Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Antireflux lifestyle factors may significantly reduce the risk of gastroesophageal reflux disease (GERD), according to an analysis involving almost 43,000 women.

Tharakorn/Getty Images

Even alongside therapy with a proton-pump inhibitor (PPI) and/or a histamine-receptor antagonist (H2RA), adherence to five antireflux lifestyle factors had a meaningful impact on risk for GERD symptoms, possibly preventing nearly 40% of cases with weekly GERD symptoms, reported lead author Raaj S. Mehta, MD, of Massachusetts General Hospital and Harvard Medical School, both in Boston, and colleagues.

“Clinicians recommend dietary and lifestyle modifications to prevent GERD symptoms, but no prospective data are available to inform these recommendations,” Dr. Mehta and colleagues wrote in JAMA Internal Medicine.

To address this gap, the investigators turned to the Nurses’ Health Study II, a nationwide, prospective study involving 116,671 women. The study, which has a follow-up rate exceeding 90%, began in 1989 and is ongoing. Participants complete biennial questionnaires that include a variety of health and lifestyle factors. In 2005, 2009, 2013, and 2017, the questionnaire inquired about heartburn or acid reflux.

The present analysis included data from 42,955 women aged 42-62 years. Participants were excluded at baseline if they had cancer, lacked dietary data, were lost to follow-up, already had GERD symptoms at least weekly, or used a PPI and/or H2RA on a regular basis. The final dataset included 392,215 person-years of follow-up, with 9,291 incident cases of GERD symptoms.

For each participant, the presence of five possible antireflux lifestyle factors were added together for a score ranging from 0 to 5: no more than two cups of soda, tea, or coffee per day; never smoking; normal body weight (BMI ≥18.5 and <25.0 kg/m²); “prudent” diet, based on top 40% of dietary pattern score; and at least 30 minutes of moderate to vigorous physical activity each day.

Multivariate logistic regression modeling showed that women who reported all five antireflux lifestyle factors had a 50% decreased risk of GERD symptoms (hazard ratio, 0.50; 95% confidence interval, 0.42-0.59), compared with women who adhered to none of them. Further analysis suggested that the collective effect of all five factors could reduce GERD symptom case volume by 37% (95% CI, 28%-46%).

Nonadherence to each antireflux lifestyle factor was independently associated with an increased risk of GERD symptoms. After mutual adjustment for other variables, BMI was associated with the highest population-attributable risk (19%), followed by physical activity (8%), food intake (7%), beverage intake (4%), and nonsmoker status (3%).

Dr. Mehta and colleagues also explored the relationship between GERD symptoms, antireflux medications, and lifestyle factors. Presence of all five antireflux factors was associated with a 53% decreased risk of GERD symptoms or initiation of PPI and/or H2RA therapy (HR, 0.47; 95% CI, 0.41-0.54). Among a group of 3,625 women who reported regular use of a PPI and/or H2RA and were free of GERD symptoms at baseline, adherence to all five lifestyle factors reduced risk of GERD symptoms by 68% (HR, 0.32; 95% CI, 0.18-0.57).

One limitation of the study was that its population was primarily White women; however, the authors noted a study suggesting GERD is more common in White women aged 30-60 years.

“Adherence to an antireflux lifestyle, even among regular users of PPIs and/or H2RAs, was associated with a decreased risk of GERD symptoms,” the investigators concluded.

Lifestyle matters

According to Ronnie Fass, MD, medical director of the Digestive Health Center at Case Western Reserve University, Cleveland, “This is the first study to show the incremental effect and thus the benefit of lifestyle factors in reducing the risk of GERD symptoms. While only five lifestyle factors were assessed in this study, potentially others may further decrease the risk for symptoms.”

Dr. Fass suggested that the nature of the data, which was self-reported, and the entirely female patient population, should inform interpretation of the findings.

“While nonerosive reflux disease is relatively more common in women, erosive esophagitis and Barrett’s esophagus are more common in men,” he said. “Furthermore, male gender is associated with more severe GERD and GERD complications.”

Yet Dr. Fass concluded by again emphasizing the merit of the analysis: “This is an important study that further supports the value of certain lifestyle factors in reducing the risk of GERD symptoms,” he said. “What is challenging for practicing physicians is to get patients to follow these lifestyle factors long term.”

The study was funded by the National Institutes of Health and by a Stuart and Suzanne Steele Massachusetts General Hospital Research Scholar Award. The investigators and Dr. Fass disclosed no conflicts of interest.

Antireflux lifestyle factors may significantly reduce the risk of gastroesophageal reflux disease (GERD), according to an analysis involving almost 43,000 women.

Tharakorn/Getty Images

Even alongside therapy with a proton-pump inhibitor (PPI) and/or a histamine-receptor antagonist (H2RA), adherence to five antireflux lifestyle factors had a meaningful impact on risk for GERD symptoms, possibly preventing nearly 40% of cases with weekly GERD symptoms, reported lead author Raaj S. Mehta, MD, of Massachusetts General Hospital and Harvard Medical School, both in Boston, and colleagues.

“Clinicians recommend dietary and lifestyle modifications to prevent GERD symptoms, but no prospective data are available to inform these recommendations,” Dr. Mehta and colleagues wrote in JAMA Internal Medicine.

To address this gap, the investigators turned to the Nurses’ Health Study II, a nationwide, prospective study involving 116,671 women. The study, which has a follow-up rate exceeding 90%, began in 1989 and is ongoing. Participants complete biennial questionnaires that include a variety of health and lifestyle factors. In 2005, 2009, 2013, and 2017, the questionnaire inquired about heartburn or acid reflux.

The present analysis included data from 42,955 women aged 42-62 years. Participants were excluded at baseline if they had cancer, lacked dietary data, were lost to follow-up, already had GERD symptoms at least weekly, or used a PPI and/or H2RA on a regular basis. The final dataset included 392,215 person-years of follow-up, with 9,291 incident cases of GERD symptoms.

For each participant, the presence of five possible antireflux lifestyle factors were added together for a score ranging from 0 to 5: no more than two cups of soda, tea, or coffee per day; never smoking; normal body weight (BMI ≥18.5 and <25.0 kg/m²); “prudent” diet, based on top 40% of dietary pattern score; and at least 30 minutes of moderate to vigorous physical activity each day.

Multivariate logistic regression modeling showed that women who reported all five antireflux lifestyle factors had a 50% decreased risk of GERD symptoms (hazard ratio, 0.50; 95% confidence interval, 0.42-0.59), compared with women who adhered to none of them. Further analysis suggested that the collective effect of all five factors could reduce GERD symptom case volume by 37% (95% CI, 28%-46%).

Nonadherence to each antireflux lifestyle factor was independently associated with an increased risk of GERD symptoms. After mutual adjustment for other variables, BMI was associated with the highest population-attributable risk (19%), followed by physical activity (8%), food intake (7%), beverage intake (4%), and nonsmoker status (3%).

Dr. Mehta and colleagues also explored the relationship between GERD symptoms, antireflux medications, and lifestyle factors. Presence of all five antireflux factors was associated with a 53% decreased risk of GERD symptoms or initiation of PPI and/or H2RA therapy (HR, 0.47; 95% CI, 0.41-0.54). Among a group of 3,625 women who reported regular use of a PPI and/or H2RA and were free of GERD symptoms at baseline, adherence to all five lifestyle factors reduced risk of GERD symptoms by 68% (HR, 0.32; 95% CI, 0.18-0.57).

One limitation of the study was that its population was primarily White women; however, the authors noted a study suggesting GERD is more common in White women aged 30-60 years.

“Adherence to an antireflux lifestyle, even among regular users of PPIs and/or H2RAs, was associated with a decreased risk of GERD symptoms,” the investigators concluded.

Lifestyle matters

According to Ronnie Fass, MD, medical director of the Digestive Health Center at Case Western Reserve University, Cleveland, “This is the first study to show the incremental effect and thus the benefit of lifestyle factors in reducing the risk of GERD symptoms. While only five lifestyle factors were assessed in this study, potentially others may further decrease the risk for symptoms.”

Dr. Fass suggested that the nature of the data, which was self-reported, and the entirely female patient population, should inform interpretation of the findings.

“While nonerosive reflux disease is relatively more common in women, erosive esophagitis and Barrett’s esophagus are more common in men,” he said. “Furthermore, male gender is associated with more severe GERD and GERD complications.”

Yet Dr. Fass concluded by again emphasizing the merit of the analysis: “This is an important study that further supports the value of certain lifestyle factors in reducing the risk of GERD symptoms,” he said. “What is challenging for practicing physicians is to get patients to follow these lifestyle factors long term.”

The study was funded by the National Institutes of Health and by a Stuart and Suzanne Steele Massachusetts General Hospital Research Scholar Award. The investigators and Dr. Fass disclosed no conflicts of interest.

Antireflux lifestyle factors may significantly reduce the risk of gastroesophageal reflux disease (GERD), according to an analysis involving almost 43,000 women.

Tharakorn/Getty Images

Even alongside therapy with a proton-pump inhibitor (PPI) and/or a histamine-receptor antagonist (H2RA), adherence to five antireflux lifestyle factors had a meaningful impact on risk for GERD symptoms, possibly preventing nearly 40% of cases with weekly GERD symptoms, reported lead author Raaj S. Mehta, MD, of Massachusetts General Hospital and Harvard Medical School, both in Boston, and colleagues.

“Clinicians recommend dietary and lifestyle modifications to prevent GERD symptoms, but no prospective data are available to inform these recommendations,” Dr. Mehta and colleagues wrote in JAMA Internal Medicine.

To address this gap, the investigators turned to the Nurses’ Health Study II, a nationwide, prospective study involving 116,671 women. The study, which has a follow-up rate exceeding 90%, began in 1989 and is ongoing. Participants complete biennial questionnaires that include a variety of health and lifestyle factors. In 2005, 2009, 2013, and 2017, the questionnaire inquired about heartburn or acid reflux.

The present analysis included data from 42,955 women aged 42-62 years. Participants were excluded at baseline if they had cancer, lacked dietary data, were lost to follow-up, already had GERD symptoms at least weekly, or used a PPI and/or H2RA on a regular basis. The final dataset included 392,215 person-years of follow-up, with 9,291 incident cases of GERD symptoms.

For each participant, the presence of five possible antireflux lifestyle factors were added together for a score ranging from 0 to 5: no more than two cups of soda, tea, or coffee per day; never smoking; normal body weight (BMI ≥18.5 and <25.0 kg/m²); “prudent” diet, based on top 40% of dietary pattern score; and at least 30 minutes of moderate to vigorous physical activity each day.

Multivariate logistic regression modeling showed that women who reported all five antireflux lifestyle factors had a 50% decreased risk of GERD symptoms (hazard ratio, 0.50; 95% confidence interval, 0.42-0.59), compared with women who adhered to none of them. Further analysis suggested that the collective effect of all five factors could reduce GERD symptom case volume by 37% (95% CI, 28%-46%).

Nonadherence to each antireflux lifestyle factor was independently associated with an increased risk of GERD symptoms. After mutual adjustment for other variables, BMI was associated with the highest population-attributable risk (19%), followed by physical activity (8%), food intake (7%), beverage intake (4%), and nonsmoker status (3%).

Dr. Mehta and colleagues also explored the relationship between GERD symptoms, antireflux medications, and lifestyle factors. Presence of all five antireflux factors was associated with a 53% decreased risk of GERD symptoms or initiation of PPI and/or H2RA therapy (HR, 0.47; 95% CI, 0.41-0.54). Among a group of 3,625 women who reported regular use of a PPI and/or H2RA and were free of GERD symptoms at baseline, adherence to all five lifestyle factors reduced risk of GERD symptoms by 68% (HR, 0.32; 95% CI, 0.18-0.57).

One limitation of the study was that its population was primarily White women; however, the authors noted a study suggesting GERD is more common in White women aged 30-60 years.

“Adherence to an antireflux lifestyle, even among regular users of PPIs and/or H2RAs, was associated with a decreased risk of GERD symptoms,” the investigators concluded.

Lifestyle matters

According to Ronnie Fass, MD, medical director of the Digestive Health Center at Case Western Reserve University, Cleveland, “This is the first study to show the incremental effect and thus the benefit of lifestyle factors in reducing the risk of GERD symptoms. While only five lifestyle factors were assessed in this study, potentially others may further decrease the risk for symptoms.”

Dr. Fass suggested that the nature of the data, which was self-reported, and the entirely female patient population, should inform interpretation of the findings.

“While nonerosive reflux disease is relatively more common in women, erosive esophagitis and Barrett’s esophagus are more common in men,” he said. “Furthermore, male gender is associated with more severe GERD and GERD complications.”

Yet Dr. Fass concluded by again emphasizing the merit of the analysis: “This is an important study that further supports the value of certain lifestyle factors in reducing the risk of GERD symptoms,” he said. “What is challenging for practicing physicians is to get patients to follow these lifestyle factors long term.”

The study was funded by the National Institutes of Health and by a Stuart and Suzanne Steele Massachusetts General Hospital Research Scholar Award. The investigators and Dr. Fass disclosed no conflicts of interest.

In January, as Mississippi health officials planned for their incoming shipments of COVID-19 vaccine, they assessed the state’s most vulnerable: health care workers, of course, and elderly people in nursing homes. But among those who needed urgent protection from the virus ripping across the Magnolia State were 1 million Mississippians with obesity.

Obesity and weight-related illnesses have been deadly liabilities in the COVID era. A report released this month by the World Obesity Federation found that increased body weight is the second-greatest predictor of COVID-related hospitalization and death across the globe, trailing only old age as a risk factor.

