Traci Sikes’s older sister Debbie had survived several health setbacks in life – a heart attack, a cancer diagnosis, and a couple of botched surgeries for a bad back. But by early 2023, the 68-year-old from Brownwood, Tex., was in remission from lymphoma, feeling stronger, and celebrating a birthday for one of her 11 beloved grandchildren. 

Then Debbie caught COVID-19. Less than 2 months later, in March, she died of severe lung damage caused by the coronavirus.

Traci was able to make the trip from her home in Washington state to Texas to be with Debbie before she died. She was grateful that she arrived while her sister was still lucid and to hear her sister’s last word – “love” – spoken to one of her grandchildren before she took her final breath.

“My sister was wonderful,” Sikes said. “And she shouldn’t be gone.” 

Just 6 months after President Joe Biden declared last fall that “the pandemic is over,” Debbie’s death was a painful reminder to Traci and her family that COVID hasn’t actually gone anywhere. Just as both the World Health Organization and U.S. government recently ended the 3-year-old coronavirus public health emergency, COVID is still killing more than 100 people every day in the U.S., according to the CDC, and amid widespread efforts to move on and drop protective measures, the country’s most vulnerable people are still at significant risk.

The prevailing attitude that we need to learn to live with the current level of risk feels like a “slap in the face,” for COVID grievers who have already paid the price,” said Sabila Khan, who cofounded a Facebook group for COVID loss support, which now has more than 14,000 members. 

It also minimizes the continuing loss of life and that so many people are still dying traumatic and unnecessary deaths, she said.

“It feels like it’s been brushed aside,” she said. “Like, ‘It’s business as usual. It’s over. Take off your mask.’ My family and I are still masked, and we’re probably the only ones masked in any given room.”

The abandoning of protective measures also fails to recognize the ongoing and catastrophic risks of long COVID and the experiences of an estimated 26 million people in the U.S. living with long COVID.

“It’s been drummed into us that death is the only serious outcome [of the virus] and we still haven’t made enough space for the idea that long COVID is a very serious outcome,” said David Putrino, PhD, director of rehabilitation innovation for the Mount Sinai Health System in New York, who has helped care for thousands of patients with long COVID.
 

Historic drop in life expectancy

More than 1.1 million Americans have died from COVID over the past 3 years, and experts say the official numbers are likely underestimated because of errors in death certificate reporting. Although deaths have waned from earlier in the pandemic, the disease has become the fourth leading cause of death in the United States after heart disease, cancer, and “unintentional injury” such as drug overdoses.

What makes these deaths all the more tragic is that COVID is a preventable disease, said Carla Sevin, MD, a critical care doctor and director of the Pulmonary Patient Care Center at Vanderbilt University Medical Center in Nashville, Tenn. Masking, available vaccines, and social distancing have all been shown to significantly lower the risk of spreading and catching the virus. New drugs have also made it possible for infected people to survive COVID.

“It’s possible to not spread COVID,” she said. “It’s possible to protect yourself against COVID. It’s possible to treat COVID. And we’re doing all of those things imperfectly.”

By the end of 2021, Americans overall were dying 3 years sooner, on average, than they were before the pandemic, with life expectancy dropping from 79 years to 76 years, the largest decline in a century. 

Globally, the COVID death toll is nearing 7 million. Across all ages, on average, each person who died passed away 10 years younger than they otherwise would have. That’s tens of millions of years wiped away.

As U.S. surgeon and health researcher Atul Gawande, MD, put it in a New York Times essay about the pandemic response: “Human development has been pushed into reverse.”
 

What is an acceptable threshold of death?

In the United States, more than 80% of deaths from the disease have been in people age 65 and older. Underlying medical conditions and disabilities also raise the risk of severe illness and dying from COVID. 

The virus is also disproportionately killing Black, Hispanic, and Indigenous people and those with less access to health care. Racialized groups are dying from COVID at younger ages. COVID advocates and Americans who’ve lost loved ones to the disease say our willingness to accept these facts and the current mortality rate amounts to health-based discrimination.

“Would politicians be approaching this differently had it mostly affected rich white people?” Ms. Khan said. 

Ms. Khan’s dad, Shafqat, was an advocate and community organizer for Pakistani immigrants. After contracting COVID, he was rushed to a hospital near his daughter’s Jersey City, N.J.,  home from a rehab facility where he was being treated for an aggressive form of Parkinson’s disease. For the 8 days her father was in the hospital, she and other family members couldn’t visit him, and he wasn’t even well enough to talk on the phone. He died from COVID in April 2020.

“My father was an extraordinary person who did so much good and he died alone, terrified in a hospital,” she said. “I can’t even wrap my head around that and how he deserved more. No one deserves that.”

At Vanderbilt University Medical Center, where she works as a critical care doctor, COVID deaths are now different from those in the early days of the pandemic, Dr. Sevin said. Most patients now in the intensive care unit are older and immunocompromised – and they tend to blend in more with others in the intensive care unit. That makes the impact of COVID even more hidden and easily ignored.

“It’s easy not to value somebody who’s an invisible number you don’t know,” she said. “You don’t see them writing their will and talking to their best friend. You don’t see the tears rolling down their face because they know what’s going to happen to them and they’re going to asphyxiate to death.” 

One COVID patient who died recently in Dr. Sevin’s ICU ward was an older woman who had no living relatives. “She was very, very lonely, and we would always stand outside the door on rounds, and she would motion for us to come in, but we had to then all gown up,” Dr. Sevin said. “It just breaks your heart that people are still having to go through it.”

Dr. Sevin finds it frustrating that so many of the measures that public health officials fought so hard for over the last 3 years – including masking guidelines, government-funded vaccine clinics, and access to potentially life-saving antiviral medications – are now going away because of the lifting of the pandemic emergency declaration.

What makes matters worse, she said, is that public consciousness about taking precautions to protect others is starting to disappear in favor of an “all or nothing attitude” about the continued risks. 

“Like either I’m going to stay home and be a hermit, or I’m going to just throw caution to the wind and go to bars and let people yell in my face,” she said. “We learned some hard lessons, and I wish we could hold onto those.”

Americans like Traci Sikes who’ve lost loved ones and health care workers on the front lines say it is particularly frustrating that so many people are framing the current response to the risks of COVID as “personal choice” over responsibility to others, as well as a sense of fatalism and lack of urgent care.

“Why does nobody seem to be angry about this?” Ms. Sikes said. “People talk about COVID like it’s just another thing to die from. But my sister didn’t have to die from it at all.”

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

Traci Sikes’s older sister Debbie had survived several health setbacks in life – a heart attack, a cancer diagnosis, and a couple of botched surgeries for a bad back. But by early 2023, the 68-year-old from Brownwood, Tex., was in remission from lymphoma, feeling stronger, and celebrating a birthday for one of her 11 beloved grandchildren. 

