was detected preoperatively in 49% of lung adenocarcinomas and 100% of lung squamous cell carcinomas.

“This finding is important when it comes to interpreting our non–small cell lung cancer relapse data from 53 TRACERx patients,” Dr. Abbosh said.

Of the 53 patients who relapsed, 42 had ctDNA detected prior to surgery and were thus considered shedders, while 11 were nonshedders. ctDNA was detectable at or before relapse in 91% (38/42) of shedders and 64% (7/11) of nonshedders.

The median time from ctDNA detection to clinical relapse was 164 days in shedders and 22 days in nonshedders. The median disease-free survival was 362 days and 640 days, respectively.

“So what these data suggest is that preoperative ctDNA detection status will be a proxy of the potential utility of ctDNA as an MRD biomarker in a clinical setting,” Dr. Abbosh explained.

Standard-of-care imaging findings in the 53 patients who relapsed further demonstrated the utility of ctDNA in this setting, Dr. Abbosh said.

All scans were divided into three categories: those showing unequivocal relapse, those with a new equivocal change (relapse, inflammation, or a nonspecific finding), and those with no evidence of relapse. Each was further categorized by preimaging MRD status.

Relapse occurred in 9 of 10 patients who were MRD positive but had a scan showing no evidence of relapse. Relapse occurred in 15 of 16 patients who were MRD positive and had scans showing new equivocal changes.

Patients with unequivocal evidence of relapse who were MRD negative at or before the scan were more likely to have a second primary cancer than to have NSCLC relapse (52% vs. 48%), which is a reflection of the specificity of the MRD assay to the primary tumor, Dr. Abbosh said.
 

Implications of the findings

The researchers’ findings are important because establishing an MRD-driven approach to treating early-stage NSCLC would facilitate escalation of standard-of-care treatment only for those patients at high risk for relapse, thereby overcoming a key challenge in conventional adjuvant drug-trial design, Dr. Abbosh said.

“If we take a patient population with high-risk early-stage disease who have undergone potentially curative resection of their cancer and we offer these patients adjuvant chemotherapy or adjuvant chemoradiation therapy, then we can improve 5-year survival outcomes in this population,” Dr. Abbosh said. “This is striking because, if we give the same treatment in the metastatic setting, we only see a progression-free survival benefit of a short number of months.”

This suggests a potential “vulnerability of low-burden residual cancer to systemic treatment following surgery,” he added. “So if we want to improve outcomes further in non–small cell lung cancer, we really need to focus on innovation in the early-stage space.”

Dr. Abbosh said he and colleagues demonstrated that “personalized cell-free DNA enrichment can detect low-frequency variant DNA in an accurate manner.

“We’ve shown that preoperative ctDNA shedding is associated with utility of ctDNA as an MRD biomarker and that MRD surveillance can lead to detection of relapse in advance of standard-of-care-imaging,” he said. “We feel that the field is now ready for MRD-driven adjuvant trials.”
 

Questions to be answered

Invited discussant Corey J. Langer, MD, of Penn Medicine in Philadelphia, outlined “fundamental questions” raised by the findings.

“We need more information on the staging and demographics of those who were MRD positive versus MRD negative,” he said.

Dr. Langer also asked about the findings for shedders versus nonshedders.

“Does this mean nonshedders fare better? This needs to addressed formally,” he said.

Another question is whether the assay “simply enables us to detect relapse sooner and increase anxiety,” or if the trajectory and outcomes in those who prove MRD positive ahead of radiographic manifestations can actually be altered.

A study comparing standard observation with early immunotherapy or chemoimmunotherapy in patients with MRD-positive radiographically occult relapse or progression – using progression-free and overall survival, along with time without symptoms of disease or relapse – would be useful, Dr. Langer said.

“A hazard ratio of 0.8 or less would be meaningful,” he added. “In this regard, there are trials looking at enhanced adjuvant treatment both in colorectal and breast cancer, and trials planned in advanced non–small cell [lung cancer].”

