The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

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

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

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

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

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

A significant proportion of community-dwelling older adults with dementia take three or more central nervous system medications despite guidelines that say to avoid this dangerous practice, new research suggests.

Investigators found that 14% of these individuals were receiving CNS-active polypharmacy, defined as combinations of multiple psychotropic and opioid medications taken for more than 30 days.

“For most patients, the risks of these medications, particularly in combination, are almost certainly greater than the potential benefits,” said Donovan Maust, MD, associate director of the geriatric psychiatry program, University of Michigan, Ann Arbor.

The study was published online March 9 in JAMA.
 

Serious risks

Memory impairment is the cardinal feature of dementia, but behavioral and psychological symptoms, which can include apathy, delusions, and agitation, are common during all stages of illness and cause significant caregiver distress, the researchers noted.

They noted that there is a dearth of high-quality evidence to support prescribing these medications in this patient population, yet “clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia in rates that far exceed use in the general older adult population.”

The Beers Criteria, from the American Geriatrics Society, advise against the practice of CNS polypharmacy because of the significant increase in risk for falls as well as impaired cognition, cardiac conduction abnormalities, respiratory suppression, and death when polypharmacy involves opioids.

They note that previous studies from Europe of polypharmacy for patients with dementia have not included antiepileptic medications or opioids, so the true extent of CNS-active polypharmacy may be “significantly” underestimated.

To determine the prevalence of polypharmacy with CNS-active medications among community-dwelling older adults with dementia, the researchers analyzed data on prescription fills for nearly 1.2 million community-dwelling Medicare patients with dementia.

The primary outcome was the prevalence of CNS-active polypharmacy in 2018. They defined CNS-active polypharmacy as exposure to three or more medications for more than 30 consecutive days from the following drug classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepines, benzodiazepine receptor agonist hypnotics, and opioids.

They found that roughly one in seven (13.9%) patients met criteria for CNS-active polypharmacy. Of those receiving a CNS-active polypharmacy regimen, 57.8% had been doing so for longer than 180 days, and 6.8% had been doing so for a year. Nearly 30% of patients were exposed to five or more medications, and 5.2% were exposed to five or more medication classes.
 

Conservative approach warranted

Nearly all (92%) patients taking three or more CNS-active medications were taking an antidepressant, “consistent with their place as the psychotropic class most commonly prescribed both to older adults overall and those with dementia,” the investigators noted.

There is minimal high-quality evidence to support the efficacy of antidepressants for the treatment of depression for patients with dementia, they pointed out.

Nearly half (47%) of patients who were taking three or more CNS-active medications received at least one antipsychotic, most often quetiapine. Antipsychotics are not approved for people with dementia but are often prescribed off label for agitation, anxiety, and sleep problems, the researchers noted.

Nearly two thirds (62%) of patients with dementia who were taking three or more CNS drugs were taking an antiepileptic (most commonly, gabapentin); 41%, benzodiazepines; 32%, opioids; and 6%, Z-drugs.

The most common polypharmacy class combination included at least one antidepressant, one antiepileptic, and one antipsychotic. These accounted for 12.9% of polypharmacy days.

Despite limited high-quality evidence of efficacy, the prescribing of psychotropic medications and opioids is “pervasive” for adults with dementia in the United States, the investigators noted.

“Especially given that older adults with dementia might not be able to convey side effects they are experiencing, I think clinicians should be more conservative in how they are prescribing these medications and skeptical about the potential for benefit,” said Dr. Maust.

Regarding study limitations, the researchers noted that prescription medication claims may have led to an overestimation of the exposure to polypharmacy, insofar as the prescriptions may have been filled but not taken or were taken only on an as-needed basis.

In addition, the investigators were unable to determine the appropriateness of the particular combinations used or to examine the specific harms associated with CNS-active polypharmacy.
 

A major clinical challenge

Weighing in on the results, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said the study is important because polypharmacy is one of the “geriatric giants, and the question is, what do you do about it?”

Dr. Fillit said it is important to conduct a careful medication review for all older patients, “making sure that the use of each drug is appropriate. The most important thing is to define what is the appropriate utilization of these kinds of drugs. That goes for both overutilization or misuse of these drugs and underutilization, where people are undertreated for symptoms that can’t be managed by behavioral management, for example,” Dr. Fillit said.

Dr. Fillit also said the finding that about 14% of dementia patients were receiving three or more of these drugs “may not be an outrageous number, because these patients, especially as they get into moderate and severe stages of disease, can be incredibly difficult to manage.

“Very often, dementia patients have depression, and up to 90% will have agitation and even psychosis during the course of dementia. And many of these patients need these types of drugs,” said Dr. Fillit.

Echoing the authors, Dr. Fillit said a key limitation of the study is not knowing whether the prescribing was appropriate or not.

The study was supported by a grant from the National Institute on Aging. Dr. Maust and Dr. Fillit have disclosed no relevant financial relationships.

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

A significant proportion of community-dwelling older adults with dementia take three or more central nervous system medications despite guidelines that say to avoid this dangerous practice, new research suggests.

Investigators found that 14% of these individuals were receiving CNS-active polypharmacy, defined as combinations of multiple psychotropic and opioid medications taken for more than 30 days.

“For most patients, the risks of these medications, particularly in combination, are almost certainly greater than the potential benefits,” said Donovan Maust, MD, associate director of the geriatric psychiatry program, University of Michigan, Ann Arbor.

The study was published online March 9 in JAMA.
 

Serious risks

Memory impairment is the cardinal feature of dementia, but behavioral and psychological symptoms, which can include apathy, delusions, and agitation, are common during all stages of illness and cause significant caregiver distress, the researchers noted.

They noted that there is a dearth of high-quality evidence to support prescribing these medications in this patient population, yet “clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia in rates that far exceed use in the general older adult population.”

The Beers Criteria, from the American Geriatrics Society, advise against the practice of CNS polypharmacy because of the significant increase in risk for falls as well as impaired cognition, cardiac conduction abnormalities, respiratory suppression, and death when polypharmacy involves opioids.

They note that previous studies from Europe of polypharmacy for patients with dementia have not included antiepileptic medications or opioids, so the true extent of CNS-active polypharmacy may be “significantly” underestimated.

To determine the prevalence of polypharmacy with CNS-active medications among community-dwelling older adults with dementia, the researchers analyzed data on prescription fills for nearly 1.2 million community-dwelling Medicare patients with dementia.

The primary outcome was the prevalence of CNS-active polypharmacy in 2018. They defined CNS-active polypharmacy as exposure to three or more medications for more than 30 consecutive days from the following drug classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepines, benzodiazepine receptor agonist hypnotics, and opioids.

They found that roughly one in seven (13.9%) patients met criteria for CNS-active polypharmacy. Of those receiving a CNS-active polypharmacy regimen, 57.8% had been doing so for longer than 180 days, and 6.8% had been doing so for a year. Nearly 30% of patients were exposed to five or more medications, and 5.2% were exposed to five or more medication classes.
 