As a fixture of life in the American South – home to 9 of the nation’s 12 heaviest states – obesity is playing a role not only in COVID outcomes, but in the calculus of the vaccination rollout. Mississippi was one of the first states to add a body mass index of 30 or more (a rough gauge of obesity tied to height and weight) to the list of qualifying medical conditions for a shot. About 40% of the state’s adults meet that definition, according to federal health survey data, and combined with the risk group already eligible for vaccination – residents 65 and older – that means fully half of Mississippi’s adults are entitled to vie for a restricted allotment of shots.

At least 29 states have green-lighted obesity for inclusion in the first phases of the vaccine rollout, according to KFF – a vast widening of eligibility that has the potential to overwhelm government efforts and heighten competition for scarce doses.

“We have a lifesaving intervention, and we don’t have enough of it,” said Jen Kates, PhD, director of global health and HIV policy for Kaiser Family Foundation. “Hard choices are being made about who should go first, and there is no right answer.”

The sheer prevalence of obesity in the nation – two in three Americans exceed what is considered a healthy weight – was a public health concern well before the pandemic. But COVID-19 dramatically fast-tracked the discussion from warnings about the long-term damage excess fat tissue can pose to heart, lung and metabolic functions to far more immediate threats.

In the United Kingdom, for example, overweight COVID patients were 67% more likely to require intensive care, and obese patients three times likelier, according to the World Obesity Federation report. A Centers for Disease Control and Prevention study released Monday found a similar trend among U.S. patients and noted that the risk of COVID-related hospitalization, ventilation and death increased with patients’ obesity level.

The counties that hug the southern Mississippi River are home to some of the most concentrated pockets of extreme obesity in the United States. Coronavirus infections began surging in Southern states early last summer, and hospitalizations rose in step.

Deaths in rural stretches of Arkansas, Louisiana, Mississippi, and Tennessee have been overshadowed by the sheer number of deaths in metropolitan areas like New York, Los Angeles, and Essex County, N.J. But as a share of the population, the coronavirus has been similarly unsparing in many Southern communities. In sparsely populated Claiborne County, Miss., on the floodplains of the Mississippi River, 30 residents – about 1 in 300 – had died as of early March. In East Feliciana Parish, La., north of Baton Rouge, with 106 deaths, about 1 in 180 had died by then.

“It’s just math. If the population is more obese and obesity clearly contributes to worse outcomes, then neighborhoods, cities, states and countries that are more obese will have a greater toll from COVID,” said Dr. James de Lemos, MD, a professor of internal medicine at UT Southwestern Medical Center in Dallas who led a study of hospitalized COVID patients published in the medical journal Circulation.

And, because in the U.S. obesity rates tend to be relatively high among African Americans and Latinos who are poor, with diminished access to health care, “it’s a triple whammy,” Dr. de Lemos said. “All these things intersect.”

Poverty and limited access to medical care are common features in the South, where residents like Michelle Antonyshyn, a former registered nurse and mother of seven in Salem, Ark., say they are afraid of the virus. Ms. Antonyshyn, 49, has obesity and debilitating pain in her knees and back, though she does not have high blood pressure or diabetes, two underlying conditions that federal health officials have determined are added risk factors for severe cases of COVID-19.

Still, she said, she “was very concerned just knowing that being obese puts you more at risk for bad outcomes such as being on a ventilator and death.” As a precaution, Ms. Antonyshyn said, she and her large brood locked down early and stopped attending church services in person, watching online instead.

“It’s not the same as having fellowship, but the risk for me was enough,” said Ms. Antonyshyn.

Governors throughout the South seem to recognize that weight can contribute to COVID-19 complications and have pushed for vaccine eligibility rules that prioritize obesity. But on the ground, local health officials are girding for having to tell newly eligible people who qualify as obese that there aren’t enough shots to go around.

In Port Gibson, Miss., Mheja Williams, MD, medical director of the Claiborne County Family Health Center, has been receiving barely enough doses to inoculate the health workers and oldest seniors in her county of 9,600. One week in early February, she received 100 doses.

Obesity and extreme obesity are endemic in Claiborne County, and health officials say the “normalization” of obesity means people often don’t register their weight as a risk factor, whether for COVID or other health issues. The risks are exacerbated by a general flouting of pandemic etiquette: Dr. Williams said that middle-aged and younger residents are not especially vigilant about physical distancing and that mask use is rare.

The rise of obesity in the United States is well documented over the past half-century, as the nation turned from a diet of fruits, vegetables and limited meats to one laden with ultra-processed foods and rich with salt, fat, sugar, and flavorings, along with copious amounts of meat, fast food, and soda. The U.S. has generally led the global obesity race, setting records as even toddlers and young children grew implausibly, dangerously overweight.

Well before COVID, obesity was a leading cause of preventable death in the United States. The National Institutes of Health declared it a disease in 1998, one that fosters heart disease, stroke, type 2 diabetes, and breast, colon, and other cancers.

Researchers say it is no coincidence that nations like the United States, the United Kingdom, and Italy, with relatively high obesity rates, have proved particularly vulnerable to the novel coronavirus.

They believe the virus may exploit underlying metabolic and physiological impairments that often exist in concert with obesity. Extra fat can lead to a cascade of metabolic disruptions, chronic systemic inflammation, and hormonal dysregulation that may thwart the body’s response to infection.

Other respiratory viruses, like influenza and SARS, which appeared in China in 2002, rely on cholesterol to spread enveloped RNA virus to neighboring cells, and researchers have proposed that a similar mechanism may play a role in the spread of the novel coronavirus.

There are also practical problems for coronavirus patients with obesity admitted to the hospital. They can be more difficult to intubate because of excess central weight pressing down on the diaphragm, making breathing with infected lungs even more difficult.

Physicians who specialize in treating patients with obesity say public health officials need to be more forthright and urgent in their messaging, telegraphing the risks of this COVID era.

“It should be explicit and direct,” said Fatima Stanford, MD, an obesity medicine specialist at Massachusetts General Hospital, Boston, and a Harvard Medical School instructor.

Dr. Stanford denounces the fat-shaming and bullying that people with obesity often experience. But telling patients – and the public – that obesity increases the risk of hospitalization and death is crucial, she said.

“I don’t think it’s stigmatizing,” she said. “If you tell them in that way, it’s not to scare you, it’s just giving information. Sometimes people are just unaware.”



KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

In January, as Mississippi health officials planned for their incoming shipments of COVID-19 vaccine, they assessed the state’s most vulnerable: health care workers, of course, and elderly people in nursing homes. But among those who needed urgent protection from the virus ripping across the Magnolia State were 1 million Mississippians with obesity.

Obesity and weight-related illnesses have been deadly liabilities in the COVID era. A report released this month by the World Obesity Federation found that increased body weight is the second-greatest predictor of COVID-related hospitalization and death across the globe, trailing only old age as a risk factor.

As a fixture of life in the American South – home to 9 of the nation’s 12 heaviest states – obesity is playing a role not only in COVID outcomes, but in the calculus of the vaccination rollout. Mississippi was one of the first states to add a body mass index of 30 or more (a rough gauge of obesity tied to height and weight) to the list of qualifying medical conditions for a shot. About 40% of the state’s adults meet that definition, according to federal health survey data, and combined with the risk group already eligible for vaccination – residents 65 and older – that means fully half of Mississippi’s adults are entitled to vie for a restricted allotment of shots.

At least 29 states have green-lighted obesity for inclusion in the first phases of the vaccine rollout, according to KFF – a vast widening of eligibility that has the potential to overwhelm government efforts and heighten competition for scarce doses.

“We have a lifesaving intervention, and we don’t have enough of it,” said Jen Kates, PhD, director of global health and HIV policy for Kaiser Family Foundation. “Hard choices are being made about who should go first, and there is no right answer.”

The sheer prevalence of obesity in the nation – two in three Americans exceed what is considered a healthy weight – was a public health concern well before the pandemic. But COVID-19 dramatically fast-tracked the discussion from warnings about the long-term damage excess fat tissue can pose to heart, lung and metabolic functions to far more immediate threats.

In the United Kingdom, for example, overweight COVID patients were 67% more likely to require intensive care, and obese patients three times likelier, according to the World Obesity Federation report. A Centers for Disease Control and Prevention study released Monday found a similar trend among U.S. patients and noted that the risk of COVID-related hospitalization, ventilation and death increased with patients’ obesity level.

The counties that hug the southern Mississippi River are home to some of the most concentrated pockets of extreme obesity in the United States. Coronavirus infections began surging in Southern states early last summer, and hospitalizations rose in step.

Deaths in rural stretches of Arkansas, Louisiana, Mississippi, and Tennessee have been overshadowed by the sheer number of deaths in metropolitan areas like New York, Los Angeles, and Essex County, N.J. But as a share of the population, the coronavirus has been similarly unsparing in many Southern communities. In sparsely populated Claiborne County, Miss., on the floodplains of the Mississippi River, 30 residents – about 1 in 300 – had died as of early March. In East Feliciana Parish, La., north of Baton Rouge, with 106 deaths, about 1 in 180 had died by then.

“It’s just math. If the population is more obese and obesity clearly contributes to worse outcomes, then neighborhoods, cities, states and countries that are more obese will have a greater toll from COVID,” said Dr. James de Lemos, MD, a professor of internal medicine at UT Southwestern Medical Center in Dallas who led a study of hospitalized COVID patients published in the medical journal Circulation.

And, because in the U.S. obesity rates tend to be relatively high among African Americans and Latinos who are poor, with diminished access to health care, “it’s a triple whammy,” Dr. de Lemos said. “All these things intersect.”

Poverty and limited access to medical care are common features in the South, where residents like Michelle Antonyshyn, a former registered nurse and mother of seven in Salem, Ark., say they are afraid of the virus. Ms. Antonyshyn, 49, has obesity and debilitating pain in her knees and back, though she does not have high blood pressure or diabetes, two underlying conditions that federal health officials have determined are added risk factors for severe cases of COVID-19.

Still, she said, she “was very concerned just knowing that being obese puts you more at risk for bad outcomes such as being on a ventilator and death.” As a precaution, Ms. Antonyshyn said, she and her large brood locked down early and stopped attending church services in person, watching online instead.

“It’s not the same as having fellowship, but the risk for me was enough,” said Ms. Antonyshyn.

Governors throughout the South seem to recognize that weight can contribute to COVID-19 complications and have pushed for vaccine eligibility rules that prioritize obesity. But on the ground, local health officials are girding for having to tell newly eligible people who qualify as obese that there aren’t enough shots to go around.

In Port Gibson, Miss., Mheja Williams, MD, medical director of the Claiborne County Family Health Center, has been receiving barely enough doses to inoculate the health workers and oldest seniors in her county of 9,600. One week in early February, she received 100 doses.

Obesity and extreme obesity are endemic in Claiborne County, and health officials say the “normalization” of obesity means people often don’t register their weight as a risk factor, whether for COVID or other health issues. The risks are exacerbated by a general flouting of pandemic etiquette: Dr. Williams said that middle-aged and younger residents are not especially vigilant about physical distancing and that mask use is rare.

The rise of obesity in the United States is well documented over the past half-century, as the nation turned from a diet of fruits, vegetables and limited meats to one laden with ultra-processed foods and rich with salt, fat, sugar, and flavorings, along with copious amounts of meat, fast food, and soda. The U.S. has generally led the global obesity race, setting records as even toddlers and young children grew implausibly, dangerously overweight.

Well before COVID, obesity was a leading cause of preventable death in the United States. The National Institutes of Health declared it a disease in 1998, one that fosters heart disease, stroke, type 2 diabetes, and breast, colon, and other cancers.

Researchers say it is no coincidence that nations like the United States, the United Kingdom, and Italy, with relatively high obesity rates, have proved particularly vulnerable to the novel coronavirus.

They believe the virus may exploit underlying metabolic and physiological impairments that often exist in concert with obesity. Extra fat can lead to a cascade of metabolic disruptions, chronic systemic inflammation, and hormonal dysregulation that may thwart the body’s response to infection.

Other respiratory viruses, like influenza and SARS, which appeared in China in 2002, rely on cholesterol to spread enveloped RNA virus to neighboring cells, and researchers have proposed that a similar mechanism may play a role in the spread of the novel coronavirus.

There are also practical problems for coronavirus patients with obesity admitted to the hospital. They can be more difficult to intubate because of excess central weight pressing down on the diaphragm, making breathing with infected lungs even more difficult.

Physicians who specialize in treating patients with obesity say public health officials need to be more forthright and urgent in their messaging, telegraphing the risks of this COVID era.

“It should be explicit and direct,” said Fatima Stanford, MD, an obesity medicine specialist at Massachusetts General Hospital, Boston, and a Harvard Medical School instructor.

Dr. Stanford denounces the fat-shaming and bullying that people with obesity often experience. But telling patients – and the public – that obesity increases the risk of hospitalization and death is crucial, she said.

“I don’t think it’s stigmatizing,” she said. “If you tell them in that way, it’s not to scare you, it’s just giving information. Sometimes people are just unaware.”



KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

In January, as Mississippi health officials planned for their incoming shipments of COVID-19 vaccine, they assessed the state’s most vulnerable: health care workers, of course, and elderly people in nursing homes. But among those who needed urgent protection from the virus ripping across the Magnolia State were 1 million Mississippians with obesity.

Obesity and weight-related illnesses have been deadly liabilities in the COVID era. A report released this month by the World Obesity Federation found that increased body weight is the second-greatest predictor of COVID-related hospitalization and death across the globe, trailing only old age as a risk factor.

As a fixture of life in the American South – home to 9 of the nation’s 12 heaviest states – obesity is playing a role not only in COVID outcomes, but in the calculus of the vaccination rollout. Mississippi was one of the first states to add a body mass index of 30 or more (a rough gauge of obesity tied to height and weight) to the list of qualifying medical conditions for a shot. About 40% of the state’s adults meet that definition, according to federal health survey data, and combined with the risk group already eligible for vaccination – residents 65 and older – that means fully half of Mississippi’s adults are entitled to vie for a restricted allotment of shots.