Then Debbie caught COVID-19. Less than 2 months later, in March, she died of severe lung damage caused by the coronavirus.

Traci was able to make the trip from her home in Washington state to Texas to be with Debbie before she died. She was grateful that she arrived while her sister was still lucid and to hear her sister’s last word – “love” – spoken to one of her grandchildren before she took her final breath.

“My sister was wonderful,” Sikes said. “And she shouldn’t be gone.” 

Just 6 months after President Joe Biden declared last fall that “the pandemic is over,” Debbie’s death was a painful reminder to Traci and her family that COVID hasn’t actually gone anywhere. Just as both the World Health Organization and U.S. government recently ended the 3-year-old coronavirus public health emergency, COVID is still killing more than 100 people every day in the U.S., according to the CDC, and amid widespread efforts to move on and drop protective measures, the country’s most vulnerable people are still at significant risk.

The prevailing attitude that we need to learn to live with the current level of risk feels like a “slap in the face,” for COVID grievers who have already paid the price,” said Sabila Khan, who cofounded a Facebook group for COVID loss support, which now has more than 14,000 members. 

It also minimizes the continuing loss of life and that so many people are still dying traumatic and unnecessary deaths, she said.

“It feels like it’s been brushed aside,” she said. “Like, ‘It’s business as usual. It’s over. Take off your mask.’ My family and I are still masked, and we’re probably the only ones masked in any given room.”

The abandoning of protective measures also fails to recognize the ongoing and catastrophic risks of long COVID and the experiences of an estimated 26 million people in the U.S. living with long COVID.

“It’s been drummed into us that death is the only serious outcome [of the virus] and we still haven’t made enough space for the idea that long COVID is a very serious outcome,” said David Putrino, PhD, director of rehabilitation innovation for the Mount Sinai Health System in New York, who has helped care for thousands of patients with long COVID.
 

Historic drop in life expectancy

More than 1.1 million Americans have died from COVID over the past 3 years, and experts say the official numbers are likely underestimated because of errors in death certificate reporting. Although deaths have waned from earlier in the pandemic, the disease has become the fourth leading cause of death in the United States after heart disease, cancer, and “unintentional injury” such as drug overdoses.

What makes these deaths all the more tragic is that COVID is a preventable disease, said Carla Sevin, MD, a critical care doctor and director of the Pulmonary Patient Care Center at Vanderbilt University Medical Center in Nashville, Tenn. Masking, available vaccines, and social distancing have all been shown to significantly lower the risk of spreading and catching the virus. New drugs have also made it possible for infected people to survive COVID.

“It’s possible to not spread COVID,” she said. “It’s possible to protect yourself against COVID. It’s possible to treat COVID. And we’re doing all of those things imperfectly.”

By the end of 2021, Americans overall were dying 3 years sooner, on average, than they were before the pandemic, with life expectancy dropping from 79 years to 76 years, the largest decline in a century. 

Globally, the COVID death toll is nearing 7 million. Across all ages, on average, each person who died passed away 10 years younger than they otherwise would have. That’s tens of millions of years wiped away.

As U.S. surgeon and health researcher Atul Gawande, MD, put it in a New York Times essay about the pandemic response: “Human development has been pushed into reverse.”
 

What is an acceptable threshold of death?

In the United States, more than 80% of deaths from the disease have been in people age 65 and older. Underlying medical conditions and disabilities also raise the risk of severe illness and dying from COVID. 

The virus is also disproportionately killing Black, Hispanic, and Indigenous people and those with less access to health care. Racialized groups are dying from COVID at younger ages. COVID advocates and Americans who’ve lost loved ones to the disease say our willingness to accept these facts and the current mortality rate amounts to health-based discrimination.

“Would politicians be approaching this differently had it mostly affected rich white people?” Ms. Khan said. 

Ms. Khan’s dad, Shafqat, was an advocate and community organizer for Pakistani immigrants. After contracting COVID, he was rushed to a hospital near his daughter’s Jersey City, N.J.,  home from a rehab facility where he was being treated for an aggressive form of Parkinson’s disease. For the 8 days her father was in the hospital, she and other family members couldn’t visit him, and he wasn’t even well enough to talk on the phone. He died from COVID in April 2020.

“My father was an extraordinary person who did so much good and he died alone, terrified in a hospital,” she said. “I can’t even wrap my head around that and how he deserved more. No one deserves that.”

At Vanderbilt University Medical Center, where she works as a critical care doctor, COVID deaths are now different from those in the early days of the pandemic, Dr. Sevin said. Most patients now in the intensive care unit are older and immunocompromised – and they tend to blend in more with others in the intensive care unit. That makes the impact of COVID even more hidden and easily ignored.

“It’s easy not to value somebody who’s an invisible number you don’t know,” she said. “You don’t see them writing their will and talking to their best friend. You don’t see the tears rolling down their face because they know what’s going to happen to them and they’re going to asphyxiate to death.” 

One COVID patient who died recently in Dr. Sevin’s ICU ward was an older woman who had no living relatives. “She was very, very lonely, and we would always stand outside the door on rounds, and she would motion for us to come in, but we had to then all gown up,” Dr. Sevin said. “It just breaks your heart that people are still having to go through it.”

Dr. Sevin finds it frustrating that so many of the measures that public health officials fought so hard for over the last 3 years – including masking guidelines, government-funded vaccine clinics, and access to potentially life-saving antiviral medications – are now going away because of the lifting of the pandemic emergency declaration.

What makes matters worse, she said, is that public consciousness about taking precautions to protect others is starting to disappear in favor of an “all or nothing attitude” about the continued risks. 

“Like either I’m going to stay home and be a hermit, or I’m going to just throw caution to the wind and go to bars and let people yell in my face,” she said. “We learned some hard lessons, and I wish we could hold onto those.”

Americans like Traci Sikes who’ve lost loved ones and health care workers on the front lines say it is particularly frustrating that so many people are framing the current response to the risks of COVID as “personal choice” over responsibility to others, as well as a sense of fatalism and lack of urgent care.

“Why does nobody seem to be angry about this?” Ms. Sikes said. “People talk about COVID like it’s just another thing to die from. But my sister didn’t have to die from it at all.”

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

Traci Sikes’s older sister Debbie had survived several health setbacks in life – a heart attack, a cancer diagnosis, and a couple of botched surgeries for a bad back. But by early 2023, the 68-year-old from Brownwood, Tex., was in remission from lymphoma, feeling stronger, and celebrating a birthday for one of her 11 beloved grandchildren. 

Then Debbie caught COVID-19. Less than 2 months later, in March, she died of severe lung damage caused by the coronavirus.

Traci was able to make the trip from her home in Washington state to Texas to be with Debbie before she died. She was grateful that she arrived while her sister was still lucid and to hear her sister’s last word – “love” – spoken to one of her grandchildren before she took her final breath.