Conservative approach warranted

Nearly all (92%) patients taking three or more CNS-active medications were taking an antidepressant, “consistent with their place as the psychotropic class most commonly prescribed both to older adults overall and those with dementia,” the investigators noted.

There is minimal high-quality evidence to support the efficacy of antidepressants for the treatment of depression for patients with dementia, they pointed out.

Nearly half (47%) of patients who were taking three or more CNS-active medications received at least one antipsychotic, most often quetiapine. Antipsychotics are not approved for people with dementia but are often prescribed off label for agitation, anxiety, and sleep problems, the researchers noted.

Nearly two thirds (62%) of patients with dementia who were taking three or more CNS drugs were taking an antiepileptic (most commonly, gabapentin); 41%, benzodiazepines; 32%, opioids; and 6%, Z-drugs.

The most common polypharmacy class combination included at least one antidepressant, one antiepileptic, and one antipsychotic. These accounted for 12.9% of polypharmacy days.

Despite limited high-quality evidence of efficacy, the prescribing of psychotropic medications and opioids is “pervasive” for adults with dementia in the United States, the investigators noted.

“Especially given that older adults with dementia might not be able to convey side effects they are experiencing, I think clinicians should be more conservative in how they are prescribing these medications and skeptical about the potential for benefit,” said Dr. Maust.

Regarding study limitations, the researchers noted that prescription medication claims may have led to an overestimation of the exposure to polypharmacy, insofar as the prescriptions may have been filled but not taken or were taken only on an as-needed basis.

In addition, the investigators were unable to determine the appropriateness of the particular combinations used or to examine the specific harms associated with CNS-active polypharmacy.
 

A major clinical challenge

Weighing in on the results, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said the study is important because polypharmacy is one of the “geriatric giants, and the question is, what do you do about it?”

Dr. Fillit said it is important to conduct a careful medication review for all older patients, “making sure that the use of each drug is appropriate. The most important thing is to define what is the appropriate utilization of these kinds of drugs. That goes for both overutilization or misuse of these drugs and underutilization, where people are undertreated for symptoms that can’t be managed by behavioral management, for example,” Dr. Fillit said.

Dr. Fillit also said the finding that about 14% of dementia patients were receiving three or more of these drugs “may not be an outrageous number, because these patients, especially as they get into moderate and severe stages of disease, can be incredibly difficult to manage.

“Very often, dementia patients have depression, and up to 90% will have agitation and even psychosis during the course of dementia. And many of these patients need these types of drugs,” said Dr. Fillit.

Echoing the authors, Dr. Fillit said a key limitation of the study is not knowing whether the prescribing was appropriate or not.

The study was supported by a grant from the National Institute on Aging. Dr. Maust and Dr. Fillit have disclosed no relevant financial relationships.

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

A significant proportion of community-dwelling older adults with dementia take three or more central nervous system medications despite guidelines that say to avoid this dangerous practice, new research suggests.

Investigators found that 14% of these individuals were receiving CNS-active polypharmacy, defined as combinations of multiple psychotropic and opioid medications taken for more than 30 days.

“For most patients, the risks of these medications, particularly in combination, are almost certainly greater than the potential benefits,” said Donovan Maust, MD, associate director of the geriatric psychiatry program, University of Michigan, Ann Arbor.

The study was published online March 9 in JAMA.
 

Serious risks

Memory impairment is the cardinal feature of dementia, but behavioral and psychological symptoms, which can include apathy, delusions, and agitation, are common during all stages of illness and cause significant caregiver distress, the researchers noted.

They noted that there is a dearth of high-quality evidence to support prescribing these medications in this patient population, yet “clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia in rates that far exceed use in the general older adult population.”

The Beers Criteria, from the American Geriatrics Society, advise against the practice of CNS polypharmacy because of the significant increase in risk for falls as well as impaired cognition, cardiac conduction abnormalities, respiratory suppression, and death when polypharmacy involves opioids.

They note that previous studies from Europe of polypharmacy for patients with dementia have not included antiepileptic medications or opioids, so the true extent of CNS-active polypharmacy may be “significantly” underestimated.

To determine the prevalence of polypharmacy with CNS-active medications among community-dwelling older adults with dementia, the researchers analyzed data on prescription fills for nearly 1.2 million community-dwelling Medicare patients with dementia.

The primary outcome was the prevalence of CNS-active polypharmacy in 2018. They defined CNS-active polypharmacy as exposure to three or more medications for more than 30 consecutive days from the following drug classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepines, benzodiazepine receptor agonist hypnotics, and opioids.

They found that roughly one in seven (13.9%) patients met criteria for CNS-active polypharmacy. Of those receiving a CNS-active polypharmacy regimen, 57.8% had been doing so for longer than 180 days, and 6.8% had been doing so for a year. Nearly 30% of patients were exposed to five or more medications, and 5.2% were exposed to five or more medication classes.
 

Conservative approach warranted

Nearly all (92%) patients taking three or more CNS-active medications were taking an antidepressant, “consistent with their place as the psychotropic class most commonly prescribed both to older adults overall and those with dementia,” the investigators noted.

There is minimal high-quality evidence to support the efficacy of antidepressants for the treatment of depression for patients with dementia, they pointed out.

Nearly half (47%) of patients who were taking three or more CNS-active medications received at least one antipsychotic, most often quetiapine. Antipsychotics are not approved for people with dementia but are often prescribed off label for agitation, anxiety, and sleep problems, the researchers noted.

Nearly two thirds (62%) of patients with dementia who were taking three or more CNS drugs were taking an antiepileptic (most commonly, gabapentin); 41%, benzodiazepines; 32%, opioids; and 6%, Z-drugs.

The most common polypharmacy class combination included at least one antidepressant, one antiepileptic, and one antipsychotic. These accounted for 12.9% of polypharmacy days.

Despite limited high-quality evidence of efficacy, the prescribing of psychotropic medications and opioids is “pervasive” for adults with dementia in the United States, the investigators noted.

“Especially given that older adults with dementia might not be able to convey side effects they are experiencing, I think clinicians should be more conservative in how they are prescribing these medications and skeptical about the potential for benefit,” said Dr. Maust.

Regarding study limitations, the researchers noted that prescription medication claims may have led to an overestimation of the exposure to polypharmacy, insofar as the prescriptions may have been filled but not taken or were taken only on an as-needed basis.

In addition, the investigators were unable to determine the appropriateness of the particular combinations used or to examine the specific harms associated with CNS-active polypharmacy.
 

A major clinical challenge

Weighing in on the results, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said the study is important because polypharmacy is one of the “geriatric giants, and the question is, what do you do about it?”

Dr. Fillit said it is important to conduct a careful medication review for all older patients, “making sure that the use of each drug is appropriate. The most important thing is to define what is the appropriate utilization of these kinds of drugs. That goes for both overutilization or misuse of these drugs and underutilization, where people are undertreated for symptoms that can’t be managed by behavioral management, for example,” Dr. Fillit said.