Dr. Langer also said it would be interesting to know if the assay can be used as an adjunct to diagnosis in frailer patients with inaccessible tumors or equivocal biopsy results or to avoid invasive procedures in patients who are stereotactic radiation candidates.

“The jury is still out on this,” he said.

TRACERx is funded by University College London in collaboration with Cancer Research UK. Dr. Abbosh disclosed relationships with AstraZeneca, Novartis, Roche Diagnostics, Bristol Myers Squibb, Achilles Therapeutics, and Archer Diagnostics. Dr. Langer reported grant/research support and/or scientific advisory work for multiple companies.

[email protected]

SOURCE: Abbosh C et al. AACR 2020, Abstract CT023.

Minimal residual disease (MRD) surveillance after surgery can detect relapse in advance of imaging in patients with early-stage non–small cell lung cancer (NSCLC), according to findings from the TRACERx study.

The findings pave the way for clinical trials of MRD-driven treatment escalation, Chris Abbosh, MD, of University College London, reported during a presentation at the AACR virtual meeting I. Data in the presentation were updated from the abstract.

Dr. Abbosh and colleagues used phylogenetic circulating tumor DNA (ctDNA) profiling to assess MRD and predict relapse in patients from the TRACERx study who underwent surgery for stage I-III NSCLC.

“The approach we take is technically termed a ‘tumor-informed, personalized cell-free DNA-enrichment approach,’” Dr. Abbosh explained. “We take out the primary tumor from the patient, we multiregion sample that tumor, and submit each region for deep whole-exome sequencing.”

The researchers prioritize variants for MRD tracking based on clonality/subclonality, high copy number status, and low background sequencing noise. The researchers then construct an anchored-multiplex PCR panel against the positions of interest, which is applied to cell-free DNA in the pre- and postoperative setting.

“We’ve developed an MRD caller to go alongside this chemistry,” Dr. Abbosh said. “The main premise behind the MRD caller is that it can calculate intralibrary error rates to inform the MRD pool.”
 

Sensitivity and specificity

To validate their approach, Dr. Abbosh and colleagues tested the assay with low DNA input (5 ng, 10 ng) and high DNA input (30 ng, 60 ng). They found the assay to be more sensitive with higher DNA input, and variant fractions were detected down to 0.003%.

The researchers also assessed how sensitivity and specificity scale with an increasing number of variants – 50, 100, or 200 variants. When tracking 200 variants, the assay was powered to detect lower ctDNA fractions than when tracking 50 variants. On the other hand, specificity was higher with 50 variants (99.8%) than with 200 variants (99.4%).

Next, Dr. Abbosh and colleagues analyzed postoperative cell-free DNA collected at 271 time points from 37 NSCLC patients who did not relapse. This included 11 patients who developed proven second primary malignancies.

Of the 271 time points when MRD negativity was expected, MRD was not detected at 269 time points, which translates to 99.3% specificity for the assay.
 

Shedding, relapse, and disease-free survival

Dr. Abbosh and colleagues also found that non-adenocarcinoma histology is associated with preoperative ctDNA shedding in NSCLC. The researchers analyzed 88 early-stage preoperative samples from NSCLC patients. ctDNA was detected preoperatively in 49% of lung adenocarcinomas and 100% of lung squamous cell carcinomas.

“This finding is important when it comes to interpreting our non–small cell lung cancer relapse data from 53 TRACERx patients,” Dr. Abbosh said.

Of the 53 patients who relapsed, 42 had ctDNA detected prior to surgery and were thus considered shedders, while 11 were nonshedders. ctDNA was detectable at or before relapse in 91% (38/42) of shedders and 64% (7/11) of nonshedders.

The median time from ctDNA detection to clinical relapse was 164 days in shedders and 22 days in nonshedders. The median disease-free survival was 362 days and 640 days, respectively.

“So what these data suggest is that preoperative ctDNA detection status will be a proxy of the potential utility of ctDNA as an MRD biomarker in a clinical setting,” Dr. Abbosh explained.

Standard-of-care imaging findings in the 53 patients who relapsed further demonstrated the utility of ctDNA in this setting, Dr. Abbosh said.