“My sister was wonderful,” Sikes said. “And she shouldn’t be gone.” 

Just 6 months after President Joe Biden declared last fall that “the pandemic is over,” Debbie’s death was a painful reminder to Traci and her family that COVID hasn’t actually gone anywhere. Just as both the World Health Organization and U.S. government recently ended the 3-year-old coronavirus public health emergency, COVID is still killing more than 100 people every day in the U.S., according to the CDC, and amid widespread efforts to move on and drop protective measures, the country’s most vulnerable people are still at significant risk.

The prevailing attitude that we need to learn to live with the current level of risk feels like a “slap in the face,” for COVID grievers who have already paid the price,” said Sabila Khan, who cofounded a Facebook group for COVID loss support, which now has more than 14,000 members. 

It also minimizes the continuing loss of life and that so many people are still dying traumatic and unnecessary deaths, she said.

“It feels like it’s been brushed aside,” she said. “Like, ‘It’s business as usual. It’s over. Take off your mask.’ My family and I are still masked, and we’re probably the only ones masked in any given room.”

The abandoning of protective measures also fails to recognize the ongoing and catastrophic risks of long COVID and the experiences of an estimated 26 million people in the U.S. living with long COVID.

“It’s been drummed into us that death is the only serious outcome [of the virus] and we still haven’t made enough space for the idea that long COVID is a very serious outcome,” said David Putrino, PhD, director of rehabilitation innovation for the Mount Sinai Health System in New York, who has helped care for thousands of patients with long COVID.
 

Historic drop in life expectancy

More than 1.1 million Americans have died from COVID over the past 3 years, and experts say the official numbers are likely underestimated because of errors in death certificate reporting. Although deaths have waned from earlier in the pandemic, the disease has become the fourth leading cause of death in the United States after heart disease, cancer, and “unintentional injury” such as drug overdoses.

What makes these deaths all the more tragic is that COVID is a preventable disease, said Carla Sevin, MD, a critical care doctor and director of the Pulmonary Patient Care Center at Vanderbilt University Medical Center in Nashville, Tenn. Masking, available vaccines, and social distancing have all been shown to significantly lower the risk of spreading and catching the virus. New drugs have also made it possible for infected people to survive COVID.

“It’s possible to not spread COVID,” she said. “It’s possible to protect yourself against COVID. It’s possible to treat COVID. And we’re doing all of those things imperfectly.”

By the end of 2021, Americans overall were dying 3 years sooner, on average, than they were before the pandemic, with life expectancy dropping from 79 years to 76 years, the largest decline in a century. 

Globally, the COVID death toll is nearing 7 million. Across all ages, on average, each person who died passed away 10 years younger than they otherwise would have. That’s tens of millions of years wiped away.

As U.S. surgeon and health researcher Atul Gawande, MD, put it in a New York Times essay about the pandemic response: “Human development has been pushed into reverse.”
 

What is an acceptable threshold of death?

In the United States, more than 80% of deaths from the disease have been in people age 65 and older. Underlying medical conditions and disabilities also raise the risk of severe illness and dying from COVID. 

The virus is also disproportionately killing Black, Hispanic, and Indigenous people and those with less access to health care. Racialized groups are dying from COVID at younger ages. COVID advocates and Americans who’ve lost loved ones to the disease say our willingness to accept these facts and the current mortality rate amounts to health-based discrimination.

“Would politicians be approaching this differently had it mostly affected rich white people?” Ms. Khan said. 

Ms. Khan’s dad, Shafqat, was an advocate and community organizer for Pakistani immigrants. After contracting COVID, he was rushed to a hospital near his daughter’s Jersey City, N.J.,  home from a rehab facility where he was being treated for an aggressive form of Parkinson’s disease. For the 8 days her father was in the hospital, she and other family members couldn’t visit him, and he wasn’t even well enough to talk on the phone. He died from COVID in April 2020.

“My father was an extraordinary person who did so much good and he died alone, terrified in a hospital,” she said. “I can’t even wrap my head around that and how he deserved more. No one deserves that.”

At Vanderbilt University Medical Center, where she works as a critical care doctor, COVID deaths are now different from those in the early days of the pandemic, Dr. Sevin said. Most patients now in the intensive care unit are older and immunocompromised – and they tend to blend in more with others in the intensive care unit. That makes the impact of COVID even more hidden and easily ignored.

“It’s easy not to value somebody who’s an invisible number you don’t know,” she said. “You don’t see them writing their will and talking to their best friend. You don’t see the tears rolling down their face because they know what’s going to happen to them and they’re going to asphyxiate to death.” 

One COVID patient who died recently in Dr. Sevin’s ICU ward was an older woman who had no living relatives. “She was very, very lonely, and we would always stand outside the door on rounds, and she would motion for us to come in, but we had to then all gown up,” Dr. Sevin said. “It just breaks your heart that people are still having to go through it.”

Dr. Sevin finds it frustrating that so many of the measures that public health officials fought so hard for over the last 3 years – including masking guidelines, government-funded vaccine clinics, and access to potentially life-saving antiviral medications – are now going away because of the lifting of the pandemic emergency declaration.

What makes matters worse, she said, is that public consciousness about taking precautions to protect others is starting to disappear in favor of an “all or nothing attitude” about the continued risks. 

“Like either I’m going to stay home and be a hermit, or I’m going to just throw caution to the wind and go to bars and let people yell in my face,” she said. “We learned some hard lessons, and I wish we could hold onto those.”

Americans like Traci Sikes who’ve lost loved ones and health care workers on the front lines say it is particularly frustrating that so many people are framing the current response to the risks of COVID as “personal choice” over responsibility to others, as well as a sense of fatalism and lack of urgent care.

“Why does nobody seem to be angry about this?” Ms. Sikes said. “People talk about COVID like it’s just another thing to die from. But my sister didn’t have to die from it at all.”

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

For patients undergoing transcatheter aortic valve replacement (TAVR), adverse outcomes are more common in those who are in cardiogenic shock than those who are not, but the greater risks appear to be completely concentrated in the early period of recovery, suggests a propensity-matched study.

“The landmark analysis we conducted at 4 weeks suggest patients do remarkably well – as good as patients without cardiogenic shock – if they survive through the initial recovery period,” reported Abhijeet Dhoble, MD, associate professor and an interventional cardiologist at McGovern Medical School, University of Texas Health Science Center, Houston.

Their results were presented at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

The study, which drew data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Replacement (STS/ACC TVR) Registry, looked only at patients who underwent TAVR with the Sapien3 or Sapience3 Ultra device. Patients with CS were propensity matched to Sapien device-treated patients in the registry without CS.