Dr. Fillit also said the finding that about 14% of dementia patients were receiving three or more of these drugs “may not be an outrageous number, because these patients, especially as they get into moderate and severe stages of disease, can be incredibly difficult to manage.

“Very often, dementia patients have depression, and up to 90% will have agitation and even psychosis during the course of dementia. And many of these patients need these types of drugs,” said Dr. Fillit.

Echoing the authors, Dr. Fillit said a key limitation of the study is not knowing whether the prescribing was appropriate or not.

The study was supported by a grant from the National Institute on Aging. Dr. Maust and Dr. Fillit have disclosed no relevant financial relationships.

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

Telemedicine has had a profound effect upon the practice of rheumatology during the COVID-19 pandemic and will continue to do so afterward, speakers predicted at the 2021 Rheumatology Winter Clinical Symposium.

FatCamera/E+

“Telemedicine will change the way we do business. It already has,” observed Eric M. Ruderman, MD, professor of medicine (rheumatology) at Northwestern University in Chicago.

“All of a sudden in March of last year we all turned on a dime and went 100% remote, and we made it work. And it has worked well. It’s not the same as seeing people in person, but I’m pretty sure that going forward probably somewhere in the range of 30% of our visits are going to be telemedicine. It’s an incredible way to deal with people who are stable and are driving in from an hour-and-a-half away to get their prescription refilled,” he said.

Conditions well suited for video patient visits are those where the physical exam isn’t informative or necessary, such as polymyalgia rheumatica, axial spondyloarthritis with axial disease only, childhood periodic fever syndromes, and even many cases of rheumatoid arthritis, in Dr. Ruderman’s view.

“People who are stable – maybe not in remission, but we’ve decided they’re at that their target – a lot of those visits can be done remotely. It’s way more efficient. Everybody loves it: We like it, the patients like it. But we have to get to where we can do it better. The technology is clumsy right now,” he said.

“We do need better and smarter platforms,” agreed Alvin F. Wells, MD, PhD, a telerheumatology pioneer who has been involved in digital/video communication with his patients for nearly 6 years. “But the biggest issue is connectivity. Not all of our patients can get on the Internet.”

The telerheumatology paradigm he has used during the pandemic and will continue to use afterward is to see every new patient in the office, then do the follow-up visits virtually.

“They don’t need to come back into the office in 4 weeks. I’ve done my physical exam, ordered the x-rays and lab work. At the virtual 4-week follow-up we go over everything and I tell them if they need to come in for training in giving their injections,” explained Dr. Wells, a rheumatologist in Franklin, Wisc.

“The telemedicine visit doesn’t take the place of an in-person visit, but it allows you to stratify, to say who needs to be seen sooner rather than later,” he added.

While he anticipates that physician-patient virtual visits will continue to be an important part of clinical practice post pandemic, he predicted the major growth areas for telerheumatology once COVID-19 is squashed will be in clinician-to-clinician interactions and remote patient monitoring using smart devices.

Dr. Wells hasn’t gone into the hospital once since the pandemic began. Initially, that was because he didn’t want to deal with the personal protective equipment shortage or expose himself to the virus. Now, it’s because it’s just a more efficient use of his time to conduct virtual – and billable – 15-minute e-consults with clinicians in the hospital.

“I’ve had a lot of appropriate consults with the hospitalists,” he said. He can walk a hospitalist through a real-time physical exam at a gout patient’s bedside and order the right laboratory tests.

“I don’t need to go into the hospital. The interventional radiologist can tap an ankle or toe as well as I can,” the rheumatologist said.

Dermatologist George Martin, MD, rose from the audience to say that while he recognizes that pandemic telemedicine has been a good fit for rheumatologists, it’s been a very different story in dermatology.

“I realize telemedicine works really well when you don’t have to lay your hands on a patient, or when you’re just doing a stable follow-up and talking about test results. But we in dermatology have found as a group that telemedicine is pretty worthless. When patients are trying to send you a video stream of what their melanoma looks like, or maybe it’s a benign seborrheic keratosis, you’re going to hang their life on that? Dermatology is a very hands-on, visual thing, and unless the camera work becomes better telemedicine is worthless, with the exception of a laboratory follow-up or a stable visit where a physical exam is not required,” declared Dr. Martin, who is in private practice in Maui.

Dr. Wells reported serving as a consultant to MiCare Path, a remote health and monitoring company.

[email protected]

Telemedicine has had a profound effect upon the practice of rheumatology during the COVID-19 pandemic and will continue to do so afterward, speakers predicted at the 2021 Rheumatology Winter Clinical Symposium.

FatCamera/E+

“Telemedicine will change the way we do business. It already has,” observed Eric M. Ruderman, MD, professor of medicine (rheumatology) at Northwestern University in Chicago.

“All of a sudden in March of last year we all turned on a dime and went 100% remote, and we made it work. And it has worked well. It’s not the same as seeing people in person, but I’m pretty sure that going forward probably somewhere in the range of 30% of our visits are going to be telemedicine. It’s an incredible way to deal with people who are stable and are driving in from an hour-and-a-half away to get their prescription refilled,” he said.

Conditions well suited for video patient visits are those where the physical exam isn’t informative or necessary, such as polymyalgia rheumatica, axial spondyloarthritis with axial disease only, childhood periodic fever syndromes, and even many cases of rheumatoid arthritis, in Dr. Ruderman’s view.

“People who are stable – maybe not in remission, but we’ve decided they’re at that their target – a lot of those visits can be done remotely. It’s way more efficient. Everybody loves it: We like it, the patients like it. But we have to get to where we can do it better. The technology is clumsy right now,” he said.

“We do need better and smarter platforms,” agreed Alvin F. Wells, MD, PhD, a telerheumatology pioneer who has been involved in digital/video communication with his patients for nearly 6 years. “But the biggest issue is connectivity. Not all of our patients can get on the Internet.”

The telerheumatology paradigm he has used during the pandemic and will continue to use afterward is to see every new patient in the office, then do the follow-up visits virtually.

“They don’t need to come back into the office in 4 weeks. I’ve done my physical exam, ordered the x-rays and lab work. At the virtual 4-week follow-up we go over everything and I tell them if they need to come in for training in giving their injections,” explained Dr. Wells, a rheumatologist in Franklin, Wisc.

“The telemedicine visit doesn’t take the place of an in-person visit, but it allows you to stratify, to say who needs to be seen sooner rather than later,” he added.

While he anticipates that physician-patient virtual visits will continue to be an important part of clinical practice post pandemic, he predicted the major growth areas for telerheumatology once COVID-19 is squashed will be in clinician-to-clinician interactions and remote patient monitoring using smart devices.

Dr. Wells hasn’t gone into the hospital once since the pandemic began. Initially, that was because he didn’t want to deal with the personal protective equipment shortage or expose himself to the virus. Now, it’s because it’s just a more efficient use of his time to conduct virtual – and billable – 15-minute e-consults with clinicians in the hospital.

“I’ve had a lot of appropriate consults with the hospitalists,” he said. He can walk a hospitalist through a real-time physical exam at a gout patient’s bedside and order the right laboratory tests.