All scans were divided into three categories: those showing unequivocal relapse, those with a new equivocal change (relapse, inflammation, or a nonspecific finding), and those with no evidence of relapse. Each was further categorized by preimaging MRD status.

Relapse occurred in 9 of 10 patients who were MRD positive but had a scan showing no evidence of relapse. Relapse occurred in 15 of 16 patients who were MRD positive and had scans showing new equivocal changes.

Patients with unequivocal evidence of relapse who were MRD negative at or before the scan were more likely to have a second primary cancer than to have NSCLC relapse (52% vs. 48%), which is a reflection of the specificity of the MRD assay to the primary tumor, Dr. Abbosh said.
 

Implications of the findings

The researchers’ findings are important because establishing an MRD-driven approach to treating early-stage NSCLC would facilitate escalation of standard-of-care treatment only for those patients at high risk for relapse, thereby overcoming a key challenge in conventional adjuvant drug-trial design, Dr. Abbosh said.

“If we take a patient population with high-risk early-stage disease who have undergone potentially curative resection of their cancer and we offer these patients adjuvant chemotherapy or adjuvant chemoradiation therapy, then we can improve 5-year survival outcomes in this population,” Dr. Abbosh said. “This is striking because, if we give the same treatment in the metastatic setting, we only see a progression-free survival benefit of a short number of months.”

This suggests a potential “vulnerability of low-burden residual cancer to systemic treatment following surgery,” he added. “So if we want to improve outcomes further in non–small cell lung cancer, we really need to focus on innovation in the early-stage space.”

Dr. Abbosh said he and colleagues demonstrated that “personalized cell-free DNA enrichment can detect low-frequency variant DNA in an accurate manner.

“We’ve shown that preoperative ctDNA shedding is associated with utility of ctDNA as an MRD biomarker and that MRD surveillance can lead to detection of relapse in advance of standard-of-care-imaging,” he said. “We feel that the field is now ready for MRD-driven adjuvant trials.”
 

Questions to be answered

Invited discussant Corey J. Langer, MD, of Penn Medicine in Philadelphia, outlined “fundamental questions” raised by the findings.

“We need more information on the staging and demographics of those who were MRD positive versus MRD negative,” he said.

Dr. Langer also asked about the findings for shedders versus nonshedders.

“Does this mean nonshedders fare better? This needs to addressed formally,” he said.

Another question is whether the assay “simply enables us to detect relapse sooner and increase anxiety,” or if the trajectory and outcomes in those who prove MRD positive ahead of radiographic manifestations can actually be altered.

A study comparing standard observation with early immunotherapy or chemoimmunotherapy in patients with MRD-positive radiographically occult relapse or progression – using progression-free and overall survival, along with time without symptoms of disease or relapse – would be useful, Dr. Langer said.

“A hazard ratio of 0.8 or less would be meaningful,” he added. “In this regard, there are trials looking at enhanced adjuvant treatment both in colorectal and breast cancer, and trials planned in advanced non–small cell [lung cancer].”

Dr. Langer also said it would be interesting to know if the assay can be used as an adjunct to diagnosis in frailer patients with inaccessible tumors or equivocal biopsy results or to avoid invasive procedures in patients who are stereotactic radiation candidates.

“The jury is still out on this,” he said.

TRACERx is funded by University College London in collaboration with Cancer Research UK. Dr. Abbosh disclosed relationships with AstraZeneca, Novartis, Roche Diagnostics, Bristol Myers Squibb, Achilles Therapeutics, and Archer Diagnostics. Dr. Langer reported grant/research support and/or scientific advisory work for multiple companies.

[email protected]

SOURCE: Abbosh C et al. AACR 2020, Abstract CT023.

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

A version of this article originally appeared on Medscape.com.

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

A version of this article originally appeared on Medscape.com.

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

A version of this article originally appeared on Medscape.com.

COVID-19 patients treated in intensive care units are at increased risk for delirium, and a bedside risk management strategy based on modifiable risk factors can help prevent lingering effects on cognition, according to an article published in Critical Care.