Taken from a pool of 9,348 patients with CS and 299,600 patients without, the matching included a large array of clinically relevant covariates, including age, gender, prior cardiovascular events, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class.

After matching, there were 4,952 patients in each arm. The baseline Society of Thoracic Surgeons (STS) risk score was approximately 10.0 in both arms. About half had atrial fibrillation and 90% were in NYHA class III or IV. The median LVEF in both groups was 39.9%.
 

Mortality more than twofold higher in CS patients

At 30 days, outcomes were worse in patients with CS, including the proportion who died (12.9% vs. 4.9%; P < .0001) and the proportion with stroke (3.3% vs. 1.9%; P < .0001).

The only major study endpoint not significantly different, although higher in the CS group, was the rate of readmission (12.0% vs. 11.0%; P = .25).

At 1 year, the differences in the rates of mortality (29.7% vs. 22.6%; P < .0001) and stroke (4.3% vs. 3.1%; P = .0004) had narrowed modestly but remained highly significant. A closer analysis indicated that almost all of the difference in the rate of events occurred prior to hospital discharge.

In fact, mortality (9.9% vs. 2.7%; P < .0001), stroke (2.9% vs. 1.5%; P < .0001), major vascular complications (2.3% vs. 1.9%; P = .0002), life-threatening bleeding (2.5% vs. 0.7%; P < .0001), new dialysis (3.5% vs. 1.1%; P < .0001) and new onset atrial fibrillation (3.8% vs. 1.6%; P < .0001) were all significantly higher in the CS group in this very early time period. By hazard ratio (HR), the risk of a major event prior to leaving the hospital was nearly threefold higher (HR 2.3; P < .0001) in the CS group.

Yet, there was no significant difference in the accumulation of adverse events after discharge. When compared for major events in the landmark analysis, the event curves were essentially superimposable from 30 days to 1 year. During this period, event rates were 19.3% versus 18.5% for CS and non-CS patients (HR 1.07; P = .2640).

The higher rate of events was unrelated to procedural complications, which were very low in both groups and did not differ significantly. Transition to open surgery, annular disruption, aortic dissection, coronary occlusion, and device embolization occurred in < 1% of patients in both groups.
 

Predictors of a poor outcome identified

On multivariate analysis, the predictors of events in the CS patients were comorbidities. Despite propensity matching, being on dialysis, having a permanent pacemaker, or having a mechanical assist device were all independent predictors of mortality risk specific to the CS group.

Age and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) score were not predictors.

These risk factors deserve consideration when evaluating CS candidates for TAVR, but Dr. Dhoble said that none are absolute contraindications. Rather, he advised that they should be considered in the context of the entire clinical picture, including the expected benefit from TAVR. Indeed, the benefit-to-risk ratio generally favors TAVR in CS patients, particularly those with obstructive CS caused by aortic stenosis, according to Dr. Dhoble.

“Efforts should be made not only to avoid delaying TAVR in such patients but also to prevent CS by early definitive treatment of patients with aortic stenosis,” he said.

These data are useful and important, said Jonathan Schwartz, MD, medical director, interventional cardiology, Atrium Health, Charlotte, N.C.

CS candidates for TAVR “are some of the sickest patients we treat. It is nice to finally have some data for this group,” he said. He agreed that CS patients can derive major benefit from TAVR if appropriately selected.

While many CS patients are already considered for TAVR, one source of hesitation has been the exclusion of CS patients from major TAVR trials, said Dr. Dhoble. He hopes these data will provide a framework for clinical decisions.

Ironically, the first TAVR patient and half of the initial series of 38 TAVR patients had CS, noted Alain G. Cribier, MD, director of cardiology, Charles Nicolle Hospital, University of Rouen, France. As the primary investigator of that initial TAVR study, conducted more than 20 years ago, he said he was not surprised by the favorable results of the propensity analysis.

“There is an almost miraculous clinical improvement to be achieved when you succeed with the procedure,” said Dr. Cribier, recounting his own experience. Improvements in LVEF of up to 30% can be achieved “within a day or two or even the first day,” he said.

Dr. Dhoble reports financial relationships with Abbott Vascular and Edwards Lifesciences. Dr. Schwartz reports that he has financial relationships with Abbott Vascular, Boston Scientific, Cordis, Edwards Lifesciences and Medtronic. Dr. Cribier reports a financial relationship with Edwards Lifesciences.

For patients undergoing transcatheter aortic valve replacement (TAVR), adverse outcomes are more common in those who are in cardiogenic shock than those who are not, but the greater risks appear to be completely concentrated in the early period of recovery, suggests a propensity-matched study.

“The landmark analysis we conducted at 4 weeks suggest patients do remarkably well – as good as patients without cardiogenic shock – if they survive through the initial recovery period,” reported Abhijeet Dhoble, MD, associate professor and an interventional cardiologist at McGovern Medical School, University of Texas Health Science Center, Houston.

Their results were presented at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

The study, which drew data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Replacement (STS/ACC TVR) Registry, looked only at patients who underwent TAVR with the Sapien3 or Sapience3 Ultra device. Patients with CS were propensity matched to Sapien device-treated patients in the registry without CS.

Taken from a pool of 9,348 patients with CS and 299,600 patients without, the matching included a large array of clinically relevant covariates, including age, gender, prior cardiovascular events, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class.

After matching, there were 4,952 patients in each arm. The baseline Society of Thoracic Surgeons (STS) risk score was approximately 10.0 in both arms. About half had atrial fibrillation and 90% were in NYHA class III or IV. The median LVEF in both groups was 39.9%.
 

Mortality more than twofold higher in CS patients

At 30 days, outcomes were worse in patients with CS, including the proportion who died (12.9% vs. 4.9%; P < .0001) and the proportion with stroke (3.3% vs. 1.9%; P < .0001).

The only major study endpoint not significantly different, although higher in the CS group, was the rate of readmission (12.0% vs. 11.0%; P = .25).

At 1 year, the differences in the rates of mortality (29.7% vs. 22.6%; P < .0001) and stroke (4.3% vs. 3.1%; P = .0004) had narrowed modestly but remained highly significant. A closer analysis indicated that almost all of the difference in the rate of events occurred prior to hospital discharge.

In fact, mortality (9.9% vs. 2.7%; P < .0001), stroke (2.9% vs. 1.5%; P < .0001), major vascular complications (2.3% vs. 1.9%; P = .0002), life-threatening bleeding (2.5% vs. 0.7%; P < .0001), new dialysis (3.5% vs. 1.1%; P < .0001) and new onset atrial fibrillation (3.8% vs. 1.6%; P < .0001) were all significantly higher in the CS group in this very early time period. By hazard ratio (HR), the risk of a major event prior to leaving the hospital was nearly threefold higher (HR 2.3; P < .0001) in the CS group.