“I don’t need to go into the hospital. The interventional radiologist can tap an ankle or toe as well as I can,” the rheumatologist said.

Dermatologist George Martin, MD, rose from the audience to say that while he recognizes that pandemic telemedicine has been a good fit for rheumatologists, it’s been a very different story in dermatology.

“I realize telemedicine works really well when you don’t have to lay your hands on a patient, or when you’re just doing a stable follow-up and talking about test results. But we in dermatology have found as a group that telemedicine is pretty worthless. When patients are trying to send you a video stream of what their melanoma looks like, or maybe it’s a benign seborrheic keratosis, you’re going to hang their life on that? Dermatology is a very hands-on, visual thing, and unless the camera work becomes better telemedicine is worthless, with the exception of a laboratory follow-up or a stable visit where a physical exam is not required,” declared Dr. Martin, who is in private practice in Maui.

Dr. Wells reported serving as a consultant to MiCare Path, a remote health and monitoring company.

[email protected]

Telemedicine has had a profound effect upon the practice of rheumatology during the COVID-19 pandemic and will continue to do so afterward, speakers predicted at the 2021 Rheumatology Winter Clinical Symposium.

FatCamera/E+

“Telemedicine will change the way we do business. It already has,” observed Eric M. Ruderman, MD, professor of medicine (rheumatology) at Northwestern University in Chicago.

“All of a sudden in March of last year we all turned on a dime and went 100% remote, and we made it work. And it has worked well. It’s not the same as seeing people in person, but I’m pretty sure that going forward probably somewhere in the range of 30% of our visits are going to be telemedicine. It’s an incredible way to deal with people who are stable and are driving in from an hour-and-a-half away to get their prescription refilled,” he said.

Conditions well suited for video patient visits are those where the physical exam isn’t informative or necessary, such as polymyalgia rheumatica, axial spondyloarthritis with axial disease only, childhood periodic fever syndromes, and even many cases of rheumatoid arthritis, in Dr. Ruderman’s view.

“People who are stable – maybe not in remission, but we’ve decided they’re at that their target – a lot of those visits can be done remotely. It’s way more efficient. Everybody loves it: We like it, the patients like it. But we have to get to where we can do it better. The technology is clumsy right now,” he said.

“We do need better and smarter platforms,” agreed Alvin F. Wells, MD, PhD, a telerheumatology pioneer who has been involved in digital/video communication with his patients for nearly 6 years. “But the biggest issue is connectivity. Not all of our patients can get on the Internet.”

The telerheumatology paradigm he has used during the pandemic and will continue to use afterward is to see every new patient in the office, then do the follow-up visits virtually.

“They don’t need to come back into the office in 4 weeks. I’ve done my physical exam, ordered the x-rays and lab work. At the virtual 4-week follow-up we go over everything and I tell them if they need to come in for training in giving their injections,” explained Dr. Wells, a rheumatologist in Franklin, Wisc.

“The telemedicine visit doesn’t take the place of an in-person visit, but it allows you to stratify, to say who needs to be seen sooner rather than later,” he added.

While he anticipates that physician-patient virtual visits will continue to be an important part of clinical practice post pandemic, he predicted the major growth areas for telerheumatology once COVID-19 is squashed will be in clinician-to-clinician interactions and remote patient monitoring using smart devices.

Dr. Wells hasn’t gone into the hospital once since the pandemic began. Initially, that was because he didn’t want to deal with the personal protective equipment shortage or expose himself to the virus. Now, it’s because it’s just a more efficient use of his time to conduct virtual – and billable – 15-minute e-consults with clinicians in the hospital.

“I’ve had a lot of appropriate consults with the hospitalists,” he said. He can walk a hospitalist through a real-time physical exam at a gout patient’s bedside and order the right laboratory tests.

“I don’t need to go into the hospital. The interventional radiologist can tap an ankle or toe as well as I can,” the rheumatologist said.

Dermatologist George Martin, MD, rose from the audience to say that while he recognizes that pandemic telemedicine has been a good fit for rheumatologists, it’s been a very different story in dermatology.

“I realize telemedicine works really well when you don’t have to lay your hands on a patient, or when you’re just doing a stable follow-up and talking about test results. But we in dermatology have found as a group that telemedicine is pretty worthless. When patients are trying to send you a video stream of what their melanoma looks like, or maybe it’s a benign seborrheic keratosis, you’re going to hang their life on that? Dermatology is a very hands-on, visual thing, and unless the camera work becomes better telemedicine is worthless, with the exception of a laboratory follow-up or a stable visit where a physical exam is not required,” declared Dr. Martin, who is in private practice in Maui.

Dr. Wells reported serving as a consultant to MiCare Path, a remote health and monitoring company.

[email protected]

Are you a napper? Unless you’re retired that may sound like a ridiculous question. When could you possibly fit in the time to doze off for even 20 minutes? I suspect there may be one or two of you who, although you are still working, have found a way to schedule a nap into your schedules. The rest of us must wait until we no longer have clinical responsibilities.

In my experience, you regular nappers seem to be the lucky few who have discovered the art of nodding off after lunch and waking up refreshed and ready to take on a full afternoon of patients. We in the unlucky majority may have tried taking a nap but run the risk of its flowing into a deep slumber the length of which we can’t control. Or, more likely, we find that we wake feeling groggy and disoriented and, even worse, the daytime nod off has messed up our nighttime schedule.

Well, it turns out the ability to take daytime naps and reap their cardiometabolic benefits is not just luck but has a significant genetic component. Investigators at Massachusetts General Hospital in Boston have recently published a study in which they report finding more than a score of gene regions that determine a person’s propensity to take daytime naps.. The researchers have also unearthed preliminary evidence supporting a link between daytime napping and cardiometabolic health. My mother began napping when my sister and I were infants and never gave it up. Unfortunately, I seem to have ended up on the wrong side of the genomic shuffle.

Although this new research is interesting, I don’t think the investigators have enough information to answer one of the questions that every pediatrician fields multiple times each week. “When should my toddler grow out of his afternoon nap?” Although it looks like we may be getting closer to a gene-based answer, I have always couched my reply in terms of behavior modification and the fostering of habit-forming associations.

As a child begins to transition from multiple short naps interspersed with feedings to a pattern of two distinct naps, I suggest to parents that they begin to think of the afternoon nap as a siesta. In other words, the nap is something that always comes immediately after lunch with no intervening shenanigans. No playtime, no Teletubbies videos, no quick trips to the grocery store, nothing, nada, zip.

At least for me, lunch has always been soporific. And I suspect we will learn eventually that association cuts across the entire genetic landscape to one degree or another. It makes sense to take advantage of that association and remove all other distractions. For some parents, that means creating the illusion that they too are taking a siesta: No TV, no phone calls. Imagine that the whole household has suddenly moved to Spain for the next hour or two. If you’ve ever been a tourist in rural Spain and tried to do anything, buy anything, or visit a museum between 2 and 4 p.m. you’ve got the idea.