At least 29 states have green-lighted obesity for inclusion in the first phases of the vaccine rollout, according to KFF – a vast widening of eligibility that has the potential to overwhelm government efforts and heighten competition for scarce doses.

“We have a lifesaving intervention, and we don’t have enough of it,” said Jen Kates, PhD, director of global health and HIV policy for Kaiser Family Foundation. “Hard choices are being made about who should go first, and there is no right answer.”

The sheer prevalence of obesity in the nation – two in three Americans exceed what is considered a healthy weight – was a public health concern well before the pandemic. But COVID-19 dramatically fast-tracked the discussion from warnings about the long-term damage excess fat tissue can pose to heart, lung and metabolic functions to far more immediate threats.

In the United Kingdom, for example, overweight COVID patients were 67% more likely to require intensive care, and obese patients three times likelier, according to the World Obesity Federation report. A Centers for Disease Control and Prevention study released Monday found a similar trend among U.S. patients and noted that the risk of COVID-related hospitalization, ventilation and death increased with patients’ obesity level.

The counties that hug the southern Mississippi River are home to some of the most concentrated pockets of extreme obesity in the United States. Coronavirus infections began surging in Southern states early last summer, and hospitalizations rose in step.

Deaths in rural stretches of Arkansas, Louisiana, Mississippi, and Tennessee have been overshadowed by the sheer number of deaths in metropolitan areas like New York, Los Angeles, and Essex County, N.J. But as a share of the population, the coronavirus has been similarly unsparing in many Southern communities. In sparsely populated Claiborne County, Miss., on the floodplains of the Mississippi River, 30 residents – about 1 in 300 – had died as of early March. In East Feliciana Parish, La., north of Baton Rouge, with 106 deaths, about 1 in 180 had died by then.

“It’s just math. If the population is more obese and obesity clearly contributes to worse outcomes, then neighborhoods, cities, states and countries that are more obese will have a greater toll from COVID,” said Dr. James de Lemos, MD, a professor of internal medicine at UT Southwestern Medical Center in Dallas who led a study of hospitalized COVID patients published in the medical journal Circulation.

And, because in the U.S. obesity rates tend to be relatively high among African Americans and Latinos who are poor, with diminished access to health care, “it’s a triple whammy,” Dr. de Lemos said. “All these things intersect.”

Poverty and limited access to medical care are common features in the South, where residents like Michelle Antonyshyn, a former registered nurse and mother of seven in Salem, Ark., say they are afraid of the virus. Ms. Antonyshyn, 49, has obesity and debilitating pain in her knees and back, though she does not have high blood pressure or diabetes, two underlying conditions that federal health officials have determined are added risk factors for severe cases of COVID-19.

Still, she said, she “was very concerned just knowing that being obese puts you more at risk for bad outcomes such as being on a ventilator and death.” As a precaution, Ms. Antonyshyn said, she and her large brood locked down early and stopped attending church services in person, watching online instead.

“It’s not the same as having fellowship, but the risk for me was enough,” said Ms. Antonyshyn.

Governors throughout the South seem to recognize that weight can contribute to COVID-19 complications and have pushed for vaccine eligibility rules that prioritize obesity. But on the ground, local health officials are girding for having to tell newly eligible people who qualify as obese that there aren’t enough shots to go around.

In Port Gibson, Miss., Mheja Williams, MD, medical director of the Claiborne County Family Health Center, has been receiving barely enough doses to inoculate the health workers and oldest seniors in her county of 9,600. One week in early February, she received 100 doses.

Obesity and extreme obesity are endemic in Claiborne County, and health officials say the “normalization” of obesity means people often don’t register their weight as a risk factor, whether for COVID or other health issues. The risks are exacerbated by a general flouting of pandemic etiquette: Dr. Williams said that middle-aged and younger residents are not especially vigilant about physical distancing and that mask use is rare.

The rise of obesity in the United States is well documented over the past half-century, as the nation turned from a diet of fruits, vegetables and limited meats to one laden with ultra-processed foods and rich with salt, fat, sugar, and flavorings, along with copious amounts of meat, fast food, and soda. The U.S. has generally led the global obesity race, setting records as even toddlers and young children grew implausibly, dangerously overweight.

Well before COVID, obesity was a leading cause of preventable death in the United States. The National Institutes of Health declared it a disease in 1998, one that fosters heart disease, stroke, type 2 diabetes, and breast, colon, and other cancers.

Researchers say it is no coincidence that nations like the United States, the United Kingdom, and Italy, with relatively high obesity rates, have proved particularly vulnerable to the novel coronavirus.

They believe the virus may exploit underlying metabolic and physiological impairments that often exist in concert with obesity. Extra fat can lead to a cascade of metabolic disruptions, chronic systemic inflammation, and hormonal dysregulation that may thwart the body’s response to infection.

Other respiratory viruses, like influenza and SARS, which appeared in China in 2002, rely on cholesterol to spread enveloped RNA virus to neighboring cells, and researchers have proposed that a similar mechanism may play a role in the spread of the novel coronavirus.

There are also practical problems for coronavirus patients with obesity admitted to the hospital. They can be more difficult to intubate because of excess central weight pressing down on the diaphragm, making breathing with infected lungs even more difficult.

Physicians who specialize in treating patients with obesity say public health officials need to be more forthright and urgent in their messaging, telegraphing the risks of this COVID era.

“It should be explicit and direct,” said Fatima Stanford, MD, an obesity medicine specialist at Massachusetts General Hospital, Boston, and a Harvard Medical School instructor.

Dr. Stanford denounces the fat-shaming and bullying that people with obesity often experience. But telling patients – and the public – that obesity increases the risk of hospitalization and death is crucial, she said.

“I don’t think it’s stigmatizing,” she said. “If you tell them in that way, it’s not to scare you, it’s just giving information. Sometimes people are just unaware.”



KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

The lungs Bill Thompson was born with told a gruesome, harrowing and unmistakable tale to Dr. Anthony Szema when he analyzed them and found the black spots, scarring, partially combusted jet fuel and metal inside.

The retired Army staff sergeant had suffered catastrophic lung damage from breathing incinerated waste burned in massive open-air pits and probably other irritants during his tour of duty in Iraq.

“There’s black spots that are burns, particles all over; there’s metal. It was all scarred,” said Szema, a pulmonologist and professor who studies toxic exposures and examined Thompson’s preserved lung tissue. “There was no gas exchange anywhere in that lung.”

Thompson is still alive, surviving on his second transplanted set of lungs. Yet the story burned into the veteran’s internal organs is not one that has been entirely convincing to the U.S. government.

The military has not linked the burn pits to illness. That means many who were exposed to burn pits and are sick do not qualify for benefits under any existing program.

Retirement and health benefits for members of the military depend on factors like length of service, active or reserve status, deployments to combat zones and whether the military considers specific injuries or illnesses to be service-related. Thompson has been able to get care through the Department of Veterans Affairs for his lung disease but has not been able to secure other benefits, like early retirement pay.

“I was denied my Army retirement because if it was not a combat action, then I don’t receive that retirement,” Thompson said at a Senate Veterans’ Affairs Committee hearing last week on service members’ exposures to toxic substances.

Thompson is one of at least 3.5 million veterans since 2001 who have served in war zones where the U.S. military decided to dispose of its trash by burning it, according to VA estimates.

It’s not clear how many people within that population have gotten sick from exposure. Only a small fraction — 234,000 — have enrolled in the VA’s online burn pit registry. Veterans’ advocacy groups have said the majority of claims to the agency stemming from toxic exposures are denied, even as most former service members report contacts with toxins in their deployments.

Soldiers returning from tours in the global war on terror have reported debilitating illnesses almost from its beginning, but got little traction with the military. This year, though, the likelihood of congressional action is high, with Democrats expressing interest and a president who suspects burn pits are to blame for his son’s death.

President Joe Biden’s son Beau died of brain cancer in 2015 at age 46. He had deployed to Iraq in two sites with burn pits — at Baghdad and Balad — around the same time Thompson was at Camp Striker, near the Baghdad airport.

“Because of exposure to burn pits — in my view, I can’t prove it yet — he came back with stage 4 glioblastoma,” Biden said in a 2019 speech.

In testimony at the March 10 hearing, Shane Liermann, who works for the group Disabled American Veterans, told the committee that 78% of burn pit claims are denied. “Part of the problem is VA is not recognizing that exposure as being toxic exposures,” Liermann said.

Aleks Morosky, with the Wounded Warrior Project, said that in his group’s survey of 28,000 veterans last year, 71% said they had “definitely” been exposed to toxic substances or hazardous chemicals, and 18% said they had “probably” been exposed. Half of those people rated their health as poor or fair. Only about 16% of the service members who believed they had suffered exposure said they got treatment from the VA, and 11% said they were denied treatment.

Thompson, who is 49, said care for his lung disease is often slow and sometimes denied. It took the VA three years to approve an air purifier for his home to filter out allergens, and the VA refused to help pay for the removal of dust-trapping carpets, he said.

Thompson’s presence at the hearing, though, was not just meant to put the spotlight on the VA. The military’s entire approach to toxic exposure is a morass that leaves ill soldiers and veterans like Thompson trying to navigate a bureaucracy more labyrinthine than the Pentagon’s corridors.

After Thompson was shipped back to Fort Stewart in Georgia, his medical ordeal was at first addressed within the military system, including a year at Walter Reed National Military Medical Center in Bethesda, Maryland, where doctors found his lungs filled with titanium, magnesium, iron and silica.

Yet he said he didn’t qualify for the Army’s traumatic-injury insurance program, which might have helped him pay to retrofit his home in West Virginia. And he can’t get his military retirement pay until he’s 60.

“I may not live to be age 60. I turn 50 this year,” Thompson said.

Illustrating the problem, several officials at the hearing with the Department of Defense, the Army and the National Guard were unable to explain why Thompson — with 23 years of service between the Guard and Army — might have such a hard time qualifying for retirement benefits when the evidence of his lungs and the findings of the Army’s own doctors are so vivid and extreme.

For advocates who have been working on the problem for decades, it reminds them all too vividly of Agent Orange, which the military is still coming to grips with.

“It’s already been, since the first Persian Gulf [War] — we’re talking 30 years — and since burn pits were again active, since 2001,” said Liermann. “We’re way behind the curve here.”

Although Congress has done relatively little to deal with burn pits, many members seem to at least be thinking along the same lines. The Senate Veterans’ Affairs hearing promised to be something of a kickoff to a year when lawmakers are poised to offer a slew of bills designed to confront the military’s inability to care for service members poisoned during their deployments.

“Make no mistake about it,” said the committee chairman, Sen. Jon Tester (D-Mont.). “We hold these hearings for two reasons: to gather information for the committee members and to help educate the VA that they might take action before Congress does.”

Republicans have also shown growing interest in the problem, offering targeted bills to ensure a handful of toxin-related diseases are covered by the VA.

At the hearing, conservative freshman Sen. Tommy Tuberville (R-Ala.) seemed especially moved.

“We got to do a better job of taking care of our young people,” Tuberville said. “If we’re going to go to war, we got to understand we got to pay the price for it on both ends.”

There is also likely to be high-profile support and attention when revised legislation starts rolling out this spring.

The broadest bill likely to be offered was first introduced by Sen. Kirsten Gillibrand (D-N.Y.) in the Senate and Rep. Raul Ruiz (D-Calif.) in the House in late 2019, with a boost from former “Daily Show” host Jon Stewart and a cadre of 9/11 responders who are turning their attention to toxic exposures.

Indeed, Ruiz and Gillibrand’s legislation is modeled in part on the 9/11 health act that passed in 2015. The burn pit bill would remove the burden of proving a service-related connection.

It would vastly simplify the lives of people like Thompson.

“I am a warrior of the United States of America. I gave my lungs for my country,” Thompson said.

He was cut off before he could finish, but his prepared remarks concluded, “Hopefully, after hearing my story, it will bring awareness for not only me but others who are battling the same or similar injuries related to burn pit exposures from Iraq or Afghanistan.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

The lungs Bill Thompson was born with told a gruesome, harrowing and unmistakable tale to Dr. Anthony Szema when he analyzed them and found the black spots, scarring, partially combusted jet fuel and metal inside.

The retired Army staff sergeant had suffered catastrophic lung damage from breathing incinerated waste burned in massive open-air pits and probably other irritants during his tour of duty in Iraq.

“There’s black spots that are burns, particles all over; there’s metal. It was all scarred,” said Szema, a pulmonologist and professor who studies toxic exposures and examined Thompson’s preserved lung tissue. “There was no gas exchange anywhere in that lung.”

Thompson is still alive, surviving on his second transplanted set of lungs. Yet the story burned into the veteran’s internal organs is not one that has been entirely convincing to the U.S. government.

The military has not linked the burn pits to illness. That means many who were exposed to burn pits and are sick do not qualify for benefits under any existing program.

Retirement and health benefits for members of the military depend on factors like length of service, active or reserve status, deployments to combat zones and whether the military considers specific injuries or illnesses to be service-related. Thompson has been able to get care through the Department of Veterans Affairs for his lung disease but has not been able to secure other benefits, like early retirement pay.

“I was denied my Army retirement because if it was not a combat action, then I don’t receive that retirement,” Thompson said at a Senate Veterans’ Affairs Committee hearing last week on service members’ exposures to toxic substances.

Thompson is one of at least 3.5 million veterans since 2001 who have served in war zones where the U.S. military decided to dispose of its trash by burning it, according to VA estimates.