Yet, there was no significant difference in the accumulation of adverse events after discharge. When compared for major events in the landmark analysis, the event curves were essentially superimposable from 30 days to 1 year. During this period, event rates were 19.3% versus 18.5% for CS and non-CS patients (HR 1.07; P = .2640).

The higher rate of events was unrelated to procedural complications, which were very low in both groups and did not differ significantly. Transition to open surgery, annular disruption, aortic dissection, coronary occlusion, and device embolization occurred in < 1% of patients in both groups.
 

Predictors of a poor outcome identified

On multivariate analysis, the predictors of events in the CS patients were comorbidities. Despite propensity matching, being on dialysis, having a permanent pacemaker, or having a mechanical assist device were all independent predictors of mortality risk specific to the CS group.

Age and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) score were not predictors.

These risk factors deserve consideration when evaluating CS candidates for TAVR, but Dr. Dhoble said that none are absolute contraindications. Rather, he advised that they should be considered in the context of the entire clinical picture, including the expected benefit from TAVR. Indeed, the benefit-to-risk ratio generally favors TAVR in CS patients, particularly those with obstructive CS caused by aortic stenosis, according to Dr. Dhoble.

“Efforts should be made not only to avoid delaying TAVR in such patients but also to prevent CS by early definitive treatment of patients with aortic stenosis,” he said.

These data are useful and important, said Jonathan Schwartz, MD, medical director, interventional cardiology, Atrium Health, Charlotte, N.C.

CS candidates for TAVR “are some of the sickest patients we treat. It is nice to finally have some data for this group,” he said. He agreed that CS patients can derive major benefit from TAVR if appropriately selected.

While many CS patients are already considered for TAVR, one source of hesitation has been the exclusion of CS patients from major TAVR trials, said Dr. Dhoble. He hopes these data will provide a framework for clinical decisions.

Ironically, the first TAVR patient and half of the initial series of 38 TAVR patients had CS, noted Alain G. Cribier, MD, director of cardiology, Charles Nicolle Hospital, University of Rouen, France. As the primary investigator of that initial TAVR study, conducted more than 20 years ago, he said he was not surprised by the favorable results of the propensity analysis.

“There is an almost miraculous clinical improvement to be achieved when you succeed with the procedure,” said Dr. Cribier, recounting his own experience. Improvements in LVEF of up to 30% can be achieved “within a day or two or even the first day,” he said.

Dr. Dhoble reports financial relationships with Abbott Vascular and Edwards Lifesciences. Dr. Schwartz reports that he has financial relationships with Abbott Vascular, Boston Scientific, Cordis, Edwards Lifesciences and Medtronic. Dr. Cribier reports a financial relationship with Edwards Lifesciences.

For patients undergoing transcatheter aortic valve replacement (TAVR), adverse outcomes are more common in those who are in cardiogenic shock than those who are not, but the greater risks appear to be completely concentrated in the early period of recovery, suggests a propensity-matched study.

“The landmark analysis we conducted at 4 weeks suggest patients do remarkably well – as good as patients without cardiogenic shock – if they survive through the initial recovery period,” reported Abhijeet Dhoble, MD, associate professor and an interventional cardiologist at McGovern Medical School, University of Texas Health Science Center, Houston.

Their results were presented at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

The study, which drew data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Replacement (STS/ACC TVR) Registry, looked only at patients who underwent TAVR with the Sapien3 or Sapience3 Ultra device. Patients with CS were propensity matched to Sapien device-treated patients in the registry without CS.

Taken from a pool of 9,348 patients with CS and 299,600 patients without, the matching included a large array of clinically relevant covariates, including age, gender, prior cardiovascular events, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class.

After matching, there were 4,952 patients in each arm. The baseline Society of Thoracic Surgeons (STS) risk score was approximately 10.0 in both arms. About half had atrial fibrillation and 90% were in NYHA class III or IV. The median LVEF in both groups was 39.9%.
 

Mortality more than twofold higher in CS patients

At 30 days, outcomes were worse in patients with CS, including the proportion who died (12.9% vs. 4.9%; P < .0001) and the proportion with stroke (3.3% vs. 1.9%; P < .0001).

The only major study endpoint not significantly different, although higher in the CS group, was the rate of readmission (12.0% vs. 11.0%; P = .25).

At 1 year, the differences in the rates of mortality (29.7% vs. 22.6%; P < .0001) and stroke (4.3% vs. 3.1%; P = .0004) had narrowed modestly but remained highly significant. A closer analysis indicated that almost all of the difference in the rate of events occurred prior to hospital discharge.

In fact, mortality (9.9% vs. 2.7%; P < .0001), stroke (2.9% vs. 1.5%; P < .0001), major vascular complications (2.3% vs. 1.9%; P = .0002), life-threatening bleeding (2.5% vs. 0.7%; P < .0001), new dialysis (3.5% vs. 1.1%; P < .0001) and new onset atrial fibrillation (3.8% vs. 1.6%; P < .0001) were all significantly higher in the CS group in this very early time period. By hazard ratio (HR), the risk of a major event prior to leaving the hospital was nearly threefold higher (HR 2.3; P < .0001) in the CS group.

Yet, there was no significant difference in the accumulation of adverse events after discharge. When compared for major events in the landmark analysis, the event curves were essentially superimposable from 30 days to 1 year. During this period, event rates were 19.3% versus 18.5% for CS and non-CS patients (HR 1.07; P = .2640).

The higher rate of events was unrelated to procedural complications, which were very low in both groups and did not differ significantly. Transition to open surgery, annular disruption, aortic dissection, coronary occlusion, and device embolization occurred in < 1% of patients in both groups.
 

Predictors of a poor outcome identified

On multivariate analysis, the predictors of events in the CS patients were comorbidities. Despite propensity matching, being on dialysis, having a permanent pacemaker, or having a mechanical assist device were all independent predictors of mortality risk specific to the CS group.

Age and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) score were not predictors.

These risk factors deserve consideration when evaluating CS candidates for TAVR, but Dr. Dhoble said that none are absolute contraindications. Rather, he advised that they should be considered in the context of the entire clinical picture, including the expected benefit from TAVR. Indeed, the benefit-to-risk ratio generally favors TAVR in CS patients, particularly those with obstructive CS caused by aortic stenosis, according to Dr. Dhoble.

“Efforts should be made not only to avoid delaying TAVR in such patients but also to prevent CS by early definitive treatment of patients with aortic stenosis,” he said.

These data are useful and important, said Jonathan Schwartz, MD, medical director, interventional cardiology, Atrium Health, Charlotte, N.C.

CS candidates for TAVR “are some of the sickest patients we treat. It is nice to finally have some data for this group,” he said. He agreed that CS patients can derive major benefit from TAVR if appropriately selected.

While many CS patients are already considered for TAVR, one source of hesitation has been the exclusion of CS patients from major TAVR trials, said Dr. Dhoble. He hopes these data will provide a framework for clinical decisions.