When the child is young he or she will probably fall asleep as long as his parents have been reasonably successful at maintaining sleep hygiene practices. As the child is gaining more stamina and gives up the morning nap, the siesta will remain as a quiet time because that’s the way it’s always been in the household. The child may sleep or play quietly, or be read a sleep-inducing story because no other options will be available until some predetermined time. An hour is usually reasonable. If sleep hasn’t overtaken them, an earlier bedtime will probably be in order. The child will outgrow the napping part of the siesta when his or her sleep need is gone. But, the siesta/quiet time can remain as an option until all-day school intervenes. This scheme works if you can get parents to appropriately prioritize their child’s sleep needs. That’s not always an easy sell.
 

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].

Are you a napper? Unless you’re retired that may sound like a ridiculous question. When could you possibly fit in the time to doze off for even 20 minutes? I suspect there may be one or two of you who, although you are still working, have found a way to schedule a nap into your schedules. The rest of us must wait until we no longer have clinical responsibilities.

In my experience, you regular nappers seem to be the lucky few who have discovered the art of nodding off after lunch and waking up refreshed and ready to take on a full afternoon of patients. We in the unlucky majority may have tried taking a nap but run the risk of its flowing into a deep slumber the length of which we can’t control. Or, more likely, we find that we wake feeling groggy and disoriented and, even worse, the daytime nod off has messed up our nighttime schedule.

Well, it turns out the ability to take daytime naps and reap their cardiometabolic benefits is not just luck but has a significant genetic component. Investigators at Massachusetts General Hospital in Boston have recently published a study in which they report finding more than a score of gene regions that determine a person’s propensity to take daytime naps.. The researchers have also unearthed preliminary evidence supporting a link between daytime napping and cardiometabolic health. My mother began napping when my sister and I were infants and never gave it up. Unfortunately, I seem to have ended up on the wrong side of the genomic shuffle.

Although this new research is interesting, I don’t think the investigators have enough information to answer one of the questions that every pediatrician fields multiple times each week. “When should my toddler grow out of his afternoon nap?” Although it looks like we may be getting closer to a gene-based answer, I have always couched my reply in terms of behavior modification and the fostering of habit-forming associations.

As a child begins to transition from multiple short naps interspersed with feedings to a pattern of two distinct naps, I suggest to parents that they begin to think of the afternoon nap as a siesta. In other words, the nap is something that always comes immediately after lunch with no intervening shenanigans. No playtime, no Teletubbies videos, no quick trips to the grocery store, nothing, nada, zip.

At least for me, lunch has always been soporific. And I suspect we will learn eventually that association cuts across the entire genetic landscape to one degree or another. It makes sense to take advantage of that association and remove all other distractions. For some parents, that means creating the illusion that they too are taking a siesta: No TV, no phone calls. Imagine that the whole household has suddenly moved to Spain for the next hour or two. If you’ve ever been a tourist in rural Spain and tried to do anything, buy anything, or visit a museum between 2 and 4 p.m. you’ve got the idea.

When the child is young he or she will probably fall asleep as long as his parents have been reasonably successful at maintaining sleep hygiene practices. As the child is gaining more stamina and gives up the morning nap, the siesta will remain as a quiet time because that’s the way it’s always been in the household. The child may sleep or play quietly, or be read a sleep-inducing story because no other options will be available until some predetermined time. An hour is usually reasonable. If sleep hasn’t overtaken them, an earlier bedtime will probably be in order. The child will outgrow the napping part of the siesta when his or her sleep need is gone. But, the siesta/quiet time can remain as an option until all-day school intervenes. This scheme works if you can get parents to appropriately prioritize their child’s sleep needs. That’s not always an easy sell.
 

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].

Are you a napper? Unless you’re retired that may sound like a ridiculous question. When could you possibly fit in the time to doze off for even 20 minutes? I suspect there may be one or two of you who, although you are still working, have found a way to schedule a nap into your schedules. The rest of us must wait until we no longer have clinical responsibilities.

In my experience, you regular nappers seem to be the lucky few who have discovered the art of nodding off after lunch and waking up refreshed and ready to take on a full afternoon of patients. We in the unlucky majority may have tried taking a nap but run the risk of its flowing into a deep slumber the length of which we can’t control. Or, more likely, we find that we wake feeling groggy and disoriented and, even worse, the daytime nod off has messed up our nighttime schedule.

Well, it turns out the ability to take daytime naps and reap their cardiometabolic benefits is not just luck but has a significant genetic component. Investigators at Massachusetts General Hospital in Boston have recently published a study in which they report finding more than a score of gene regions that determine a person’s propensity to take daytime naps.. The researchers have also unearthed preliminary evidence supporting a link between daytime napping and cardiometabolic health. My mother began napping when my sister and I were infants and never gave it up. Unfortunately, I seem to have ended up on the wrong side of the genomic shuffle.

Although this new research is interesting, I don’t think the investigators have enough information to answer one of the questions that every pediatrician fields multiple times each week. “When should my toddler grow out of his afternoon nap?” Although it looks like we may be getting closer to a gene-based answer, I have always couched my reply in terms of behavior modification and the fostering of habit-forming associations.

As a child begins to transition from multiple short naps interspersed with feedings to a pattern of two distinct naps, I suggest to parents that they begin to think of the afternoon nap as a siesta. In other words, the nap is something that always comes immediately after lunch with no intervening shenanigans. No playtime, no Teletubbies videos, no quick trips to the grocery store, nothing, nada, zip.

At least for me, lunch has always been soporific. And I suspect we will learn eventually that association cuts across the entire genetic landscape to one degree or another. It makes sense to take advantage of that association and remove all other distractions. For some parents, that means creating the illusion that they too are taking a siesta: No TV, no phone calls. Imagine that the whole household has suddenly moved to Spain for the next hour or two. If you’ve ever been a tourist in rural Spain and tried to do anything, buy anything, or visit a museum between 2 and 4 p.m. you’ve got the idea.

When the child is young he or she will probably fall asleep as long as his parents have been reasonably successful at maintaining sleep hygiene practices. As the child is gaining more stamina and gives up the morning nap, the siesta will remain as a quiet time because that’s the way it’s always been in the household. The child may sleep or play quietly, or be read a sleep-inducing story because no other options will be available until some predetermined time. An hour is usually reasonable. If sleep hasn’t overtaken them, an earlier bedtime will probably be in order. The child will outgrow the napping part of the siesta when his or her sleep need is gone. But, the siesta/quiet time can remain as an option until all-day school intervenes. This scheme works if you can get parents to appropriately prioritize their child’s sleep needs. That’s not always an easy sell.
 

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 number of new COVID-19 cases in children dropped by 17.1% in the latest reporting week, after 2 consecutive weeks of relatively small declines, according to data gathered by the American Academy of Pediatrics and the Children’s Hospital Association.