Andrei Malov/Thinkstock

Several factors can contribute to an increased risk of ICU delirium in COVID-19 patients, wrote Katarzyna Kotfis, MD, of Pomeranian Medical University, Szczecin, Poland, and colleagues.

“In patients with COVID-19, delirium may be a manifestation of direct central nervous system invasion, induction of CNS inflammatory mediators, a secondary effect of other organ system failure, an effect of sedative strategies, prolonged mechanical ventilation time, or environmental factors, including social isolation,” they said.

Delirium in the context of COVID-19 can mean an early sign of infection, so patients should be screened using dedicated psychometric tools, the researchers wrote. Also, COVID-19 has been shown to cause pneumonia in elderly patients, who are at high risk for severe pulmonary disease related to COVID-19 and for ICU delirium generally, they said.

In addition, don’t underestimate the impact of social isolation created by quarantines, the researchers said.

“What is needed now, is not only high-quality ICU care, concentrated on providing adequate respiratory support to critically ill patients, but an identification of the source and degree of mental and spiritual suffering of patients as well as their families to provide the most ethical and person-centered care during this humanitarian crisis,” they emphasized. However, they acknowledged that nonpharmacologic interventions such as mobility outside the ICU room and interactions with family members are limited by the COVID-19 situation.

The researchers noted several mechanisms by which the COVID-19 virus may cause brain damage, including through the dysfunction of the renin-angiotensin system.

“Inflammatory response of the CNS to viral infection seems to be another important reason for poor neurological outcome and occurrence of delirium,” in COVID-19 patients, they said.

As for risk-reduction strategies, the researchers noted that “delirium in mechanically ventilated patients can be reduced dramatically to 50% using a culture of lighter sedation and mobilization via the implementation of the safety bundle called the ABCDEFs promoted by the Society of Critical Care Medicine in their ICU Liberation Collaborative,” although COVID-19 isolation is a barrier, they said.

The ABCDEF bundle consists of Assessment of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation, Delirium (hyperactive or hypoactive), Early mobility, and Family presence; all of which are challenging in the COVID-19 environment, the researchers said.

They advised implementing easy screening methods for delirium to reduce the burden on medical staff, and emphasized the importance of regular patient orientation, despite social separation from family and caregivers.

“No drugs can be recommended for the prevention or treatment of ICU delirium other than avoidance of overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management,” they added.

“Delirium is so common and so hard to manage in the COVID-19 population,” Mangala Narasimhan, DO, of Northwell Health in New Hyde Park, N.Y., said in an interview. Delirium is impacted by many sources including a viral encephalopathy, the amount and duration of sedation medications, and prolonged intubation and hypoxemia, she said. “Managing the delirium allows you to wake the patient up successfully and without a lot of discoordination. This will help with weaning,” she noted. Barriers to delirium management for COVID-19 patients include the length of time on a ventilator, as well as amount of sedatives and paralytics, and the added issues of renal insufficiency, she noted. “How they can be addressed is thoughtful plans on the addition of long-term sedation for withdrawal symptoms, and anxiolytics for the profound anxiety associated with arousal from this type of sedation on ventilators, she said. The take-home message for clinicians is the need to perform weaning trials to manage delirium in the ICU. “We have to combat this delirium in order to be successful in taking these patients off of ventilators,” she said. Dr. Narasimhan added that more research is needed on areas including drug-to-drug interactions, duration of efficacy of various drugs, and how the virus affects the brain.

“Adherence to the ABCDEF bundle can reduce the incidence of delirium, from approximately 75% of mechanically ventilated patients to 50% or less,” David L. Bowton, MD, of Wake Forest Baptist Health in Winston-Salem, N.C., said in an interview.

“Importantly, in most studies, bundle adherence reduces mortality and ICU length of stay and lowers the total cost of care. However, isolation of patients and protection of staff, visitor restrictions, and potentially stressed staffing will likely alter how most institutions approach bundle compliance,” he said. “Gathering input from infection control clinicians and bedside providers from multiple disciplines that consider these factors to critically examine current bundle procedures and workflow will be essential to the creation and/or revision of bundle processes of care that maintain the integrity of the ABCDEF bundle yet preserve staff, patient, and family safety,” he said.