Ironically, the first TAVR patient and half of the initial series of 38 TAVR patients had CS, noted Alain G. Cribier, MD, director of cardiology, Charles Nicolle Hospital, University of Rouen, France. As the primary investigator of that initial TAVR study, conducted more than 20 years ago, he said he was not surprised by the favorable results of the propensity analysis.

“There is an almost miraculous clinical improvement to be achieved when you succeed with the procedure,” said Dr. Cribier, recounting his own experience. Improvements in LVEF of up to 30% can be achieved “within a day or two or even the first day,” he said.

Dr. Dhoble reports financial relationships with Abbott Vascular and Edwards Lifesciences. Dr. Schwartz reports that he has financial relationships with Abbott Vascular, Boston Scientific, Cordis, Edwards Lifesciences and Medtronic. Dr. Cribier reports a financial relationship with Edwards Lifesciences.

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

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

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

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

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

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

When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.

The question that arises from this policy change is whether the CDC will now have sufficient information on the evolution and spread of COVID to inform public health decisions in a timely manner. The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.

While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.

“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”

Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”

William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”

Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
 

What data is being deleted

The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.

Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”

Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.

Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
 

CDC justifies its new policy

To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.

In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”

Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.

CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
 

Ready to shift to voluntary reporting?

In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.

The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.

If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”

Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
 

Vaccinations: The sleeping dragon

COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.

Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”

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

When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.

The question that arises from this policy change is whether the CDC will now have sufficient information on the evolution and spread of COVID to inform public health decisions in a timely manner. The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.

While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.

“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”

Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”

William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”

Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
 

What data is being deleted

The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.

Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”

Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.

Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
 

CDC justifies its new policy

To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.

In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”

Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.

CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
 

Ready to shift to voluntary reporting?

In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.

The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.

If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”

Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
 

Vaccinations: The sleeping dragon

COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.

Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”

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

When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.

The question that arises from this policy change is whether the CDC will now have sufficient information on the evolution and spread of COVID to inform public health decisions in a timely manner. The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.

While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.

“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”

Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”

William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”

Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
 

What data is being deleted

The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.

Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”

Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.

Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
 

CDC justifies its new policy

To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.

In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”

Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.

CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
 

Ready to shift to voluntary reporting?

In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.

The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.

If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”

Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
 

Vaccinations: The sleeping dragon

COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.

Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”

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

A self-led, practitioner-supported form of mindfulness therapy was more effective and more cost-effective than self-help cognitive-behavioral therapy (CBT-SH), results from a head-to-head study show.

Self-help mindfulness-based cognitive therapy (MBCT-SH) produced better outcomes for participants with depression and was more cost-effective than CBT-SH.

Practitioner-supported self-help therapy regimens are growing in popularity as a way to expand access to mental health services and to address the shortage of mental health professionals.

Generally, mindfulness-based cognitive therapy aims to increase awareness of the depression maintenance cycle while fostering a nonjudgmental attitude toward present-moment experiences, the investigators note.

In contrast, CBT aims to challenge negative and unrealistic thought patterns that may perpetuate depression, replacing them with more realistic and objective thoughts.

“Practitioner-supported MBCT-SH should be routinely offered as an intervention for mild to moderate depression alongside practitioner-supported CBT-SH,” the investigators note.

The study was published online in JAMA Psychiatry.
 

Better recovery rates?

CBT-SH traditionally had been associated with high attrition rates, and alternative forms of self-help therapy are becoming increasingly necessary to fill this treatment gap, the researchers note. To compare the efficacy and cost-effectiveness of both treatment types, the researchers recruited 410 participants with mild to moderate depression at 10 sites in the United Kingdom. Participants were randomly assigned to receive either MBCT-SH or CBT-SH between November 2017 and January 2020. A total of 204 participants received MBCT-SH, and 206 received CBT-SH.

All participants were given specific self-help workbooks, depending on the study group to which they were assigned. Those who received MBCT-SH used “The Mindful Way Workbook: An 8-Week Program to Free Yourself From Depression and Emotional Distress,” while those who received CBT-SH used “Overcoming Depression and Low Mood: A Five Areas Approach, 3rd Edition.”

Investigators asked all participants to guide themselves through six 30- to 45-minute sessions, using the information in the workbooks. Trained psychological well-being practitioners supported participants as they moved through the workbooks during the six sessions.

Participants were assessed at baseline with the Patient Health Questionnaire–9 (PHQ-9) and the Clinical Interview Schedule–Revised at 16 weeks and 24 weeks.

At 16 weeks post randomization, results showed that practitioner-supported MBCT-SH led to significantly greater reductions in depression symptom severity, compared with practitioner-supported CBT-SH (mean [standard deviation] PHQ-9 score, 7.2 [4.8] points vs. 8.6 [5.5] points; between-group difference, –1.5 points; 95% confidence interval, –2.6 to –0.4; P = .009).

Results also showed that on average, the CBT-SH intervention cost $631 more per participant than the MBCT-SH intervention over the 42-week follow-up.

The investigators explain that “a substantial proportion of this additional cost was accounted for by additional face-to-face individual psychological therapy accessed by CBT-SH participants outside of the study intervention.

“In conclusion, this study found that a novel intervention, practitioner-supported MBCT-SH, was clinically superior in targeting depressive symptom severity at postintervention and cost-effective, compared with the criterion standard of practitioner-supported CBT-SH for adults experiencing mild to moderate depression,” the investigators write.

“If study findings are translated into routine practice, this would see many more people recovering from depression while costing health services less money,” they add.
 

Clinically meaningful?

Commenting on the study for this article, Lauren Bylsma, PhD, professor of psychiatry and psychology at the University of Pittsburgh, cast doubt on the ability of such a short trial to determine meaningful change.

She said that the extra costs incurred by participants in the CBT-SH arm of the study are likely, since it is “difficult to do CBT alone – you need an objective person to guide you as you practice.”

Dr. Bylsma noted that ultimately, more real-world studies of therapy are needed, given the great need for mental health.

The study was funded by the National Institute for Health and Care Research. The original article contains a full list of the authors’ relevant financial relationships.

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

A self-led, practitioner-supported form of mindfulness therapy was more effective and more cost-effective than self-help cognitive-behavioral therapy (CBT-SH), results from a head-to-head study show.

Self-help mindfulness-based cognitive therapy (MBCT-SH) produced better outcomes for participants with depression and was more cost-effective than CBT-SH.

Practitioner-supported self-help therapy regimens are growing in popularity as a way to expand access to mental health services and to address the shortage of mental health professionals.

Generally, mindfulness-based cognitive therapy aims to increase awareness of the depression maintenance cycle while fostering a nonjudgmental attitude toward present-moment experiences, the investigators note.