From Feb. 19 to March 4, the drop in new cases averaged just 5% each week, compared with 13.3% per week over the 5-week period from Jan. 15 to Feb. 18. For the week of March 5-11, a total of 52,695 COVID-19 cases were reported in children, down from 63,562 the previous week and the lowest number since late October, based on data from 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

In those jurisdictions, 3.28 million children have been infected with SARS-CoV-2, representing 13.2% of all cases since the beginning of the pandemic. The cumulative rate of COVID-19 has now risen to 4,364 cases per 100,000 children nationally, with state rates ranging from 1,062 per 100,000 in Hawaii to 8,692 per 100,000 in North Dakota, the AAP and CHA said in their weekly COVID-19 report.

Hospitalization data are more limited – 24 states and New York City – but continue to show that serious illness is much less common in younger individuals: Children represent just 1.9% of all hospitalizations, and only 0.8% of the children who have been infected were hospitalized. Neither rate has changed since early February, the AAP and CHA said.

The number of deaths in children, however, rose from 253 to 266, the largest 1-week increase since early February in the 43 states (along with New York City, Puerto Rico, and Guam) that are tracking mortality data by age, the AAP and CHA reported.

Among those 46 jurisdictions, there are 10 (9 states and the District of Columbia) that have not yet reported a COVID-19–related child death, while Texas has almost twice as many deaths, 47, as the next state, Arizona, which has 24. Meanwhile, California’s total of 452,000 cases is almost 2½ times higher than the 183,000 recorded by Illinois, according to the report.

[email protected]

The number of new COVID-19 cases in children dropped by 17.1% in the latest reporting week, after 2 consecutive weeks of relatively small declines, according to data gathered by the American Academy of Pediatrics and the Children’s Hospital Association.

From Feb. 19 to March 4, the drop in new cases averaged just 5% each week, compared with 13.3% per week over the 5-week period from Jan. 15 to Feb. 18. For the week of March 5-11, a total of 52,695 COVID-19 cases were reported in children, down from 63,562 the previous week and the lowest number since late October, based on data from 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

In those jurisdictions, 3.28 million children have been infected with SARS-CoV-2, representing 13.2% of all cases since the beginning of the pandemic. The cumulative rate of COVID-19 has now risen to 4,364 cases per 100,000 children nationally, with state rates ranging from 1,062 per 100,000 in Hawaii to 8,692 per 100,000 in North Dakota, the AAP and CHA said in their weekly COVID-19 report.

Hospitalization data are more limited – 24 states and New York City – but continue to show that serious illness is much less common in younger individuals: Children represent just 1.9% of all hospitalizations, and only 0.8% of the children who have been infected were hospitalized. Neither rate has changed since early February, the AAP and CHA said.

The number of deaths in children, however, rose from 253 to 266, the largest 1-week increase since early February in the 43 states (along with New York City, Puerto Rico, and Guam) that are tracking mortality data by age, the AAP and CHA reported.

Among those 46 jurisdictions, there are 10 (9 states and the District of Columbia) that have not yet reported a COVID-19–related child death, while Texas has almost twice as many deaths, 47, as the next state, Arizona, which has 24. Meanwhile, California’s total of 452,000 cases is almost 2½ times higher than the 183,000 recorded by Illinois, according to the report.

[email protected]

The number of new COVID-19 cases in children dropped by 17.1% in the latest reporting week, after 2 consecutive weeks of relatively small declines, according to data gathered by the American Academy of Pediatrics and the Children’s Hospital Association.

From Feb. 19 to March 4, the drop in new cases averaged just 5% each week, compared with 13.3% per week over the 5-week period from Jan. 15 to Feb. 18. For the week of March 5-11, a total of 52,695 COVID-19 cases were reported in children, down from 63,562 the previous week and the lowest number since late October, based on data from 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

In those jurisdictions, 3.28 million children have been infected with SARS-CoV-2, representing 13.2% of all cases since the beginning of the pandemic. The cumulative rate of COVID-19 has now risen to 4,364 cases per 100,000 children nationally, with state rates ranging from 1,062 per 100,000 in Hawaii to 8,692 per 100,000 in North Dakota, the AAP and CHA said in their weekly COVID-19 report.

Hospitalization data are more limited – 24 states and New York City – but continue to show that serious illness is much less common in younger individuals: Children represent just 1.9% of all hospitalizations, and only 0.8% of the children who have been infected were hospitalized. Neither rate has changed since early February, the AAP and CHA said.

The number of deaths in children, however, rose from 253 to 266, the largest 1-week increase since early February in the 43 states (along with New York City, Puerto Rico, and Guam) that are tracking mortality data by age, the AAP and CHA reported.

Among those 46 jurisdictions, there are 10 (9 states and the District of Columbia) that have not yet reported a COVID-19–related child death, while Texas has almost twice as many deaths, 47, as the next state, Arizona, which has 24. Meanwhile, California’s total of 452,000 cases is almost 2½ times higher than the 183,000 recorded by Illinois, according to the report.

[email protected]

As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. Despite doubts about whether patients would resume in-person visits, however, office visits and demand for cosmetic procedures are more popular than ever.

SDI Productions/E+

While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
 

The Zoom effect

One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.

Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.

Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.

The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.

While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. Despite doubts about whether patients would resume in-person visits, however, office visits and demand for cosmetic procedures are more popular than ever.

SDI Productions/E+

While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
 

The Zoom effect

One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.

Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.

Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.

The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.

While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. Despite doubts about whether patients would resume in-person visits, however, office visits and demand for cosmetic procedures are more popular than ever.

SDI Productions/E+

While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
 

The Zoom effect

One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.

Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.

Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.

The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.

While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

A man I saw earlier this year called my office recently. He’d read my note, and after discussing it with his attorney, wanted me to make changes. He said that the way I’d described his symptoms would be damaging to a legal action he was involved in, and so he wanted it reworded.

Obviously, I said “no.” I’m not a fiction writer. My notes are what people tell me happened. I don’t make them up.

He wasn’t happy about this, and a few days later I got a request to send his records to another neurologist, which I gladly did.

In this business a large measure of what we do is based on the patient’s symptoms. what they report to us, and how they describe it. When I put their story into a written note, my goal is to be as accurate to what they told me as possible. I’m not here to embellish, disparage, or minimize their history.

A chart, as was drilled into me throughout training, is a legal document. Once I’ve signed off on a note it can’t be changed. To do so is to look bad at the very least and open yourself up to malpractice and legal charges at worst.

This isn’t to say errors can’t be modified. I’m far from perfect. Sometimes I might misunderstand something a patient tells me, or get information crossed up. When that happens there’s nothing wrong with writing an addendum, clarifying or correcting what my earlier note said – but not changing the original note.

I asked the unhappy patient to write down what he thought was incorrect, and I’d be willing to include that in his chart. He wasn’t willing to do that, and there was no way I would ever change a note. I tried to politely explain the reasons why, but he wasn’t listening.

So I lost him as a patient. After 23 years of practice, that doesn’t bother me. I learned a long time ago that I can’t please everyone, nor can I be everyone’s doctor. Saying “no” is just as important as saying “yes,” though at times more difficult.