“We did not have strong evidence to suggest an optimal approach to treating delirium before the advent of the COVID-19 pandemic, so I do not believe we know what the best approach is in the current environment,” Dr. Bowton added. “Further, vigilance will be necessary to ensure that altered consciousness or cognition is ICU delirium and not attributable to another cause such as drug withdrawal, drug adverse effect, or primary central nervous system infection or immune response that mandates specific therapy,” he emphasized.

For clinicians, “this study reminds us of the importance of the ABCDEF bundle to improve outcomes of critical illness,” said Dr. Bowton. “It highlights the difficulties of providing frequent reassessment of pain, comfort, reassurance, and reorientation to critically ill patients. To me, it underscores the importance of each institution critically examining staffing needs and staffing roles to mitigate these difficulties and to explore novel methods of maintaining staff-patient and family-patient interactions to enhance compliance with all elements of the ABCDEF bundle while maintaining the safety of staff and families.”

Dr. Bowton added, “When necessary, explicit modifications to existing ABCDEF bundles should be developed and disseminated to provide realistic, readily understood guidance to achieve the best possible compliance with each bundle element. One potentially underrecognized issue will be the large, hopefully temporary, number of people requiring post–critical illness rehabilitation and mental health services,” he said. “In many regions these services are already underfunded and ill-equipped to handle an increased demand for these services,” he noted.

Additional research is needed in many areas, said Dr. Bowton. “While compliance with the ABCDEF bundle decreases the incidence and duration of delirium, decreases ICU length of stay, decreases duration of mechanical ventilation, and improves mortality, many questions remain. Individual elements of the bundle have been inconsistently associated with improved outcomes,” he said. “What is the relative importance of specific elements and what are the mechanisms by which they improve outcomes?” he asked. “We still do not know how to best achieve physical/functional recovery following critical illness, which, in light of these authors’ studies relating persisting physical debility to depression (Lancet Respir Med. 2014; 2[5]:369-79), may be a key component to improving long-term outcomes,” he said.

The study received no specific funding, although several coauthors disclosed grants from agencies including the National Center for Advancing Translational Sciences, National Institute of General Medical Sciences, National Heart, Lung, and Blood Institute, and National Institute on Aging. Dr. Narasimhan and Dr. Bowton had no financial conflicts to disclose.

SOURCE: Kotfis K et al. Critical Care. 2020 Apr 28. doi: 10.1186/s13054-020-02882-x.

COVID-19 patients treated in intensive care units are at increased risk for delirium, and a bedside risk management strategy based on modifiable risk factors can help prevent lingering effects on cognition, according to an article published in Critical Care.

Andrei Malov/Thinkstock

Several factors can contribute to an increased risk of ICU delirium in COVID-19 patients, wrote Katarzyna Kotfis, MD, of Pomeranian Medical University, Szczecin, Poland, and colleagues.

“In patients with COVID-19, delirium may be a manifestation of direct central nervous system invasion, induction of CNS inflammatory mediators, a secondary effect of other organ system failure, an effect of sedative strategies, prolonged mechanical ventilation time, or environmental factors, including social isolation,” they said.

Delirium in the context of COVID-19 can mean an early sign of infection, so patients should be screened using dedicated psychometric tools, the researchers wrote. Also, COVID-19 has been shown to cause pneumonia in elderly patients, who are at high risk for severe pulmonary disease related to COVID-19 and for ICU delirium generally, they said.

In addition, don’t underestimate the impact of social isolation created by quarantines, the researchers said.

“What is needed now, is not only high-quality ICU care, concentrated on providing adequate respiratory support to critically ill patients, but an identification of the source and degree of mental and spiritual suffering of patients as well as their families to provide the most ethical and person-centered care during this humanitarian crisis,” they emphasized. However, they acknowledged that nonpharmacologic interventions such as mobility outside the ICU room and interactions with family members are limited by the COVID-19 situation.