In contrast, CBT aims to challenge negative and unrealistic thought patterns that may perpetuate depression, replacing them with more realistic and objective thoughts.

“Practitioner-supported MBCT-SH should be routinely offered as an intervention for mild to moderate depression alongside practitioner-supported CBT-SH,” the investigators note.

The study was published online in JAMA Psychiatry.
 

Better recovery rates?

CBT-SH traditionally had been associated with high attrition rates, and alternative forms of self-help therapy are becoming increasingly necessary to fill this treatment gap, the researchers note. To compare the efficacy and cost-effectiveness of both treatment types, the researchers recruited 410 participants with mild to moderate depression at 10 sites in the United Kingdom. Participants were randomly assigned to receive either MBCT-SH or CBT-SH between November 2017 and January 2020. A total of 204 participants received MBCT-SH, and 206 received CBT-SH.

All participants were given specific self-help workbooks, depending on the study group to which they were assigned. Those who received MBCT-SH used “The Mindful Way Workbook: An 8-Week Program to Free Yourself From Depression and Emotional Distress,” while those who received CBT-SH used “Overcoming Depression and Low Mood: A Five Areas Approach, 3rd Edition.”

Investigators asked all participants to guide themselves through six 30- to 45-minute sessions, using the information in the workbooks. Trained psychological well-being practitioners supported participants as they moved through the workbooks during the six sessions.

Participants were assessed at baseline with the Patient Health Questionnaire–9 (PHQ-9) and the Clinical Interview Schedule–Revised at 16 weeks and 24 weeks.

At 16 weeks post randomization, results showed that practitioner-supported MBCT-SH led to significantly greater reductions in depression symptom severity, compared with practitioner-supported CBT-SH (mean [standard deviation] PHQ-9 score, 7.2 [4.8] points vs. 8.6 [5.5] points; between-group difference, –1.5 points; 95% confidence interval, –2.6 to –0.4; P = .009).

Results also showed that on average, the CBT-SH intervention cost $631 more per participant than the MBCT-SH intervention over the 42-week follow-up.

The investigators explain that “a substantial proportion of this additional cost was accounted for by additional face-to-face individual psychological therapy accessed by CBT-SH participants outside of the study intervention.

“In conclusion, this study found that a novel intervention, practitioner-supported MBCT-SH, was clinically superior in targeting depressive symptom severity at postintervention and cost-effective, compared with the criterion standard of practitioner-supported CBT-SH for adults experiencing mild to moderate depression,” the investigators write.

“If study findings are translated into routine practice, this would see many more people recovering from depression while costing health services less money,” they add.
 

Clinically meaningful?

Commenting on the study for this article, Lauren Bylsma, PhD, professor of psychiatry and psychology at the University of Pittsburgh, cast doubt on the ability of such a short trial to determine meaningful change.

She said that the extra costs incurred by participants in the CBT-SH arm of the study are likely, since it is “difficult to do CBT alone – you need an objective person to guide you as you practice.”

Dr. Bylsma noted that ultimately, more real-world studies of therapy are needed, given the great need for mental health.

The study was funded by the National Institute for Health and Care Research. The original article contains a full list of the authors’ relevant financial relationships.

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

A self-led, practitioner-supported form of mindfulness therapy was more effective and more cost-effective than self-help cognitive-behavioral therapy (CBT-SH), results from a head-to-head study show.

Self-help mindfulness-based cognitive therapy (MBCT-SH) produced better outcomes for participants with depression and was more cost-effective than CBT-SH.

Practitioner-supported self-help therapy regimens are growing in popularity as a way to expand access to mental health services and to address the shortage of mental health professionals.

Generally, mindfulness-based cognitive therapy aims to increase awareness of the depression maintenance cycle while fostering a nonjudgmental attitude toward present-moment experiences, the investigators note.

In contrast, CBT aims to challenge negative and unrealistic thought patterns that may perpetuate depression, replacing them with more realistic and objective thoughts.

“Practitioner-supported MBCT-SH should be routinely offered as an intervention for mild to moderate depression alongside practitioner-supported CBT-SH,” the investigators note.

The study was published online in JAMA Psychiatry.
 

Better recovery rates?

CBT-SH traditionally had been associated with high attrition rates, and alternative forms of self-help therapy are becoming increasingly necessary to fill this treatment gap, the researchers note. To compare the efficacy and cost-effectiveness of both treatment types, the researchers recruited 410 participants with mild to moderate depression at 10 sites in the United Kingdom. Participants were randomly assigned to receive either MBCT-SH or CBT-SH between November 2017 and January 2020. A total of 204 participants received MBCT-SH, and 206 received CBT-SH.

All participants were given specific self-help workbooks, depending on the study group to which they were assigned. Those who received MBCT-SH used “The Mindful Way Workbook: An 8-Week Program to Free Yourself From Depression and Emotional Distress,” while those who received CBT-SH used “Overcoming Depression and Low Mood: A Five Areas Approach, 3rd Edition.”

Investigators asked all participants to guide themselves through six 30- to 45-minute sessions, using the information in the workbooks. Trained psychological well-being practitioners supported participants as they moved through the workbooks during the six sessions.

Participants were assessed at baseline with the Patient Health Questionnaire–9 (PHQ-9) and the Clinical Interview Schedule–Revised at 16 weeks and 24 weeks.

At 16 weeks post randomization, results showed that practitioner-supported MBCT-SH led to significantly greater reductions in depression symptom severity, compared with practitioner-supported CBT-SH (mean [standard deviation] PHQ-9 score, 7.2 [4.8] points vs. 8.6 [5.5] points; between-group difference, –1.5 points; 95% confidence interval, –2.6 to –0.4; P = .009).

Results also showed that on average, the CBT-SH intervention cost $631 more per participant than the MBCT-SH intervention over the 42-week follow-up.

The investigators explain that “a substantial proportion of this additional cost was accounted for by additional face-to-face individual psychological therapy accessed by CBT-SH participants outside of the study intervention.

“In conclusion, this study found that a novel intervention, practitioner-supported MBCT-SH, was clinically superior in targeting depressive symptom severity at postintervention and cost-effective, compared with the criterion standard of practitioner-supported CBT-SH for adults experiencing mild to moderate depression,” the investigators write.

“If study findings are translated into routine practice, this would see many more people recovering from depression while costing health services less money,” they add.
 

Clinically meaningful?

Commenting on the study for this article, Lauren Bylsma, PhD, professor of psychiatry and psychology at the University of Pittsburgh, cast doubt on the ability of such a short trial to determine meaningful change.

She said that the extra costs incurred by participants in the CBT-SH arm of the study are likely, since it is “difficult to do CBT alone – you need an objective person to guide you as you practice.”

Dr. Bylsma noted that ultimately, more real-world studies of therapy are needed, given the great need for mental health.