This time, though, the answer was pretty obvious, and will be the same next time I get the same request from a patient.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A man I saw earlier this year called my office recently. He’d read my note, and after discussing it with his attorney, wanted me to make changes. He said that the way I’d described his symptoms would be damaging to a legal action he was involved in, and so he wanted it reworded.

Obviously, I said “no.” I’m not a fiction writer. My notes are what people tell me happened. I don’t make them up.

He wasn’t happy about this, and a few days later I got a request to send his records to another neurologist, which I gladly did.

In this business a large measure of what we do is based on the patient’s symptoms. what they report to us, and how they describe it. When I put their story into a written note, my goal is to be as accurate to what they told me as possible. I’m not here to embellish, disparage, or minimize their history.

A chart, as was drilled into me throughout training, is a legal document. Once I’ve signed off on a note it can’t be changed. To do so is to look bad at the very least and open yourself up to malpractice and legal charges at worst.

This isn’t to say errors can’t be modified. I’m far from perfect. Sometimes I might misunderstand something a patient tells me, or get information crossed up. When that happens there’s nothing wrong with writing an addendum, clarifying or correcting what my earlier note said – but not changing the original note.

I asked the unhappy patient to write down what he thought was incorrect, and I’d be willing to include that in his chart. He wasn’t willing to do that, and there was no way I would ever change a note. I tried to politely explain the reasons why, but he wasn’t listening.

So I lost him as a patient. After 23 years of practice, that doesn’t bother me. I learned a long time ago that I can’t please everyone, nor can I be everyone’s doctor. Saying “no” is just as important as saying “yes,” though at times more difficult.

This time, though, the answer was pretty obvious, and will be the same next time I get the same request from a patient.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A man I saw earlier this year called my office recently. He’d read my note, and after discussing it with his attorney, wanted me to make changes. He said that the way I’d described his symptoms would be damaging to a legal action he was involved in, and so he wanted it reworded.

Obviously, I said “no.” I’m not a fiction writer. My notes are what people tell me happened. I don’t make them up.

He wasn’t happy about this, and a few days later I got a request to send his records to another neurologist, which I gladly did.

In this business a large measure of what we do is based on the patient’s symptoms. what they report to us, and how they describe it. When I put their story into a written note, my goal is to be as accurate to what they told me as possible. I’m not here to embellish, disparage, or minimize their history.

A chart, as was drilled into me throughout training, is a legal document. Once I’ve signed off on a note it can’t be changed. To do so is to look bad at the very least and open yourself up to malpractice and legal charges at worst.

This isn’t to say errors can’t be modified. I’m far from perfect. Sometimes I might misunderstand something a patient tells me, or get information crossed up. When that happens there’s nothing wrong with writing an addendum, clarifying or correcting what my earlier note said – but not changing the original note.

I asked the unhappy patient to write down what he thought was incorrect, and I’d be willing to include that in his chart. He wasn’t willing to do that, and there was no way I would ever change a note. I tried to politely explain the reasons why, but he wasn’t listening.

So I lost him as a patient. After 23 years of practice, that doesn’t bother me. I learned a long time ago that I can’t please everyone, nor can I be everyone’s doctor. Saying “no” is just as important as saying “yes,” though at times more difficult.

This time, though, the answer was pretty obvious, and will be the same next time I get the same request from a patient.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Nearly one in three patients with blood cancer, and survivors, say they are unlikely to get a COVID-19 vaccine or unsure about getting it if one were available. The findings come from a nationwide survey by The Leukemia & Lymphoma Society, which collected 6,517 responses.

“These findings are worrisome, to say the least,” Gwen Nichols, MD, chief medical officer of the society, said in a statement.

“We know cancer patients – and blood cancer patients in particular – are susceptible to the worst effects of the virus [and] all of us in the medical community need to help cancer patients understand the importance of getting vaccinated,” she added.

The survey – the largest ever done in which cancer patients and survivors were asked about their attitudes toward COVID-19 vaccines – was published online March 8 by The Leukemia & Lymphoma Society.
 

Survey sample

The survey asked patients with blood cancer, and survivors, about their attitudes regarding COVID-19 and COVID-19 vaccines.

“The main outcome [was] vaccine attitudes,” noted the authors, headed by Rena Conti, PhD, dean’s research scholar, Boston University.

Respondents were asked: “How likely are you to choose to get the vaccine?” Participants could indicate they were very unlikely, unlikely, neither likely nor unlikely, likely, or very likely to get vaccinated.

“We found that 17% of respondents indicate[d] that they [were] unlikely or very unlikely to take a vaccine,” Dr. Conti and colleagues observed.

Among the 17% – deemed to be “vaccine hesitant” – slightly over half (54%) stated they had concerns about the side effects associated with COVID-19 vaccination and believed neither of the two newly approved vaccines had been or would ever be tested properly.

The survey authors noted that there is no reason to believe COVID-19 vaccines are any less safe in patients with blood cancers, but concerns have been expressed that patients with some forms of blood cancer or those undergoing certain treatments may not achieve the same immune response to the vaccine as would noncancer controls.

Importantly, the survey was conducted Dec. 1-21, 2020, and responses differed depending on whether respondents answered the survey before or after the Pfizer-BioNTech and Moderna vaccines had been given emergency use authorization by the Food and Drug Administration starting Dec. 10, 2020. 

There was a slight increase in positive responses after the vaccines were granted regulatory approval. (One-third of those who responded to the survey after the approval were 3.7% more likely to indicate they would get vaccinated). “This suggests that hesitancy may be influenced by emerging information dissemination, government action, and vaccine availability, transforming the hypothetical opportunity of vaccination to a real one,” the survey authors speculated.

Survey respondents who were vaccine hesitant were also over 14% more likely to indicate that they didn’t think they would require hospitalization should they contract COVID-19. But clinical data have suggested that approximately half of patients with a hematological malignancy who required hospitalization for COVID-19 die from the infection, the authors noted.

“Vaccine hesitant respondents [were] also significantly less likely to engage in protective health behaviors,” the survey authors pointed out. For example, they were almost 4% less likely to have worn a face mask and 1.6% less likely to have taken other protective measures to guard against COVID-19 infection.
 

Need for clear messaging

To counter vaccine hesitancy, the authors suggest there is a need for clear, consistent messaging targeting patients with cancer that emphasize the risks of COVID-19 and underscore vaccine benefits.

Dr. Conti pointed out that patients with blood cancer are, in fact, being given preferential access to vaccines in many communities, although this clearly doesn’t mean patients are willing to get vaccinated, as she also noted.

“We need both adequate supply and strong demand to keep this vulnerable population safe,” Dr. Conti emphasized.

The Leukemia & Lymphoma Society plans to repeat the survey in the near future to assess patients’ and survivors’ access to vaccines as well as their willingness to get vaccinated.

The authors have reported no relevant financial relationships.

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

Nearly one in three patients with blood cancer, and survivors, say they are unlikely to get a COVID-19 vaccine or unsure about getting it if one were available. The findings come from a nationwide survey by The Leukemia & Lymphoma Society, which collected 6,517 responses.