The researchers noted several mechanisms by which the COVID-19 virus may cause brain damage, including through the dysfunction of the renin-angiotensin system.

“Inflammatory response of the CNS to viral infection seems to be another important reason for poor neurological outcome and occurrence of delirium,” in COVID-19 patients, they said.

As for risk-reduction strategies, the researchers noted that “delirium in mechanically ventilated patients can be reduced dramatically to 50% using a culture of lighter sedation and mobilization via the implementation of the safety bundle called the ABCDEFs promoted by the Society of Critical Care Medicine in their ICU Liberation Collaborative,” although COVID-19 isolation is a barrier, they said.

The ABCDEF bundle consists of Assessment of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation, Delirium (hyperactive or hypoactive), Early mobility, and Family presence; all of which are challenging in the COVID-19 environment, the researchers said.

They advised implementing easy screening methods for delirium to reduce the burden on medical staff, and emphasized the importance of regular patient orientation, despite social separation from family and caregivers.

“No drugs can be recommended for the prevention or treatment of ICU delirium other than avoidance of overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management,” they added.

“Delirium is so common and so hard to manage in the COVID-19 population,” Mangala Narasimhan, DO, of Northwell Health in New Hyde Park, N.Y., said in an interview. Delirium is impacted by many sources including a viral encephalopathy, the amount and duration of sedation medications, and prolonged intubation and hypoxemia, she said. “Managing the delirium allows you to wake the patient up successfully and without a lot of discoordination. This will help with weaning,” she noted. Barriers to delirium management for COVID-19 patients include the length of time on a ventilator, as well as amount of sedatives and paralytics, and the added issues of renal insufficiency, she noted. “How they can be addressed is thoughtful plans on the addition of long-term sedation for withdrawal symptoms, and anxiolytics for the profound anxiety associated with arousal from this type of sedation on ventilators, she said. The take-home message for clinicians is the need to perform weaning trials to manage delirium in the ICU. “We have to combat this delirium in order to be successful in taking these patients off of ventilators,” she said. Dr. Narasimhan added that more research is needed on areas including drug-to-drug interactions, duration of efficacy of various drugs, and how the virus affects the brain.

“Adherence to the ABCDEF bundle can reduce the incidence of delirium, from approximately 75% of mechanically ventilated patients to 50% or less,” David L. Bowton, MD, of Wake Forest Baptist Health in Winston-Salem, N.C., said in an interview.

“Importantly, in most studies, bundle adherence reduces mortality and ICU length of stay and lowers the total cost of care. However, isolation of patients and protection of staff, visitor restrictions, and potentially stressed staffing will likely alter how most institutions approach bundle compliance,” he said. “Gathering input from infection control clinicians and bedside providers from multiple disciplines that consider these factors to critically examine current bundle procedures and workflow will be essential to the creation and/or revision of bundle processes of care that maintain the integrity of the ABCDEF bundle yet preserve staff, patient, and family safety,” he said.

“We did not have strong evidence to suggest an optimal approach to treating delirium before the advent of the COVID-19 pandemic, so I do not believe we know what the best approach is in the current environment,” Dr. Bowton added. “Further, vigilance will be necessary to ensure that altered consciousness or cognition is ICU delirium and not attributable to another cause such as drug withdrawal, drug adverse effect, or primary central nervous system infection or immune response that mandates specific therapy,” he emphasized.

For clinicians, “this study reminds us of the importance of the ABCDEF bundle to improve outcomes of critical illness,” said Dr. Bowton. “It highlights the difficulties of providing frequent reassessment of pain, comfort, reassurance, and reorientation to critically ill patients. To me, it underscores the importance of each institution critically examining staffing needs and staffing roles to mitigate these difficulties and to explore novel methods of maintaining staff-patient and family-patient interactions to enhance compliance with all elements of the ABCDEF bundle while maintaining the safety of staff and families.”