It’s not clear how many people within that population have gotten sick from exposure. Only a small fraction — 234,000 — have enrolled in the VA’s online burn pit registry. Veterans’ advocacy groups have said the majority of claims to the agency stemming from toxic exposures are denied, even as most former service members report contacts with toxins in their deployments.

Soldiers returning from tours in the global war on terror have reported debilitating illnesses almost from its beginning, but got little traction with the military. This year, though, the likelihood of congressional action is high, with Democrats expressing interest and a president who suspects burn pits are to blame for his son’s death.

President Joe Biden’s son Beau died of brain cancer in 2015 at age 46. He had deployed to Iraq in two sites with burn pits — at Baghdad and Balad — around the same time Thompson was at Camp Striker, near the Baghdad airport.

“Because of exposure to burn pits — in my view, I can’t prove it yet — he came back with stage 4 glioblastoma,” Biden said in a 2019 speech.

In testimony at the March 10 hearing, Shane Liermann, who works for the group Disabled American Veterans, told the committee that 78% of burn pit claims are denied. “Part of the problem is VA is not recognizing that exposure as being toxic exposures,” Liermann said.

Aleks Morosky, with the Wounded Warrior Project, said that in his group’s survey of 28,000 veterans last year, 71% said they had “definitely” been exposed to toxic substances or hazardous chemicals, and 18% said they had “probably” been exposed. Half of those people rated their health as poor or fair. Only about 16% of the service members who believed they had suffered exposure said they got treatment from the VA, and 11% said they were denied treatment.

Thompson, who is 49, said care for his lung disease is often slow and sometimes denied. It took the VA three years to approve an air purifier for his home to filter out allergens, and the VA refused to help pay for the removal of dust-trapping carpets, he said.

Thompson’s presence at the hearing, though, was not just meant to put the spotlight on the VA. The military’s entire approach to toxic exposure is a morass that leaves ill soldiers and veterans like Thompson trying to navigate a bureaucracy more labyrinthine than the Pentagon’s corridors.

After Thompson was shipped back to Fort Stewart in Georgia, his medical ordeal was at first addressed within the military system, including a year at Walter Reed National Military Medical Center in Bethesda, Maryland, where doctors found his lungs filled with titanium, magnesium, iron and silica.

Yet he said he didn’t qualify for the Army’s traumatic-injury insurance program, which might have helped him pay to retrofit his home in West Virginia. And he can’t get his military retirement pay until he’s 60.

“I may not live to be age 60. I turn 50 this year,” Thompson said.

Illustrating the problem, several officials at the hearing with the Department of Defense, the Army and the National Guard were unable to explain why Thompson — with 23 years of service between the Guard and Army — might have such a hard time qualifying for retirement benefits when the evidence of his lungs and the findings of the Army’s own doctors are so vivid and extreme.

For advocates who have been working on the problem for decades, it reminds them all too vividly of Agent Orange, which the military is still coming to grips with.

“It’s already been, since the first Persian Gulf [War] — we’re talking 30 years — and since burn pits were again active, since 2001,” said Liermann. “We’re way behind the curve here.”

Although Congress has done relatively little to deal with burn pits, many members seem to at least be thinking along the same lines. The Senate Veterans’ Affairs hearing promised to be something of a kickoff to a year when lawmakers are poised to offer a slew of bills designed to confront the military’s inability to care for service members poisoned during their deployments.

“Make no mistake about it,” said the committee chairman, Sen. Jon Tester (D-Mont.). “We hold these hearings for two reasons: to gather information for the committee members and to help educate the VA that they might take action before Congress does.”

Republicans have also shown growing interest in the problem, offering targeted bills to ensure a handful of toxin-related diseases are covered by the VA.

At the hearing, conservative freshman Sen. Tommy Tuberville (R-Ala.) seemed especially moved.

“We got to do a better job of taking care of our young people,” Tuberville said. “If we’re going to go to war, we got to understand we got to pay the price for it on both ends.”

There is also likely to be high-profile support and attention when revised legislation starts rolling out this spring.

The broadest bill likely to be offered was first introduced by Sen. Kirsten Gillibrand (D-N.Y.) in the Senate and Rep. Raul Ruiz (D-Calif.) in the House in late 2019, with a boost from former “Daily Show” host Jon Stewart and a cadre of 9/11 responders who are turning their attention to toxic exposures.

Indeed, Ruiz and Gillibrand’s legislation is modeled in part on the 9/11 health act that passed in 2015. The burn pit bill would remove the burden of proving a service-related connection.

It would vastly simplify the lives of people like Thompson.

“I am a warrior of the United States of America. I gave my lungs for my country,” Thompson said.

He was cut off before he could finish, but his prepared remarks concluded, “Hopefully, after hearing my story, it will bring awareness for not only me but others who are battling the same or similar injuries related to burn pit exposures from Iraq or Afghanistan.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

The lungs Bill Thompson was born with told a gruesome, harrowing and unmistakable tale to Dr. Anthony Szema when he analyzed them and found the black spots, scarring, partially combusted jet fuel and metal inside.

The retired Army staff sergeant had suffered catastrophic lung damage from breathing incinerated waste burned in massive open-air pits and probably other irritants during his tour of duty in Iraq.

“There’s black spots that are burns, particles all over; there’s metal. It was all scarred,” said Szema, a pulmonologist and professor who studies toxic exposures and examined Thompson’s preserved lung tissue. “There was no gas exchange anywhere in that lung.”

Thompson is still alive, surviving on his second transplanted set of lungs. Yet the story burned into the veteran’s internal organs is not one that has been entirely convincing to the U.S. government.

The military has not linked the burn pits to illness. That means many who were exposed to burn pits and are sick do not qualify for benefits under any existing program.

Retirement and health benefits for members of the military depend on factors like length of service, active or reserve status, deployments to combat zones and whether the military considers specific injuries or illnesses to be service-related. Thompson has been able to get care through the Department of Veterans Affairs for his lung disease but has not been able to secure other benefits, like early retirement pay.

“I was denied my Army retirement because if it was not a combat action, then I don’t receive that retirement,” Thompson said at a Senate Veterans’ Affairs Committee hearing last week on service members’ exposures to toxic substances.

Thompson is one of at least 3.5 million veterans since 2001 who have served in war zones where the U.S. military decided to dispose of its trash by burning it, according to VA estimates.

It’s not clear how many people within that population have gotten sick from exposure. Only a small fraction — 234,000 — have enrolled in the VA’s online burn pit registry. Veterans’ advocacy groups have said the majority of claims to the agency stemming from toxic exposures are denied, even as most former service members report contacts with toxins in their deployments.

Soldiers returning from tours in the global war on terror have reported debilitating illnesses almost from its beginning, but got little traction with the military. This year, though, the likelihood of congressional action is high, with Democrats expressing interest and a president who suspects burn pits are to blame for his son’s death.

President Joe Biden’s son Beau died of brain cancer in 2015 at age 46. He had deployed to Iraq in two sites with burn pits — at Baghdad and Balad — around the same time Thompson was at Camp Striker, near the Baghdad airport.

“Because of exposure to burn pits — in my view, I can’t prove it yet — he came back with stage 4 glioblastoma,” Biden said in a 2019 speech.

In testimony at the March 10 hearing, Shane Liermann, who works for the group Disabled American Veterans, told the committee that 78% of burn pit claims are denied. “Part of the problem is VA is not recognizing that exposure as being toxic exposures,” Liermann said.

Aleks Morosky, with the Wounded Warrior Project, said that in his group’s survey of 28,000 veterans last year, 71% said they had “definitely” been exposed to toxic substances or hazardous chemicals, and 18% said they had “probably” been exposed. Half of those people rated their health as poor or fair. Only about 16% of the service members who believed they had suffered exposure said they got treatment from the VA, and 11% said they were denied treatment.

Thompson, who is 49, said care for his lung disease is often slow and sometimes denied. It took the VA three years to approve an air purifier for his home to filter out allergens, and the VA refused to help pay for the removal of dust-trapping carpets, he said.

Thompson’s presence at the hearing, though, was not just meant to put the spotlight on the VA. The military’s entire approach to toxic exposure is a morass that leaves ill soldiers and veterans like Thompson trying to navigate a bureaucracy more labyrinthine than the Pentagon’s corridors.

After Thompson was shipped back to Fort Stewart in Georgia, his medical ordeal was at first addressed within the military system, including a year at Walter Reed National Military Medical Center in Bethesda, Maryland, where doctors found his lungs filled with titanium, magnesium, iron and silica.

Yet he said he didn’t qualify for the Army’s traumatic-injury insurance program, which might have helped him pay to retrofit his home in West Virginia. And he can’t get his military retirement pay until he’s 60.

“I may not live to be age 60. I turn 50 this year,” Thompson said.

Illustrating the problem, several officials at the hearing with the Department of Defense, the Army and the National Guard were unable to explain why Thompson — with 23 years of service between the Guard and Army — might have such a hard time qualifying for retirement benefits when the evidence of his lungs and the findings of the Army’s own doctors are so vivid and extreme.

For advocates who have been working on the problem for decades, it reminds them all too vividly of Agent Orange, which the military is still coming to grips with.

“It’s already been, since the first Persian Gulf [War] — we’re talking 30 years — and since burn pits were again active, since 2001,” said Liermann. “We’re way behind the curve here.”

Although Congress has done relatively little to deal with burn pits, many members seem to at least be thinking along the same lines. The Senate Veterans’ Affairs hearing promised to be something of a kickoff to a year when lawmakers are poised to offer a slew of bills designed to confront the military’s inability to care for service members poisoned during their deployments.

“Make no mistake about it,” said the committee chairman, Sen. Jon Tester (D-Mont.). “We hold these hearings for two reasons: to gather information for the committee members and to help educate the VA that they might take action before Congress does.”

Republicans have also shown growing interest in the problem, offering targeted bills to ensure a handful of toxin-related diseases are covered by the VA.

At the hearing, conservative freshman Sen. Tommy Tuberville (R-Ala.) seemed especially moved.

“We got to do a better job of taking care of our young people,” Tuberville said. “If we’re going to go to war, we got to understand we got to pay the price for it on both ends.”

There is also likely to be high-profile support and attention when revised legislation starts rolling out this spring.

The broadest bill likely to be offered was first introduced by Sen. Kirsten Gillibrand (D-N.Y.) in the Senate and Rep. Raul Ruiz (D-Calif.) in the House in late 2019, with a boost from former “Daily Show” host Jon Stewart and a cadre of 9/11 responders who are turning their attention to toxic exposures.

Indeed, Ruiz and Gillibrand’s legislation is modeled in part on the 9/11 health act that passed in 2015. The burn pit bill would remove the burden of proving a service-related connection.

It would vastly simplify the lives of people like Thompson.

“I am a warrior of the United States of America. I gave my lungs for my country,” Thompson said.

He was cut off before he could finish, but his prepared remarks concluded, “Hopefully, after hearing my story, it will bring awareness for not only me but others who are battling the same or similar injuries related to burn pit exposures from Iraq or Afghanistan.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

The first large study of its kind reveals that SARS-CoV-2 reinfections remain rare, although people older than 65 are at higher risk.

When researchers analyzed test results of 4 million people in Denmark, they found that less than 1% of those who tested positive experienced reinfection.

Initial infection was associated with about 80% protection overall against getting SARS-CoV-2 again. However, among those older than 65, the protection plummeted to 47%.

“Not everybody is protected against reinfection after a first infection. Older people are at higher risk of catching it again,” co–lead author Daniela Michlmayr, PhD, said in an interview. “Our findings emphasize the importance of policies to protect the elderly and of adhering to infection control measures and restrictions, even if previously infected with COVID-19.”
 

Verifying the need for vaccination

“The findings also highlight the need to vaccinate people who had COVID-19 before, as natural immunity to infection – especially among the elderly 65 and older – cannot be relied upon,” added Dr. Michlmayr, a researcher in the department of bacteria, parasites, and fungi at the Staten Serums Institut, Copenhagen.

The population-based observational study was published online March 17 in The Lancet.

“The findings make sense, as patients who are immunocompromised or of advanced age may not mount an immune response that is as long-lasting,” David Hirschwerk, MD, said in an interview. “It does underscore the importance of vaccination for people of more advanced age, even if they previously were infected with COVID.

“For those who were infected last spring and have not yet been vaccinated, this helps to support the value of still pursuing the vaccine,” added Dr. Hirschwerk, an infectious disease specialist at Northwell Health in Manhasset, N.Y.

Evidence on reinfection risk was limited prior to this study. “Little is known about protection against SARS-CoV-2 repeat infections, but two studies in the UK have found that immunity could last at least 5 to 6 months after infection,” the authors noted.

Along with co–lead author Christian Holm Hansen, PhD, Dr. Michlmayr and colleagues found that 2.11% of 525,339 individuals tested positive for SARS-CoV-2 during the first surge in Denmark from March to May 2020. Within this group, 0.65% tested positive during a second surge from September to December.

By the end of 2020, more than 10 million people had undergone free polymerase chain reaction testing by the Danish government or through the national TestDenmark program.

“My overall take is that it is great to have such a big dataset looking at this question,” E. John Wherry, PhD, said in an interview. The findings support “what we’ve seen in previous, smaller studies.”

Natural protection against reinfection of approximately 80% “is not as good as the vaccines, but not bad,” added Dr. Wherry, director of the Institute for Immunology at the University of Pennsylvania, Philadelphia.
 

Age alters immunity?

“Our finding that older people were more likely than younger people to test positive again if they had already tested positive could be explained by natural age-related changes in the immune system of older adults, also referred to as immune senescence,” the authors noted.

The investigators found no significant differences in reinfection rates between women and men.