“These findings are worrisome, to say the least,” Gwen Nichols, MD, chief medical officer of the society, said in a statement.

“We know cancer patients – and blood cancer patients in particular – are susceptible to the worst effects of the virus [and] all of us in the medical community need to help cancer patients understand the importance of getting vaccinated,” she added.

The survey – the largest ever done in which cancer patients and survivors were asked about their attitudes toward COVID-19 vaccines – was published online March 8 by The Leukemia & Lymphoma Society.
 

Survey sample

The survey asked patients with blood cancer, and survivors, about their attitudes regarding COVID-19 and COVID-19 vaccines.

“The main outcome [was] vaccine attitudes,” noted the authors, headed by Rena Conti, PhD, dean’s research scholar, Boston University.

Respondents were asked: “How likely are you to choose to get the vaccine?” Participants could indicate they were very unlikely, unlikely, neither likely nor unlikely, likely, or very likely to get vaccinated.

“We found that 17% of respondents indicate[d] that they [were] unlikely or very unlikely to take a vaccine,” Dr. Conti and colleagues observed.

Among the 17% – deemed to be “vaccine hesitant” – slightly over half (54%) stated they had concerns about the side effects associated with COVID-19 vaccination and believed neither of the two newly approved vaccines had been or would ever be tested properly.

The survey authors noted that there is no reason to believe COVID-19 vaccines are any less safe in patients with blood cancers, but concerns have been expressed that patients with some forms of blood cancer or those undergoing certain treatments may not achieve the same immune response to the vaccine as would noncancer controls.

Importantly, the survey was conducted Dec. 1-21, 2020, and responses differed depending on whether respondents answered the survey before or after the Pfizer-BioNTech and Moderna vaccines had been given emergency use authorization by the Food and Drug Administration starting Dec. 10, 2020. 

There was a slight increase in positive responses after the vaccines were granted regulatory approval. (One-third of those who responded to the survey after the approval were 3.7% more likely to indicate they would get vaccinated). “This suggests that hesitancy may be influenced by emerging information dissemination, government action, and vaccine availability, transforming the hypothetical opportunity of vaccination to a real one,” the survey authors speculated.

Survey respondents who were vaccine hesitant were also over 14% more likely to indicate that they didn’t think they would require hospitalization should they contract COVID-19. But clinical data have suggested that approximately half of patients with a hematological malignancy who required hospitalization for COVID-19 die from the infection, the authors noted.

“Vaccine hesitant respondents [were] also significantly less likely to engage in protective health behaviors,” the survey authors pointed out. For example, they were almost 4% less likely to have worn a face mask and 1.6% less likely to have taken other protective measures to guard against COVID-19 infection.
 

Need for clear messaging

To counter vaccine hesitancy, the authors suggest there is a need for clear, consistent messaging targeting patients with cancer that emphasize the risks of COVID-19 and underscore vaccine benefits.

Dr. Conti pointed out that patients with blood cancer are, in fact, being given preferential access to vaccines in many communities, although this clearly doesn’t mean patients are willing to get vaccinated, as she also noted.

“We need both adequate supply and strong demand to keep this vulnerable population safe,” Dr. Conti emphasized.

The Leukemia & Lymphoma Society plans to repeat the survey in the near future to assess patients’ and survivors’ access to vaccines as well as their willingness to get vaccinated.

The authors have reported no relevant financial relationships.

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

Nearly one in three patients with blood cancer, and survivors, say they are unlikely to get a COVID-19 vaccine or unsure about getting it if one were available. The findings come from a nationwide survey by The Leukemia & Lymphoma Society, which collected 6,517 responses.

“These findings are worrisome, to say the least,” Gwen Nichols, MD, chief medical officer of the society, said in a statement.

“We know cancer patients – and blood cancer patients in particular – are susceptible to the worst effects of the virus [and] all of us in the medical community need to help cancer patients understand the importance of getting vaccinated,” she added.

The survey – the largest ever done in which cancer patients and survivors were asked about their attitudes toward COVID-19 vaccines – was published online March 8 by The Leukemia & Lymphoma Society.
 

Survey sample

The survey asked patients with blood cancer, and survivors, about their attitudes regarding COVID-19 and COVID-19 vaccines.

“The main outcome [was] vaccine attitudes,” noted the authors, headed by Rena Conti, PhD, dean’s research scholar, Boston University.

Respondents were asked: “How likely are you to choose to get the vaccine?” Participants could indicate they were very unlikely, unlikely, neither likely nor unlikely, likely, or very likely to get vaccinated.

“We found that 17% of respondents indicate[d] that they [were] unlikely or very unlikely to take a vaccine,” Dr. Conti and colleagues observed.

Among the 17% – deemed to be “vaccine hesitant” – slightly over half (54%) stated they had concerns about the side effects associated with COVID-19 vaccination and believed neither of the two newly approved vaccines had been or would ever be tested properly.

The survey authors noted that there is no reason to believe COVID-19 vaccines are any less safe in patients with blood cancers, but concerns have been expressed that patients with some forms of blood cancer or those undergoing certain treatments may not achieve the same immune response to the vaccine as would noncancer controls.

Importantly, the survey was conducted Dec. 1-21, 2020, and responses differed depending on whether respondents answered the survey before or after the Pfizer-BioNTech and Moderna vaccines had been given emergency use authorization by the Food and Drug Administration starting Dec. 10, 2020. 

There was a slight increase in positive responses after the vaccines were granted regulatory approval. (One-third of those who responded to the survey after the approval were 3.7% more likely to indicate they would get vaccinated). “This suggests that hesitancy may be influenced by emerging information dissemination, government action, and vaccine availability, transforming the hypothetical opportunity of vaccination to a real one,” the survey authors speculated.

Survey respondents who were vaccine hesitant were also over 14% more likely to indicate that they didn’t think they would require hospitalization should they contract COVID-19. But clinical data have suggested that approximately half of patients with a hematological malignancy who required hospitalization for COVID-19 die from the infection, the authors noted.

“Vaccine hesitant respondents [were] also significantly less likely to engage in protective health behaviors,” the survey authors pointed out. For example, they were almost 4% less likely to have worn a face mask and 1.6% less likely to have taken other protective measures to guard against COVID-19 infection.
 

Need for clear messaging

To counter vaccine hesitancy, the authors suggest there is a need for clear, consistent messaging targeting patients with cancer that emphasize the risks of COVID-19 and underscore vaccine benefits.

Dr. Conti pointed out that patients with blood cancer are, in fact, being given preferential access to vaccines in many communities, although this clearly doesn’t mean patients are willing to get vaccinated, as she also noted.

“We need both adequate supply and strong demand to keep this vulnerable population safe,” Dr. Conti emphasized.

The Leukemia & Lymphoma Society plans to repeat the survey in the near future to assess patients’ and survivors’ access to vaccines as well as their willingness to get vaccinated.

The authors have reported no relevant financial relationships.

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