Dr. Bowton added, “When necessary, explicit modifications to existing ABCDEF bundles should be developed and disseminated to provide realistic, readily understood guidance to achieve the best possible compliance with each bundle element. One potentially underrecognized issue will be the large, hopefully temporary, number of people requiring post–critical illness rehabilitation and mental health services,” he said. “In many regions these services are already underfunded and ill-equipped to handle an increased demand for these services,” he noted.

Additional research is needed in many areas, said Dr. Bowton. “While compliance with the ABCDEF bundle decreases the incidence and duration of delirium, decreases ICU length of stay, decreases duration of mechanical ventilation, and improves mortality, many questions remain. Individual elements of the bundle have been inconsistently associated with improved outcomes,” he said. “What is the relative importance of specific elements and what are the mechanisms by which they improve outcomes?” he asked. “We still do not know how to best achieve physical/functional recovery following critical illness, which, in light of these authors’ studies relating persisting physical debility to depression (Lancet Respir Med. 2014; 2[5]:369-79), may be a key component to improving long-term outcomes,” he said.

The study received no specific funding, although several coauthors disclosed grants from agencies including the National Center for Advancing Translational Sciences, National Institute of General Medical Sciences, National Heart, Lung, and Blood Institute, and National Institute on Aging. Dr. Narasimhan and Dr. Bowton had no financial conflicts to disclose.

SOURCE: Kotfis K et al. Critical Care. 2020 Apr 28. doi: 10.1186/s13054-020-02882-x.

COVID-19 patients treated in intensive care units are at increased risk for delirium, and a bedside risk management strategy based on modifiable risk factors can help prevent lingering effects on cognition, according to an article published in Critical Care.

Andrei Malov/Thinkstock

Several factors can contribute to an increased risk of ICU delirium in COVID-19 patients, wrote Katarzyna Kotfis, MD, of Pomeranian Medical University, Szczecin, Poland, and colleagues.

“In patients with COVID-19, delirium may be a manifestation of direct central nervous system invasion, induction of CNS inflammatory mediators, a secondary effect of other organ system failure, an effect of sedative strategies, prolonged mechanical ventilation time, or environmental factors, including social isolation,” they said.

Delirium in the context of COVID-19 can mean an early sign of infection, so patients should be screened using dedicated psychometric tools, the researchers wrote. Also, COVID-19 has been shown to cause pneumonia in elderly patients, who are at high risk for severe pulmonary disease related to COVID-19 and for ICU delirium generally, they said.

In addition, don’t underestimate the impact of social isolation created by quarantines, the researchers said.

“What is needed now, is not only high-quality ICU care, concentrated on providing adequate respiratory support to critically ill patients, but an identification of the source and degree of mental and spiritual suffering of patients as well as their families to provide the most ethical and person-centered care during this humanitarian crisis,” they emphasized. However, they acknowledged that nonpharmacologic interventions such as mobility outside the ICU room and interactions with family members are limited by the COVID-19 situation.

The researchers noted several mechanisms by which the COVID-19 virus may cause brain damage, including through the dysfunction of the renin-angiotensin system.

“Inflammatory response of the CNS to viral infection seems to be another important reason for poor neurological outcome and occurrence of delirium,” in COVID-19 patients, they said.

As for risk-reduction strategies, the researchers noted that “delirium in mechanically ventilated patients can be reduced dramatically to 50% using a culture of lighter sedation and mobilization via the implementation of the safety bundle called the ABCDEFs promoted by the Society of Critical Care Medicine in their ICU Liberation Collaborative,” although COVID-19 isolation is a barrier, they said.

The ABCDEF bundle consists of Assessment of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation, Delirium (hyperactive or hypoactive), Early mobility, and Family presence; all of which are challenging in the COVID-19 environment, the researchers said.

They advised implementing easy screening methods for delirium to reduce the burden on medical staff, and emphasized the importance of regular patient orientation, despite social separation from family and caregivers.

“No drugs can be recommended for the prevention or treatment of ICU delirium other than avoidance of overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management,” they added.