As with the previous research, this study also indicates that an initial bout with SARS-CoV-2 infection appears to confer protection for at least 6 months. The researchers found no significant differences between people who were followed for 3-6 months and those followed for 7 months or longer.
 

Variants not included

To account for possible bias among people who got tested repeatedly, Dr. Michlmayr and colleagues performed a sensitivity analysis in a subgroup. They assessed reinfection rates among people who underwent testing frequently and routinely – nurses, doctors, social workers, and health care assistants – and found that 1.2% tested positive a second time during the second surge.

A limitation of the study was the inability to correlate symptoms with risk for reinfection. Also, the researchers did not account for SARS-CoV-2 variants, noting that “during the study period, such variants were not yet established in Denmark; although into 2021 this pattern is changing.”

Asked to speculate whether the results would be different had the study accounted for variants, Dr. Hirschwerk said, “It depends upon the variant, but certainly for the B.1.351 variant, there already has been data clearly demonstrating risk of reinfection with SARS-CoV-2 despite prior infection with the original strain of virus.”

The emergence of SARS-CoV-2 variants of concern that could escape natural and vaccine-related immunity “complicates matters further,” Rosemary J. Boyton, MBBS, and Daniel M. Altmann, PhD, both of Imperial College London, wrote in an accompanying comment in The Lancet.

“Emerging variants of concern might shift immunity below a protective margin, prompting the need for updated vaccines. Interestingly, vaccine responses even after single dose are substantially enhanced in individuals with a history of infection with SARS-CoV-2,” they added.

The current study confirms that “the hope of protective immunity through natural infections might not be within our reach, and a global vaccination program with high efficacy vaccines is the enduring solution,” Dr. Boyton and Dr. Altmann noted.

Cause for alarm?

Despite evidence that reinfection is relatively rare, “many will find the data reported by Hansen and colleagues about protection through natural infection relatively alarming,” Dr. Boyton and Dr. Altmann wrote in their commentary. The 80% protection rate from reinfection in general and the 47% rate among people aged 65 and older “are more concerning figures than offered by previous studies.”

Vaccines appear to provide better quality, quantity, and durability of protection against repeated infection – measured in terms of neutralizing antibodies and T cells – compared with previous infection with SARS-CoV-2, Dr. Boyton and Dr. Altmann wrote.
 

More research needed

The duration of natural protection against reinfection remains an unanswered question, the researchers noted, “because too little time has elapsed since the beginning of the pandemic.”

Future prospective and longitudinal cohort studies coupled with molecular surveillance are needed to characterize antibody titers and waning of protection against repeat infections, the authors noted. Furthermore, more answers are needed regarding how some virus variants might contribute to reinfection risk.

No funding for the study has been reported. Dr. Michlmayr, Dr. Hirschwerk, Dr. Wherry, Dr. Boyton, and Dr. Altmann have disclosed no relevant financial relationships.
 

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

The first large study of its kind reveals that SARS-CoV-2 reinfections remain rare, although people older than 65 are at higher risk.

When researchers analyzed test results of 4 million people in Denmark, they found that less than 1% of those who tested positive experienced reinfection.

Initial infection was associated with about 80% protection overall against getting SARS-CoV-2 again. However, among those older than 65, the protection plummeted to 47%.

“Not everybody is protected against reinfection after a first infection. Older people are at higher risk of catching it again,” co–lead author Daniela Michlmayr, PhD, said in an interview. “Our findings emphasize the importance of policies to protect the elderly and of adhering to infection control measures and restrictions, even if previously infected with COVID-19.”
 

Verifying the need for vaccination

“The findings also highlight the need to vaccinate people who had COVID-19 before, as natural immunity to infection – especially among the elderly 65 and older – cannot be relied upon,” added Dr. Michlmayr, a researcher in the department of bacteria, parasites, and fungi at the Staten Serums Institut, Copenhagen.

The population-based observational study was published online March 17 in The Lancet.

“The findings make sense, as patients who are immunocompromised or of advanced age may not mount an immune response that is as long-lasting,” David Hirschwerk, MD, said in an interview. “It does underscore the importance of vaccination for people of more advanced age, even if they previously were infected with COVID.

“For those who were infected last spring and have not yet been vaccinated, this helps to support the value of still pursuing the vaccine,” added Dr. Hirschwerk, an infectious disease specialist at Northwell Health in Manhasset, N.Y.

Evidence on reinfection risk was limited prior to this study. “Little is known about protection against SARS-CoV-2 repeat infections, but two studies in the UK have found that immunity could last at least 5 to 6 months after infection,” the authors noted.

Along with co–lead author Christian Holm Hansen, PhD, Dr. Michlmayr and colleagues found that 2.11% of 525,339 individuals tested positive for SARS-CoV-2 during the first surge in Denmark from March to May 2020. Within this group, 0.65% tested positive during a second surge from September to December.

By the end of 2020, more than 10 million people had undergone free polymerase chain reaction testing by the Danish government or through the national TestDenmark program.

“My overall take is that it is great to have such a big dataset looking at this question,” E. John Wherry, PhD, said in an interview. The findings support “what we’ve seen in previous, smaller studies.”

Natural protection against reinfection of approximately 80% “is not as good as the vaccines, but not bad,” added Dr. Wherry, director of the Institute for Immunology at the University of Pennsylvania, Philadelphia.
 

Age alters immunity?

“Our finding that older people were more likely than younger people to test positive again if they had already tested positive could be explained by natural age-related changes in the immune system of older adults, also referred to as immune senescence,” the authors noted.

The investigators found no significant differences in reinfection rates between women and men.

As with the previous research, this study also indicates that an initial bout with SARS-CoV-2 infection appears to confer protection for at least 6 months. The researchers found no significant differences between people who were followed for 3-6 months and those followed for 7 months or longer.
 

Variants not included

To account for possible bias among people who got tested repeatedly, Dr. Michlmayr and colleagues performed a sensitivity analysis in a subgroup. They assessed reinfection rates among people who underwent testing frequently and routinely – nurses, doctors, social workers, and health care assistants – and found that 1.2% tested positive a second time during the second surge.

A limitation of the study was the inability to correlate symptoms with risk for reinfection. Also, the researchers did not account for SARS-CoV-2 variants, noting that “during the study period, such variants were not yet established in Denmark; although into 2021 this pattern is changing.”

Asked to speculate whether the results would be different had the study accounted for variants, Dr. Hirschwerk said, “It depends upon the variant, but certainly for the B.1.351 variant, there already has been data clearly demonstrating risk of reinfection with SARS-CoV-2 despite prior infection with the original strain of virus.”

The emergence of SARS-CoV-2 variants of concern that could escape natural and vaccine-related immunity “complicates matters further,” Rosemary J. Boyton, MBBS, and Daniel M. Altmann, PhD, both of Imperial College London, wrote in an accompanying comment in The Lancet.

“Emerging variants of concern might shift immunity below a protective margin, prompting the need for updated vaccines. Interestingly, vaccine responses even after single dose are substantially enhanced in individuals with a history of infection with SARS-CoV-2,” they added.

The current study confirms that “the hope of protective immunity through natural infections might not be within our reach, and a global vaccination program with high efficacy vaccines is the enduring solution,” Dr. Boyton and Dr. Altmann noted.

Cause for alarm?

Despite evidence that reinfection is relatively rare, “many will find the data reported by Hansen and colleagues about protection through natural infection relatively alarming,” Dr. Boyton and Dr. Altmann wrote in their commentary. The 80% protection rate from reinfection in general and the 47% rate among people aged 65 and older “are more concerning figures than offered by previous studies.”

Vaccines appear to provide better quality, quantity, and durability of protection against repeated infection – measured in terms of neutralizing antibodies and T cells – compared with previous infection with SARS-CoV-2, Dr. Boyton and Dr. Altmann wrote.
 

More research needed

The duration of natural protection against reinfection remains an unanswered question, the researchers noted, “because too little time has elapsed since the beginning of the pandemic.”

Future prospective and longitudinal cohort studies coupled with molecular surveillance are needed to characterize antibody titers and waning of protection against repeat infections, the authors noted. Furthermore, more answers are needed regarding how some virus variants might contribute to reinfection risk.

No funding for the study has been reported. Dr. Michlmayr, Dr. Hirschwerk, Dr. Wherry, Dr. Boyton, and Dr. Altmann have disclosed no relevant financial relationships.
 

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

The first large study of its kind reveals that SARS-CoV-2 reinfections remain rare, although people older than 65 are at higher risk.

When researchers analyzed test results of 4 million people in Denmark, they found that less than 1% of those who tested positive experienced reinfection.

Initial infection was associated with about 80% protection overall against getting SARS-CoV-2 again. However, among those older than 65, the protection plummeted to 47%.

“Not everybody is protected against reinfection after a first infection. Older people are at higher risk of catching it again,” co–lead author Daniela Michlmayr, PhD, said in an interview. “Our findings emphasize the importance of policies to protect the elderly and of adhering to infection control measures and restrictions, even if previously infected with COVID-19.”
 

Verifying the need for vaccination

“The findings also highlight the need to vaccinate people who had COVID-19 before, as natural immunity to infection – especially among the elderly 65 and older – cannot be relied upon,” added Dr. Michlmayr, a researcher in the department of bacteria, parasites, and fungi at the Staten Serums Institut, Copenhagen.

The population-based observational study was published online March 17 in The Lancet.

“The findings make sense, as patients who are immunocompromised or of advanced age may not mount an immune response that is as long-lasting,” David Hirschwerk, MD, said in an interview. “It does underscore the importance of vaccination for people of more advanced age, even if they previously were infected with COVID.

“For those who were infected last spring and have not yet been vaccinated, this helps to support the value of still pursuing the vaccine,” added Dr. Hirschwerk, an infectious disease specialist at Northwell Health in Manhasset, N.Y.

Evidence on reinfection risk was limited prior to this study. “Little is known about protection against SARS-CoV-2 repeat infections, but two studies in the UK have found that immunity could last at least 5 to 6 months after infection,” the authors noted.

Along with co–lead author Christian Holm Hansen, PhD, Dr. Michlmayr and colleagues found that 2.11% of 525,339 individuals tested positive for SARS-CoV-2 during the first surge in Denmark from March to May 2020. Within this group, 0.65% tested positive during a second surge from September to December.

By the end of 2020, more than 10 million people had undergone free polymerase chain reaction testing by the Danish government or through the national TestDenmark program.

“My overall take is that it is great to have such a big dataset looking at this question,” E. John Wherry, PhD, said in an interview. The findings support “what we’ve seen in previous, smaller studies.”

Natural protection against reinfection of approximately 80% “is not as good as the vaccines, but not bad,” added Dr. Wherry, director of the Institute for Immunology at the University of Pennsylvania, Philadelphia.
 

Age alters immunity?

“Our finding that older people were more likely than younger people to test positive again if they had already tested positive could be explained by natural age-related changes in the immune system of older adults, also referred to as immune senescence,” the authors noted.

The investigators found no significant differences in reinfection rates between women and men.

As with the previous research, this study also indicates that an initial bout with SARS-CoV-2 infection appears to confer protection for at least 6 months. The researchers found no significant differences between people who were followed for 3-6 months and those followed for 7 months or longer.
 

Variants not included

To account for possible bias among people who got tested repeatedly, Dr. Michlmayr and colleagues performed a sensitivity analysis in a subgroup. They assessed reinfection rates among people who underwent testing frequently and routinely – nurses, doctors, social workers, and health care assistants – and found that 1.2% tested positive a second time during the second surge.

A limitation of the study was the inability to correlate symptoms with risk for reinfection. Also, the researchers did not account for SARS-CoV-2 variants, noting that “during the study period, such variants were not yet established in Denmark; although into 2021 this pattern is changing.”

Asked to speculate whether the results would be different had the study accounted for variants, Dr. Hirschwerk said, “It depends upon the variant, but certainly for the B.1.351 variant, there already has been data clearly demonstrating risk of reinfection with SARS-CoV-2 despite prior infection with the original strain of virus.”

The emergence of SARS-CoV-2 variants of concern that could escape natural and vaccine-related immunity “complicates matters further,” Rosemary J. Boyton, MBBS, and Daniel M. Altmann, PhD, both of Imperial College London, wrote in an accompanying comment in The Lancet.

“Emerging variants of concern might shift immunity below a protective margin, prompting the need for updated vaccines. Interestingly, vaccine responses even after single dose are substantially enhanced in individuals with a history of infection with SARS-CoV-2,” they added.

The current study confirms that “the hope of protective immunity through natural infections might not be within our reach, and a global vaccination program with high efficacy vaccines is the enduring solution,” Dr. Boyton and Dr. Altmann noted.

Cause for alarm?

Despite evidence that reinfection is relatively rare, “many will find the data reported by Hansen and colleagues about protection through natural infection relatively alarming,” Dr. Boyton and Dr. Altmann wrote in their commentary. The 80% protection rate from reinfection in general and the 47% rate among people aged 65 and older “are more concerning figures than offered by previous studies.”

Vaccines appear to provide better quality, quantity, and durability of protection against repeated infection – measured in terms of neutralizing antibodies and T cells – compared with previous infection with SARS-CoV-2, Dr. Boyton and Dr. Altmann wrote.
 

More research needed

The duration of natural protection against reinfection remains an unanswered question, the researchers noted, “because too little time has elapsed since the beginning of the pandemic.”

Future prospective and longitudinal cohort studies coupled with molecular surveillance are needed to characterize antibody titers and waning of protection against repeat infections, the authors noted. Furthermore, more answers are needed regarding how some virus variants might contribute to reinfection risk.

No funding for the study has been reported. Dr. Michlmayr, Dr. Hirschwerk, Dr. Wherry, Dr. Boyton, and Dr. Altmann have disclosed no relevant financial relationships.
 