“Delirium is so common and so hard to manage in the COVID-19 population,” Mangala Narasimhan, DO, of Northwell Health in New Hyde Park, N.Y., said in an interview. Delirium is impacted by many sources including a viral encephalopathy, the amount and duration of sedation medications, and prolonged intubation and hypoxemia, she said. “Managing the delirium allows you to wake the patient up successfully and without a lot of discoordination. This will help with weaning,” she noted. Barriers to delirium management for COVID-19 patients include the length of time on a ventilator, as well as amount of sedatives and paralytics, and the added issues of renal insufficiency, she noted. “How they can be addressed is thoughtful plans on the addition of long-term sedation for withdrawal symptoms, and anxiolytics for the profound anxiety associated with arousal from this type of sedation on ventilators, she said. The take-home message for clinicians is the need to perform weaning trials to manage delirium in the ICU. “We have to combat this delirium in order to be successful in taking these patients off of ventilators,” she said. Dr. Narasimhan added that more research is needed on areas including drug-to-drug interactions, duration of efficacy of various drugs, and how the virus affects the brain.

“Adherence to the ABCDEF bundle can reduce the incidence of delirium, from approximately 75% of mechanically ventilated patients to 50% or less,” David L. Bowton, MD, of Wake Forest Baptist Health in Winston-Salem, N.C., said in an interview.

“Importantly, in most studies, bundle adherence reduces mortality and ICU length of stay and lowers the total cost of care. However, isolation of patients and protection of staff, visitor restrictions, and potentially stressed staffing will likely alter how most institutions approach bundle compliance,” he said. “Gathering input from infection control clinicians and bedside providers from multiple disciplines that consider these factors to critically examine current bundle procedures and workflow will be essential to the creation and/or revision of bundle processes of care that maintain the integrity of the ABCDEF bundle yet preserve staff, patient, and family safety,” he said.

“We did not have strong evidence to suggest an optimal approach to treating delirium before the advent of the COVID-19 pandemic, so I do not believe we know what the best approach is in the current environment,” Dr. Bowton added. “Further, vigilance will be necessary to ensure that altered consciousness or cognition is ICU delirium and not attributable to another cause such as drug withdrawal, drug adverse effect, or primary central nervous system infection or immune response that mandates specific therapy,” he emphasized.

For clinicians, “this study reminds us of the importance of the ABCDEF bundle to improve outcomes of critical illness,” said Dr. Bowton. “It highlights the difficulties of providing frequent reassessment of pain, comfort, reassurance, and reorientation to critically ill patients. To me, it underscores the importance of each institution critically examining staffing needs and staffing roles to mitigate these difficulties and to explore novel methods of maintaining staff-patient and family-patient interactions to enhance compliance with all elements of the ABCDEF bundle while maintaining the safety of staff and families.”

Dr. Bowton added, “When necessary, explicit modifications to existing ABCDEF bundles should be developed and disseminated to provide realistic, readily understood guidance to achieve the best possible compliance with each bundle element. One potentially underrecognized issue will be the large, hopefully temporary, number of people requiring post–critical illness rehabilitation and mental health services,” he said. “In many regions these services are already underfunded and ill-equipped to handle an increased demand for these services,” he noted.

Additional research is needed in many areas, said Dr. Bowton. “While compliance with the ABCDEF bundle decreases the incidence and duration of delirium, decreases ICU length of stay, decreases duration of mechanical ventilation, and improves mortality, many questions remain. Individual elements of the bundle have been inconsistently associated with improved outcomes,” he said. “What is the relative importance of specific elements and what are the mechanisms by which they improve outcomes?” he asked. “We still do not know how to best achieve physical/functional recovery following critical illness, which, in light of these authors’ studies relating persisting physical debility to depression (Lancet Respir Med. 2014; 2[5]:369-79), may be a key component to improving long-term outcomes,” he said.

The study received no specific funding, although several coauthors disclosed grants from agencies including the National Center for Advancing Translational Sciences, National Institute of General Medical Sciences, National Heart, Lung, and Blood Institute, and National Institute on Aging. Dr. Narasimhan and Dr. Bowton had no financial conflicts to disclose.

SOURCE: Kotfis K et al. Critical Care. 2020 Apr 28. doi: 10.1186/s13054-020-02882-x.