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

In a summary of abstracts presented at the ACTRIMS Forum 2021, Dr. Mark Freedman shares that he and his colleagues found no apparent increased risk of COVID-19 with long-term use of interferon β-1a in patients with multiple sclerosis (MS).

Dr. Freedman also highlights several abstracts examining the use of cladribine and ocrelizumab in older patients with MS.

A post hoc analysis of lymphocyte subsets in the combined safety populations of CLARITY, CLARITY Extension, and ORACLE-MS found that by week 96, the effects of cladribine tablets 3.5 mg/kg on CD19+ B, CD4+ T, and CD8+ T lymphocytes in younger and older patients with MS were similar, with steady recovery following nadir.

Another study on younger and older patients treated with cladribine tablets 3.5 mg/kg found that around a quarter of both groups had transient periods of Grade ≥3 lymphopenia during the study, and the rate of certain infection-related treatment-emergent adverse events was higher in the older patients.

A single-center study found that 25% of patients in the older population stopped ocrelizumab, the most common reasons being disease progression and repeated or severe infections.

Lastly, an evaluation of older patients with progressive MS found no statistical difference in 2-year clinical endpoints for patients taking ocrelizumab compared to prior to anti-CD20 therapy.

--

Mark S. Freedman, MSc, MD is a Professor, Department of Neurology, University of Ottawa and The Ottawa Hospital Research Institute; and Director, Multiple Sclerosis Research Unit, The Ottawa Hospital–General Campus.

Mark S. Freedman, MSc, MD, has disclosed the following relevant financial relationships:

Serve(d) on the advisory board, board of directors, or other similar groups for: Actelion (Janssen/Johnson and Johnson); Alexion; Atara Biotherapeutics; Bayer Healthcare; Biogen Idec; Celgene; Clene Nanomedicine; GRI Bio; Hoffmann-La Roche; Magenta Therapeutics; Merck Serono; MedDay Pharmaceuticals; Novartis; Sanofi Genzyme; Teva Canada.

Serve(d) as a member of a speakers bureau for: Sanofi Genzyme; EMD Serono.

Received honoraria or consultation fees for: Actelion (Janssen/Johnson and Johnson); Alexion; Biogen Idec; Celgene (BMS); EMD Inc; Sanofi Genzyme; Hoffmann-La Roche; Merck Serono; Novartis; Teva Canada.

Received research or educational grants from: EMD Inc; Hoffmann-La Roche; Sanofi Genzyme Canada.

In a summary of abstracts presented at the ACTRIMS Forum 2021, Dr. Mark Freedman shares that he and his colleagues found no apparent increased risk of COVID-19 with long-term use of interferon β-1a in patients with multiple sclerosis (MS).

Dr. Freedman also highlights several abstracts examining the use of cladribine and ocrelizumab in older patients with MS.

A post hoc analysis of lymphocyte subsets in the combined safety populations of CLARITY, CLARITY Extension, and ORACLE-MS found that by week 96, the effects of cladribine tablets 3.5 mg/kg on CD19+ B, CD4+ T, and CD8+ T lymphocytes in younger and older patients with MS were similar, with steady recovery following nadir.

Another study on younger and older patients treated with cladribine tablets 3.5 mg/kg found that around a quarter of both groups had transient periods of Grade ≥3 lymphopenia during the study, and the rate of certain infection-related treatment-emergent adverse events was higher in the older patients.

A single-center study found that 25% of patients in the older population stopped ocrelizumab, the most common reasons being disease progression and repeated or severe infections.

Lastly, an evaluation of older patients with progressive MS found no statistical difference in 2-year clinical endpoints for patients taking ocrelizumab compared to prior to anti-CD20 therapy.

--

Mark S. Freedman, MSc, MD is a Professor, Department of Neurology, University of Ottawa and The Ottawa Hospital Research Institute; and Director, Multiple Sclerosis Research Unit, The Ottawa Hospital–General Campus.

Mark S. Freedman, MSc, MD, has disclosed the following relevant financial relationships:

Serve(d) on the advisory board, board of directors, or other similar groups for: Actelion (Janssen/Johnson and Johnson); Alexion; Atara Biotherapeutics; Bayer Healthcare; Biogen Idec; Celgene; Clene Nanomedicine; GRI Bio; Hoffmann-La Roche; Magenta Therapeutics; Merck Serono; MedDay Pharmaceuticals; Novartis; Sanofi Genzyme; Teva Canada.

Serve(d) as a member of a speakers bureau for: Sanofi Genzyme; EMD Serono.

Received honoraria or consultation fees for: Actelion (Janssen/Johnson and Johnson); Alexion; Biogen Idec; Celgene (BMS); EMD Inc; Sanofi Genzyme; Hoffmann-La Roche; Merck Serono; Novartis; Teva Canada.

Received research or educational grants from: EMD Inc; Hoffmann-La Roche; Sanofi Genzyme Canada.

In a summary of abstracts presented at the ACTRIMS Forum 2021, Dr. Mark Freedman shares that he and his colleagues found no apparent increased risk of COVID-19 with long-term use of interferon β-1a in patients with multiple sclerosis (MS).

Dr. Freedman also highlights several abstracts examining the use of cladribine and ocrelizumab in older patients with MS.

A post hoc analysis of lymphocyte subsets in the combined safety populations of CLARITY, CLARITY Extension, and ORACLE-MS found that by week 96, the effects of cladribine tablets 3.5 mg/kg on CD19+ B, CD4+ T, and CD8+ T lymphocytes in younger and older patients with MS were similar, with steady recovery following nadir.

Another study on younger and older patients treated with cladribine tablets 3.5 mg/kg found that around a quarter of both groups had transient periods of Grade ≥3 lymphopenia during the study, and the rate of certain infection-related treatment-emergent adverse events was higher in the older patients.

A single-center study found that 25% of patients in the older population stopped ocrelizumab, the most common reasons being disease progression and repeated or severe infections.

Lastly, an evaluation of older patients with progressive MS found no statistical difference in 2-year clinical endpoints for patients taking ocrelizumab compared to prior to anti-CD20 therapy.

--

Mark S. Freedman, MSc, MD is a Professor, Department of Neurology, University of Ottawa and The Ottawa Hospital Research Institute; and Director, Multiple Sclerosis Research Unit, The Ottawa Hospital–General Campus.

Mark S. Freedman, MSc, MD, has disclosed the following relevant financial relationships:

Serve(d) on the advisory board, board of directors, or other similar groups for: Actelion (Janssen/Johnson and Johnson); Alexion; Atara Biotherapeutics; Bayer Healthcare; Biogen Idec; Celgene; Clene Nanomedicine; GRI Bio; Hoffmann-La Roche; Magenta Therapeutics; Merck Serono; MedDay Pharmaceuticals; Novartis; Sanofi Genzyme; Teva Canada.

Serve(d) as a member of a speakers bureau for: Sanofi Genzyme; EMD Serono.

Received honoraria or consultation fees for: Actelion (Janssen/Johnson and Johnson); Alexion; Biogen Idec; Celgene (BMS); EMD Inc; Sanofi Genzyme; Hoffmann-La Roche; Merck Serono; Novartis; Teva Canada.

Received research or educational grants from: EMD Inc; Hoffmann-La Roche; Sanofi Genzyme Canada.

Joseph Berger, MD, Associate Chief of the Multiple Sclerosis Division at Perelman School of Medicine at the University of Pennsylvania, presents highlights in multiple sclerosis (MS) symptom management from the ACTRIMS Forum 2021.

A follow-up of participants in the self-management program called Fatigue: Take Control found that while patients did not report any significant improvement in fatigue 5-6 years later, they also did not have greater fatigue than at baseline, suggesting that fatigue may not be a progressive symptom.

Next, a literature review of efficacy studies in MS rodent models found a complementary pharmacology of CBD and other constituents of nabiximols that may add additional benefit and mitigate THC tolerability.

A small study looking at pain prevalence in patients with relapsing-remitting MS (RRMS) found that 76% of patients had a pain syndrome, and 48% had neuropathic pain. The study also found that gabapentin 900 mg per day for 30 days was effective in decreasing pain intensity and frequency.

A multi-site study of 282 patients with MS reporting fatigue between 2013 and 2014 found that 21% of patients reported using prescription opiates, 76% of whom reported regular daily use.

Lastly, participants in Spasticity: Take Control—an education and lower extremity stretching program—reported significantly decreased pain severity and interference at 6 months, compared with range-of-motion exercises.

--

Professor and Associate Chief, Department of Neurology, Multiple Sclerosis Division. Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania.

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech.

Received income in an amount ≥$250 from: Amgen; Biogen; Bristol Myers Squibb; Celgene; Encycle; Excision BioTherapeutics; Dr. Reddy; Genzyme; Inhibikase Therapeutics; Mapi-Pharma; Merck; Morphic Therapeutic; Novartis; Serono.

Joseph Berger, MD, Associate Chief of the Multiple Sclerosis Division at Perelman School of Medicine at the University of Pennsylvania, presents highlights in multiple sclerosis (MS) symptom management from the ACTRIMS Forum 2021.

A follow-up of participants in the self-management program called Fatigue: Take Control found that while patients did not report any significant improvement in fatigue 5-6 years later, they also did not have greater fatigue than at baseline, suggesting that fatigue may not be a progressive symptom.

Next, a literature review of efficacy studies in MS rodent models found a complementary pharmacology of CBD and other constituents of nabiximols that may add additional benefit and mitigate THC tolerability.

A small study looking at pain prevalence in patients with relapsing-remitting MS (RRMS) found that 76% of patients had a pain syndrome, and 48% had neuropathic pain. The study also found that gabapentin 900 mg per day for 30 days was effective in decreasing pain intensity and frequency.

A multi-site study of 282 patients with MS reporting fatigue between 2013 and 2014 found that 21% of patients reported using prescription opiates, 76% of whom reported regular daily use.

Lastly, participants in Spasticity: Take Control—an education and lower extremity stretching program—reported significantly decreased pain severity and interference at 6 months, compared with range-of-motion exercises.

--

Professor and Associate Chief, Department of Neurology, Multiple Sclerosis Division. Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania.

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech.

Received income in an amount ≥$250 from: Amgen; Biogen; Bristol Myers Squibb; Celgene; Encycle; Excision BioTherapeutics; Dr. Reddy; Genzyme; Inhibikase Therapeutics; Mapi-Pharma; Merck; Morphic Therapeutic; Novartis; Serono.

Joseph Berger, MD, Associate Chief of the Multiple Sclerosis Division at Perelman School of Medicine at the University of Pennsylvania, presents highlights in multiple sclerosis (MS) symptom management from the ACTRIMS Forum 2021.

A follow-up of participants in the self-management program called Fatigue: Take Control found that while patients did not report any significant improvement in fatigue 5-6 years later, they also did not have greater fatigue than at baseline, suggesting that fatigue may not be a progressive symptom.

Next, a literature review of efficacy studies in MS rodent models found a complementary pharmacology of CBD and other constituents of nabiximols that may add additional benefit and mitigate THC tolerability.

A small study looking at pain prevalence in patients with relapsing-remitting MS (RRMS) found that 76% of patients had a pain syndrome, and 48% had neuropathic pain. The study also found that gabapentin 900 mg per day for 30 days was effective in decreasing pain intensity and frequency.

A multi-site study of 282 patients with MS reporting fatigue between 2013 and 2014 found that 21% of patients reported using prescription opiates, 76% of whom reported regular daily use.

Lastly, participants in Spasticity: Take Control—an education and lower extremity stretching program—reported significantly decreased pain severity and interference at 6 months, compared with range-of-motion exercises.

--

Professor and Associate Chief, Department of Neurology, Multiple Sclerosis Division. Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania.

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech.

Received income in an amount ≥$250 from: Amgen; Biogen; Bristol Myers Squibb; Celgene; Encycle; Excision BioTherapeutics; Dr. Reddy; Genzyme; Inhibikase Therapeutics; Mapi-Pharma; Merck; Morphic Therapeutic; Novartis; Serono.

A baby girl who was born 3 weeks after her mom got the first dose of the Moderna COVID-19 vaccine has antibodies against the coronavirus, according to a preprint paper published on the medRxiv server Feb. 5. The paper hasn’t yet been peer reviewed.

The mom, a health care worker in Florida, developed COVID-19 antibodies after she received the shot. Testing showed that the antibodies passed through the placenta to the baby.

“Maternal vaccination for influenza and TDaP have been well studied in terms of safety and efficacy for protection of the newborn by placental passage of antibodies,” Paul Gilbert, MD, and Chad Rudnick, MD, pediatricians and researchers at Florida Atlantic University, wrote in the paper.

Previous research has indicated that moms who have recovered from COVID-19 can deliver babies with antibodies, according to Insider, but this may be the first report that shows how vaccination during pregnancy can provide antibodies as well.

Dr. Gilbert and Dr. Rudnick said they were fortunate to connect with the mom in Boca Raton. She hadn’t contracted COVID-19 and was able to get the vaccine at the end of her pregnancy in January. When the baby was born, they were able to test the cord blood to look for antibodies specifically from the vaccine.

“We were very excited to see, once the test result came back, that the antibodies from the mom’s vaccine did in fact pass through the placenta to the newborn,” Dr. Rudnick told WPTV, an NBC affiliate in West Palm Beach.

“We knew that we were going to be potentially one of the first in the world to report it, and that opportunity probably only comes once in a career,” Dr. Gilbert told WPTV.

In the preprint, Dr. Gilbert and Dr. Rudnick said a “vigorous, healthy, full-term” baby was born, and the mom received the second dose of the Moderna vaccine during the postpartum period. The newborn received a normal “well-infant” evaluation and was breastfeeding.

The two doctors called for a “significant and urgent need” to research the safety and efficacy of COVID-19 vaccines during pregnancy. They also encouraged other researchers to create pregnancy and breastfeeding registries to study COVID-19 vaccines in pregnant and breastfeeding moms and newborns.

Dr. Gilbert and Dr. Rudnick are now preparing their research for publication and hope future studies will investigate the amount and length of antibody response in newborns.

“Total antibody measurements may be used to determine how long protection is expected, which may help to determine when the best time would be to begin vaccination,” they wrote.

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

A baby girl who was born 3 weeks after her mom got the first dose of the Moderna COVID-19 vaccine has antibodies against the coronavirus, according to a preprint paper published on the medRxiv server Feb. 5. The paper hasn’t yet been peer reviewed.

The mom, a health care worker in Florida, developed COVID-19 antibodies after she received the shot. Testing showed that the antibodies passed through the placenta to the baby.

“Maternal vaccination for influenza and TDaP have been well studied in terms of safety and efficacy for protection of the newborn by placental passage of antibodies,” Paul Gilbert, MD, and Chad Rudnick, MD, pediatricians and researchers at Florida Atlantic University, wrote in the paper.

Previous research has indicated that moms who have recovered from COVID-19 can deliver babies with antibodies, according to Insider, but this may be the first report that shows how vaccination during pregnancy can provide antibodies as well.

Dr. Gilbert and Dr. Rudnick said they were fortunate to connect with the mom in Boca Raton. She hadn’t contracted COVID-19 and was able to get the vaccine at the end of her pregnancy in January. When the baby was born, they were able to test the cord blood to look for antibodies specifically from the vaccine.

“We were very excited to see, once the test result came back, that the antibodies from the mom’s vaccine did in fact pass through the placenta to the newborn,” Dr. Rudnick told WPTV, an NBC affiliate in West Palm Beach.

“We knew that we were going to be potentially one of the first in the world to report it, and that opportunity probably only comes once in a career,” Dr. Gilbert told WPTV.

In the preprint, Dr. Gilbert and Dr. Rudnick said a “vigorous, healthy, full-term” baby was born, and the mom received the second dose of the Moderna vaccine during the postpartum period. The newborn received a normal “well-infant” evaluation and was breastfeeding.

The two doctors called for a “significant and urgent need” to research the safety and efficacy of COVID-19 vaccines during pregnancy. They also encouraged other researchers to create pregnancy and breastfeeding registries to study COVID-19 vaccines in pregnant and breastfeeding moms and newborns.

Dr. Gilbert and Dr. Rudnick are now preparing their research for publication and hope future studies will investigate the amount and length of antibody response in newborns.

“Total antibody measurements may be used to determine how long protection is expected, which may help to determine when the best time would be to begin vaccination,” they wrote.

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

A baby girl who was born 3 weeks after her mom got the first dose of the Moderna COVID-19 vaccine has antibodies against the coronavirus, according to a preprint paper published on the medRxiv server Feb. 5. The paper hasn’t yet been peer reviewed.

The mom, a health care worker in Florida, developed COVID-19 antibodies after she received the shot. Testing showed that the antibodies passed through the placenta to the baby.

“Maternal vaccination for influenza and TDaP have been well studied in terms of safety and efficacy for protection of the newborn by placental passage of antibodies,” Paul Gilbert, MD, and Chad Rudnick, MD, pediatricians and researchers at Florida Atlantic University, wrote in the paper.

Previous research has indicated that moms who have recovered from COVID-19 can deliver babies with antibodies, according to Insider, but this may be the first report that shows how vaccination during pregnancy can provide antibodies as well.

Dr. Gilbert and Dr. Rudnick said they were fortunate to connect with the mom in Boca Raton. She hadn’t contracted COVID-19 and was able to get the vaccine at the end of her pregnancy in January. When the baby was born, they were able to test the cord blood to look for antibodies specifically from the vaccine.

“We were very excited to see, once the test result came back, that the antibodies from the mom’s vaccine did in fact pass through the placenta to the newborn,” Dr. Rudnick told WPTV, an NBC affiliate in West Palm Beach.

“We knew that we were going to be potentially one of the first in the world to report it, and that opportunity probably only comes once in a career,” Dr. Gilbert told WPTV.

In the preprint, Dr. Gilbert and Dr. Rudnick said a “vigorous, healthy, full-term” baby was born, and the mom received the second dose of the Moderna vaccine during the postpartum period. The newborn received a normal “well-infant” evaluation and was breastfeeding.

The two doctors called for a “significant and urgent need” to research the safety and efficacy of COVID-19 vaccines during pregnancy. They also encouraged other researchers to create pregnancy and breastfeeding registries to study COVID-19 vaccines in pregnant and breastfeeding moms and newborns.

Dr. Gilbert and Dr. Rudnick are now preparing their research for publication and hope future studies will investigate the amount and length of antibody response in newborns.

“Total antibody measurements may be used to determine how long protection is expected, which may help to determine when the best time would be to begin vaccination,” they wrote.

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

There is a Chinese curse which says “May he live in interesting times.” Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also more open to the creative energy of men than any other time in history.

–Robert Kennedy, Cape Town, South Africa, 1966
 

Well, you may not know it, but price transparency is coming to medicine, including dermatology. The transparency of coverage rule was finalized and released on Oct. 29, 2020, by the

Centers for Medicare & Medicaid Services. It has survived a challenge by the American Hospital Association in federal court, which generally means it is going to “stick.” Its effects should start to appear on Jan. 1, 2022.

The newly finalized rule will require insurers to publicly disclose in-network provider-negotiated rates, historical out-of-network allowed amounts, associated facility fees, and drug-pricing information in easily accessible machine-readable files. This information will be disclosed for the 500 most commonly billed physician services starting Jan. 1, 2022, and expanded to include all services the following year. Understand that you, as a practitioner, do not have to do anything, as insurers will do it for you, but your charge data will be on display. It is not clear if there is an appeal mechanism for physicians to correct erroneous data.

This should provide a fascinating look at just what things really cost, and may prove, as we suspect, small practices are less expensive. Important exemptions to reporting include emergency services, anesthesia, lab tests, and pathology fees, which will not be required, but recommended, to be disclosed.

Bear in mind that this rule was not designed to benefit physicians or hospitals, but rather to allow patients to comparison shop and drive down the cost of medical care. True price transparency may well accomplish this, particularly in our age of sky-high deductibles, if the information is accurate and readily accessible.

Although studies of patient behavior have shown that few patients actually use price comparison tools, the data required to be publicly disclosed and accessible will make this much easier. The Wall Street Journal or ProPublica will likely be all over this with applications to make comparisons easier. Still, many patients are price insensitive, particularly if they are Medicare recipients and only responsible for a nominal deductible.

Almost all the evaluation and management codes, as well as many dermatology procedure codes, are listed in the top 500 items and services included in the initial stage of the finalized rule. These include skin biopsies, destructions, drainages, several different benign and malignant excisions and, of course, Mohs surgery (but only the first stage, the 2nd stage will be listed in 2023).

While it is unlikely for patients to doctor shop for services that are performed on the same day as the office visit, such as a biopsies or destructions, we would expect comparisons for more expensive, planned procedures such as Mohs surgery and cancer excisions. Considering the rule, Mohs surgery may compare favorably to excisions performed in the hospital if the operating room charges are included, but not so well if the pathology and anesthesia charges are not included in the cost. It is inherently unfair to compare Mohs to excision in an operating room since the Mohs procedure has the anesthesia and pathology work embedded in the code (at 55% of the value of the code), and the multiple frozen sections taken by the surgeon in the operating room will not be listed as they are technically considered to be exempt additional pathology services.

This could put the Mohs surgeon in the interesting position of billing for excisions and frozen sections instead of Mohs surgery in order to compete with the hospital-based surgeon. This is not unbundling, if overall charges are lower and if distinctly different procedures are followed and different paperwork is generated. This is how I currently handle patients who demand Mohs surgery for inappropriate sites.

The effect on hospital groups that can charge facility fees could be quite dramatic, as it could be on large groups and on private equity groups who may have negotiated better rates. These increased costs will be revealed to consumers. In January 2023, the insurers will have to deploy a tool on their web site, updated monthly, that details rates for the 500 most common procedures for all in- and out-of-network providers and how much the patient can expect to pay out of pocket. All facility fees for procedures will be included. As noted earlier, we would expect third parties to already have done this. The historical and current costs for medications will also be included, which should make for interesting times in the pharmaceutical industry.

In January 2024, insurers will be required to post all the additional codes they cover, including complex closures, flaps, and grafts and any associated facility fees. Of course, a patient or a surgeon does not know what sort of repair a patient will need after Mohs surgery, but with high deductibles hitting harder, we would expect more patients requesting healing by second intent.

Whether these price comparisons will drive patients from relatively high-cost centers to less costly ones is unclear. This has certainly been the case for MRI and CT imaging. Price transparency for MRIs increased use of less costly providers and triggered provider competition.

Whether the price differentials will allow smaller practices some leverage in negotiating rates is also uncertain. Who knows, perhaps the out-of-network rate is greater than what your contract currently specifies, which could spur you to drop their network entirely. There may be great opportunity here for the smaller practitioner who has been boxed out of the big-group pricing and networks.

Be prepared in January 2022, to discuss these issues with patients and insurers, and be sure to check where you fall in cost comparisons. What possible logic could an insurer have for excluding you from a network where your average charges are less than their current panel? As noted before, this may be a boon for small practices that have been forced to the fringes of reimbursement and an opportunity to demonstrate that they are really much less expensive. We live in interesting times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Bishop is doing a fellowship in micrographic surgery and dermatologic oncology with Dr. Coldiron at the Skin Cancer Center in Cincinnati. Write to Dr. Coldiron at [email protected].

There is a Chinese curse which says “May he live in interesting times.” Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also more open to the creative energy of men than any other time in history.

–Robert Kennedy, Cape Town, South Africa, 1966
 

Well, you may not know it, but price transparency is coming to medicine, including dermatology. The transparency of coverage rule was finalized and released on Oct. 29, 2020, by the

Centers for Medicare & Medicaid Services. It has survived a challenge by the American Hospital Association in federal court, which generally means it is going to “stick.” Its effects should start to appear on Jan. 1, 2022.

The newly finalized rule will require insurers to publicly disclose in-network provider-negotiated rates, historical out-of-network allowed amounts, associated facility fees, and drug-pricing information in easily accessible machine-readable files. This information will be disclosed for the 500 most commonly billed physician services starting Jan. 1, 2022, and expanded to include all services the following year. Understand that you, as a practitioner, do not have to do anything, as insurers will do it for you, but your charge data will be on display. It is not clear if there is an appeal mechanism for physicians to correct erroneous data.

This should provide a fascinating look at just what things really cost, and may prove, as we suspect, small practices are less expensive. Important exemptions to reporting include emergency services, anesthesia, lab tests, and pathology fees, which will not be required, but recommended, to be disclosed.

Bear in mind that this rule was not designed to benefit physicians or hospitals, but rather to allow patients to comparison shop and drive down the cost of medical care. True price transparency may well accomplish this, particularly in our age of sky-high deductibles, if the information is accurate and readily accessible.

Although studies of patient behavior have shown that few patients actually use price comparison tools, the data required to be publicly disclosed and accessible will make this much easier. The Wall Street Journal or ProPublica will likely be all over this with applications to make comparisons easier. Still, many patients are price insensitive, particularly if they are Medicare recipients and only responsible for a nominal deductible.

Almost all the evaluation and management codes, as well as many dermatology procedure codes, are listed in the top 500 items and services included in the initial stage of the finalized rule. These include skin biopsies, destructions, drainages, several different benign and malignant excisions and, of course, Mohs surgery (but only the first stage, the 2nd stage will be listed in 2023).

While it is unlikely for patients to doctor shop for services that are performed on the same day as the office visit, such as a biopsies or destructions, we would expect comparisons for more expensive, planned procedures such as Mohs surgery and cancer excisions. Considering the rule, Mohs surgery may compare favorably to excisions performed in the hospital if the operating room charges are included, but not so well if the pathology and anesthesia charges are not included in the cost. It is inherently unfair to compare Mohs to excision in an operating room since the Mohs procedure has the anesthesia and pathology work embedded in the code (at 55% of the value of the code), and the multiple frozen sections taken by the surgeon in the operating room will not be listed as they are technically considered to be exempt additional pathology services.

This could put the Mohs surgeon in the interesting position of billing for excisions and frozen sections instead of Mohs surgery in order to compete with the hospital-based surgeon. This is not unbundling, if overall charges are lower and if distinctly different procedures are followed and different paperwork is generated. This is how I currently handle patients who demand Mohs surgery for inappropriate sites.

The effect on hospital groups that can charge facility fees could be quite dramatic, as it could be on large groups and on private equity groups who may have negotiated better rates. These increased costs will be revealed to consumers. In January 2023, the insurers will have to deploy a tool on their web site, updated monthly, that details rates for the 500 most common procedures for all in- and out-of-network providers and how much the patient can expect to pay out of pocket. All facility fees for procedures will be included. As noted earlier, we would expect third parties to already have done this. The historical and current costs for medications will also be included, which should make for interesting times in the pharmaceutical industry.

In January 2024, insurers will be required to post all the additional codes they cover, including complex closures, flaps, and grafts and any associated facility fees. Of course, a patient or a surgeon does not know what sort of repair a patient will need after Mohs surgery, but with high deductibles hitting harder, we would expect more patients requesting healing by second intent.

Whether these price comparisons will drive patients from relatively high-cost centers to less costly ones is unclear. This has certainly been the case for MRI and CT imaging. Price transparency for MRIs increased use of less costly providers and triggered provider competition.

Whether the price differentials will allow smaller practices some leverage in negotiating rates is also uncertain. Who knows, perhaps the out-of-network rate is greater than what your contract currently specifies, which could spur you to drop their network entirely. There may be great opportunity here for the smaller practitioner who has been boxed out of the big-group pricing and networks.

Be prepared in January 2022, to discuss these issues with patients and insurers, and be sure to check where you fall in cost comparisons. What possible logic could an insurer have for excluding you from a network where your average charges are less than their current panel? As noted before, this may be a boon for small practices that have been forced to the fringes of reimbursement and an opportunity to demonstrate that they are really much less expensive. We live in interesting times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Bishop is doing a fellowship in micrographic surgery and dermatologic oncology with Dr. Coldiron at the Skin Cancer Center in Cincinnati. Write to Dr. Coldiron at [email protected].

There is a Chinese curse which says “May he live in interesting times.” Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also more open to the creative energy of men than any other time in history.

–Robert Kennedy, Cape Town, South Africa, 1966
 

Well, you may not know it, but price transparency is coming to medicine, including dermatology. The transparency of coverage rule was finalized and released on Oct. 29, 2020, by the

Centers for Medicare & Medicaid Services. It has survived a challenge by the American Hospital Association in federal court, which generally means it is going to “stick.” Its effects should start to appear on Jan. 1, 2022.

The newly finalized rule will require insurers to publicly disclose in-network provider-negotiated rates, historical out-of-network allowed amounts, associated facility fees, and drug-pricing information in easily accessible machine-readable files. This information will be disclosed for the 500 most commonly billed physician services starting Jan. 1, 2022, and expanded to include all services the following year. Understand that you, as a practitioner, do not have to do anything, as insurers will do it for you, but your charge data will be on display. It is not clear if there is an appeal mechanism for physicians to correct erroneous data.

This should provide a fascinating look at just what things really cost, and may prove, as we suspect, small practices are less expensive. Important exemptions to reporting include emergency services, anesthesia, lab tests, and pathology fees, which will not be required, but recommended, to be disclosed.

Bear in mind that this rule was not designed to benefit physicians or hospitals, but rather to allow patients to comparison shop and drive down the cost of medical care. True price transparency may well accomplish this, particularly in our age of sky-high deductibles, if the information is accurate and readily accessible.

Although studies of patient behavior have shown that few patients actually use price comparison tools, the data required to be publicly disclosed and accessible will make this much easier. The Wall Street Journal or ProPublica will likely be all over this with applications to make comparisons easier. Still, many patients are price insensitive, particularly if they are Medicare recipients and only responsible for a nominal deductible.

Almost all the evaluation and management codes, as well as many dermatology procedure codes, are listed in the top 500 items and services included in the initial stage of the finalized rule. These include skin biopsies, destructions, drainages, several different benign and malignant excisions and, of course, Mohs surgery (but only the first stage, the 2nd stage will be listed in 2023).

While it is unlikely for patients to doctor shop for services that are performed on the same day as the office visit, such as a biopsies or destructions, we would expect comparisons for more expensive, planned procedures such as Mohs surgery and cancer excisions. Considering the rule, Mohs surgery may compare favorably to excisions performed in the hospital if the operating room charges are included, but not so well if the pathology and anesthesia charges are not included in the cost. It is inherently unfair to compare Mohs to excision in an operating room since the Mohs procedure has the anesthesia and pathology work embedded in the code (at 55% of the value of the code), and the multiple frozen sections taken by the surgeon in the operating room will not be listed as they are technically considered to be exempt additional pathology services.

This could put the Mohs surgeon in the interesting position of billing for excisions and frozen sections instead of Mohs surgery in order to compete with the hospital-based surgeon. This is not unbundling, if overall charges are lower and if distinctly different procedures are followed and different paperwork is generated. This is how I currently handle patients who demand Mohs surgery for inappropriate sites.

The effect on hospital groups that can charge facility fees could be quite dramatic, as it could be on large groups and on private equity groups who may have negotiated better rates. These increased costs will be revealed to consumers. In January 2023, the insurers will have to deploy a tool on their web site, updated monthly, that details rates for the 500 most common procedures for all in- and out-of-network providers and how much the patient can expect to pay out of pocket. All facility fees for procedures will be included. As noted earlier, we would expect third parties to already have done this. The historical and current costs for medications will also be included, which should make for interesting times in the pharmaceutical industry.

In January 2024, insurers will be required to post all the additional codes they cover, including complex closures, flaps, and grafts and any associated facility fees. Of course, a patient or a surgeon does not know what sort of repair a patient will need after Mohs surgery, but with high deductibles hitting harder, we would expect more patients requesting healing by second intent.

Whether these price comparisons will drive patients from relatively high-cost centers to less costly ones is unclear. This has certainly been the case for MRI and CT imaging. Price transparency for MRIs increased use of less costly providers and triggered provider competition.

Whether the price differentials will allow smaller practices some leverage in negotiating rates is also uncertain. Who knows, perhaps the out-of-network rate is greater than what your contract currently specifies, which could spur you to drop their network entirely. There may be great opportunity here for the smaller practitioner who has been boxed out of the big-group pricing and networks.

Be prepared in January 2022, to discuss these issues with patients and insurers, and be sure to check where you fall in cost comparisons. What possible logic could an insurer have for excluding you from a network where your average charges are less than their current panel? As noted before, this may be a boon for small practices that have been forced to the fringes of reimbursement and an opportunity to demonstrate that they are really much less expensive. We live in interesting times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Bishop is doing a fellowship in micrographic surgery and dermatologic oncology with Dr. Coldiron at the Skin Cancer Center in Cincinnati. Write to Dr. Coldiron at [email protected].

The light at the end of the pandemic tunnel seems even brighter than it did just a month ago and in its glow it’s tempting to look back on the adjustments we have made in our lives and consider how many of those adjustments will solidify into new standards. Certainly, near the top of the changes wrought by SARS-CoV-2 is an explosive use of the Internet as a vehicle for group interaction and communication. Did you even know what Zoom was a year ago?

From remote education to international business meetings our screen time has increased dramatically. In homes across the country families have relaxed any restrictions they might have had on video exposure as they struggled to amuse and entertain children who have been shut off from their playmates. As reported in the Washington Post, the monitoring company Bark found that children sent and received 144% more Internet messages in 2020 than they had the year before..

Even families that I know who have been incredibly creative in finding physical activities, both indoor and outdoor, for their children have scaled back their restrictions on screen time. While the term “survival mode” is a bit too strong to describe this phenomenon, it was simply a matter of finding solutions given a limited supply of options.

The increase in screen time has prompted many parents to worry about its effect on their children. The American Academy of Pediatrics has already expressed concern about the cumulative effects of screen exposure on visual acuity. And it seems reasonable to expect that the obesity epidemic will accelerate as more children become more sedentary watching video screens. Whether the dire predictions of educators about lost learning will come true remains to be seen.

We can hope that this relaxation of screen time limits will be temporary. But that hope has a slim chance of becoming a reality as we have realized how powerful the Internet can be as an imperfect but effective educational tool. We have seen that apps such as Zoom, GoToMeeting, and FaceTime can allow families to connect on holidays when to face-to-face meetings are impractical. How should parents, and those of us who advise them, begin to restructure sensible and enforceable guidelines for screen time given the sea change we have just experienced?

There will certainly be significant resistance on the part of children to unlearn screen habits developed during the darkest hours of the pandemic: Texting a friend whom you will now be able to see in school, playing a video game instead of biking around the neighborhood with on a sunny afternoon, or, binging on sitcoms in the evening with your parents when they knew you didn’t have to get up early to catch the school bus.

It could be a herculean task to nudge the screen time pendulum back toward the prepandemic “norm.” In the past we haven’t done a very good job of promoting a healthy screen time diet for children. When the only screen in town was television the American Academy of Pediatrics’ focus was more on content than quantity. Quality is often difficult to assess and parents, like most everyone, seem more comfortable with guidelines that include a time metric – even if they don’t seem to be very good at enforcing it.

Maybe screen time is too big a boulder to roll up the hill. The good news is that during the pandemic, activity – particularly outdoor activity – has increased dramatically. Bicycles went off the shelves like toilet paper. National and state parks have been overflowing with families. While we must not ignore the downside of excess screen time, we should put more effort into promoting the healthy alternative of outdoor recreation. Let’s not allow a positive trend slip into becoming a short-lived fad.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The light at the end of the pandemic tunnel seems even brighter than it did just a month ago and in its glow it’s tempting to look back on the adjustments we have made in our lives and consider how many of those adjustments will solidify into new standards. Certainly, near the top of the changes wrought by SARS-CoV-2 is an explosive use of the Internet as a vehicle for group interaction and communication. Did you even know what Zoom was a year ago?

From remote education to international business meetings our screen time has increased dramatically. In homes across the country families have relaxed any restrictions they might have had on video exposure as they struggled to amuse and entertain children who have been shut off from their playmates. As reported in the Washington Post, the monitoring company Bark found that children sent and received 144% more Internet messages in 2020 than they had the year before..

Even families that I know who have been incredibly creative in finding physical activities, both indoor and outdoor, for their children have scaled back their restrictions on screen time. While the term “survival mode” is a bit too strong to describe this phenomenon, it was simply a matter of finding solutions given a limited supply of options.

The increase in screen time has prompted many parents to worry about its effect on their children. The American Academy of Pediatrics has already expressed concern about the cumulative effects of screen exposure on visual acuity. And it seems reasonable to expect that the obesity epidemic will accelerate as more children become more sedentary watching video screens. Whether the dire predictions of educators about lost learning will come true remains to be seen.

We can hope that this relaxation of screen time limits will be temporary. But that hope has a slim chance of becoming a reality as we have realized how powerful the Internet can be as an imperfect but effective educational tool. We have seen that apps such as Zoom, GoToMeeting, and FaceTime can allow families to connect on holidays when to face-to-face meetings are impractical. How should parents, and those of us who advise them, begin to restructure sensible and enforceable guidelines for screen time given the sea change we have just experienced?

There will certainly be significant resistance on the part of children to unlearn screen habits developed during the darkest hours of the pandemic: Texting a friend whom you will now be able to see in school, playing a video game instead of biking around the neighborhood with on a sunny afternoon, or, binging on sitcoms in the evening with your parents when they knew you didn’t have to get up early to catch the school bus.

It could be a herculean task to nudge the screen time pendulum back toward the prepandemic “norm.” In the past we haven’t done a very good job of promoting a healthy screen time diet for children. When the only screen in town was television the American Academy of Pediatrics’ focus was more on content than quantity. Quality is often difficult to assess and parents, like most everyone, seem more comfortable with guidelines that include a time metric – even if they don’t seem to be very good at enforcing it.

Maybe screen time is too big a boulder to roll up the hill. The good news is that during the pandemic, activity – particularly outdoor activity – has increased dramatically. Bicycles went off the shelves like toilet paper. National and state parks have been overflowing with families. While we must not ignore the downside of excess screen time, we should put more effort into promoting the healthy alternative of outdoor recreation. Let’s not allow a positive trend slip into becoming a short-lived fad.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The light at the end of the pandemic tunnel seems even brighter than it did just a month ago and in its glow it’s tempting to look back on the adjustments we have made in our lives and consider how many of those adjustments will solidify into new standards. Certainly, near the top of the changes wrought by SARS-CoV-2 is an explosive use of the Internet as a vehicle for group interaction and communication. Did you even know what Zoom was a year ago?

From remote education to international business meetings our screen time has increased dramatically. In homes across the country families have relaxed any restrictions they might have had on video exposure as they struggled to amuse and entertain children who have been shut off from their playmates. As reported in the Washington Post, the monitoring company Bark found that children sent and received 144% more Internet messages in 2020 than they had the year before..

Even families that I know who have been incredibly creative in finding physical activities, both indoor and outdoor, for their children have scaled back their restrictions on screen time. While the term “survival mode” is a bit too strong to describe this phenomenon, it was simply a matter of finding solutions given a limited supply of options.

The increase in screen time has prompted many parents to worry about its effect on their children. The American Academy of Pediatrics has already expressed concern about the cumulative effects of screen exposure on visual acuity. And it seems reasonable to expect that the obesity epidemic will accelerate as more children become more sedentary watching video screens. Whether the dire predictions of educators about lost learning will come true remains to be seen.

We can hope that this relaxation of screen time limits will be temporary. But that hope has a slim chance of becoming a reality as we have realized how powerful the Internet can be as an imperfect but effective educational tool. We have seen that apps such as Zoom, GoToMeeting, and FaceTime can allow families to connect on holidays when to face-to-face meetings are impractical. How should parents, and those of us who advise them, begin to restructure sensible and enforceable guidelines for screen time given the sea change we have just experienced?

There will certainly be significant resistance on the part of children to unlearn screen habits developed during the darkest hours of the pandemic: Texting a friend whom you will now be able to see in school, playing a video game instead of biking around the neighborhood with on a sunny afternoon, or, binging on sitcoms in the evening with your parents when they knew you didn’t have to get up early to catch the school bus.

It could be a herculean task to nudge the screen time pendulum back toward the prepandemic “norm.” In the past we haven’t done a very good job of promoting a healthy screen time diet for children. When the only screen in town was television the American Academy of Pediatrics’ focus was more on content than quantity. Quality is often difficult to assess and parents, like most everyone, seem more comfortable with guidelines that include a time metric – even if they don’t seem to be very good at enforcing it.

Maybe screen time is too big a boulder to roll up the hill. The good news is that during the pandemic, activity – particularly outdoor activity – has increased dramatically. Bicycles went off the shelves like toilet paper. National and state parks have been overflowing with families. While we must not ignore the downside of excess screen time, we should put more effort into promoting the healthy alternative of outdoor recreation. Let’s not allow a positive trend slip into becoming a short-lived fad.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].