The study was funded by the National Institute for Health and Care Research. The original article contains a full list of the authors’ relevant financial relationships.

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

“What am I allowed to do?” radiation oncologist Vivek Kavadi, MD, asked the business manager at Texas Oncology in Sugar Land, Tex.

Dr. Kavadi wanted to give his patient with early-stage breast cancer a standard radiation treatment – hypofractionated 3D conformal radiation therapy – following her lumpectomy.

But his hands were tied.

Dr. Kavadi had submitted a prior authorization request, but the patient’s health insurance was dragging its feet. And without prior authorization, Dr. Kavadi couldn’t schedule his patient’s first treatment.

“I chose the most cost-effective, standard treatment, but nothing could begin without the insurance company’s permission,” he said.

One of the most challenging aspects of the delay was explaining to his patient why he couldn’t schedule her treatment. “We would love to start, but your insurance company has not given us approval. The best I can do is give you a tentative appointment,” he recalled telling her.

After a few days with no word, calls to the insurance company began. “My patient called, I called, my office called,” Dr. Kavadi said. “It was a week or more of aggravation, stress, and time wasted for my patient and my team.”

This type of delay has become increasingly common in radiation oncology. One recent analysis estimated that 97% of radiation oncology services now require prior authorization under Medicare Advantage. And another analysis found that almost all radiation oncologists said prior authorization delays life-saving care for their patients.

The rise of prior authorization requirements may boil down to the fact that prior authorization is no longer reserved for uncertain or high-cost care. Terrence Cunningham, director of administrative simplification policy for the American Hospital Association, told this news organization last year that “prior authorization used to be applied only to new, costly, or high-risk services,” but now “many insurers require authorizations for even routine care, which is inappropriate.”

The growth of prior authorization requirements has forced many doctors, nurses, and pharmacists to dedicate part of their workday to handling requests and appealing denials and has forced many practices to hire staff exclusively for prior authorizations.

This additional work is costly.

One recent study found that the radiation oncology department of Vanderbilt University, Nashville, Tenn., spent nearly $500,000 annually in employee time to obtain prior authorization for radiation therapy treatments. Extrapolated nationally, the researchers estimated that physicians’ annual compensation for prior authorization duties came to an estimated $46 million. Overall, 86% of these costs were for treatments that were ultimately approved, the majority on initial request and some on appeal.

Dr. Kavadi has five full-time employees dedicated to managing prior authorization requests and challenges.

And after a week of delays and hours on the phone with the insurer, his patient’s radiation treatment was ultimately approved.

Dr. Kavadi wondered why something so simple needed to be so onerous.

Stretching out an approval for a standard radiation treatment “feels like a means of intentionally delaying care,” Dr. Kavadi said. “This is an example of a process that has run so far amok. It’s just a burden across the board.”

And even with his 30 years of experience, “I still have to ask my business supervisor what I am allowed to do,” he said. “I can’t just proceed with what’s best for my patient, what the patient has consented to, and what also happens to be the least expensive option.”

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

“What am I allowed to do?” radiation oncologist Vivek Kavadi, MD, asked the business manager at Texas Oncology in Sugar Land, Tex.

Dr. Kavadi wanted to give his patient with early-stage breast cancer a standard radiation treatment – hypofractionated 3D conformal radiation therapy – following her lumpectomy.

But his hands were tied.

Dr. Kavadi had submitted a prior authorization request, but the patient’s health insurance was dragging its feet. And without prior authorization, Dr. Kavadi couldn’t schedule his patient’s first treatment.

“I chose the most cost-effective, standard treatment, but nothing could begin without the insurance company’s permission,” he said.

One of the most challenging aspects of the delay was explaining to his patient why he couldn’t schedule her treatment. “We would love to start, but your insurance company has not given us approval. The best I can do is give you a tentative appointment,” he recalled telling her.

After a few days with no word, calls to the insurance company began. “My patient called, I called, my office called,” Dr. Kavadi said. “It was a week or more of aggravation, stress, and time wasted for my patient and my team.”

This type of delay has become increasingly common in radiation oncology. One recent analysis estimated that 97% of radiation oncology services now require prior authorization under Medicare Advantage. And another analysis found that almost all radiation oncologists said prior authorization delays life-saving care for their patients.

The rise of prior authorization requirements may boil down to the fact that prior authorization is no longer reserved for uncertain or high-cost care. Terrence Cunningham, director of administrative simplification policy for the American Hospital Association, told this news organization last year that “prior authorization used to be applied only to new, costly, or high-risk services,” but now “many insurers require authorizations for even routine care, which is inappropriate.”

The growth of prior authorization requirements has forced many doctors, nurses, and pharmacists to dedicate part of their workday to handling requests and appealing denials and has forced many practices to hire staff exclusively for prior authorizations.

This additional work is costly.

One recent study found that the radiation oncology department of Vanderbilt University, Nashville, Tenn., spent nearly $500,000 annually in employee time to obtain prior authorization for radiation therapy treatments. Extrapolated nationally, the researchers estimated that physicians’ annual compensation for prior authorization duties came to an estimated $46 million. Overall, 86% of these costs were for treatments that were ultimately approved, the majority on initial request and some on appeal.

Dr. Kavadi has five full-time employees dedicated to managing prior authorization requests and challenges.

And after a week of delays and hours on the phone with the insurer, his patient’s radiation treatment was ultimately approved.

Dr. Kavadi wondered why something so simple needed to be so onerous.

Stretching out an approval for a standard radiation treatment “feels like a means of intentionally delaying care,” Dr. Kavadi said. “This is an example of a process that has run so far amok. It’s just a burden across the board.”

And even with his 30 years of experience, “I still have to ask my business supervisor what I am allowed to do,” he said. “I can’t just proceed with what’s best for my patient, what the patient has consented to, and what also happens to be the least expensive option.”

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

“What am I allowed to do?” radiation oncologist Vivek Kavadi, MD, asked the business manager at Texas Oncology in Sugar Land, Tex.

Dr. Kavadi wanted to give his patient with early-stage breast cancer a standard radiation treatment – hypofractionated 3D conformal radiation therapy – following her lumpectomy.

But his hands were tied.

Dr. Kavadi had submitted a prior authorization request, but the patient’s health insurance was dragging its feet. And without prior authorization, Dr. Kavadi couldn’t schedule his patient’s first treatment.

“I chose the most cost-effective, standard treatment, but nothing could begin without the insurance company’s permission,” he said.

One of the most challenging aspects of the delay was explaining to his patient why he couldn’t schedule her treatment. “We would love to start, but your insurance company has not given us approval. The best I can do is give you a tentative appointment,” he recalled telling her.

After a few days with no word, calls to the insurance company began. “My patient called, I called, my office called,” Dr. Kavadi said. “It was a week or more of aggravation, stress, and time wasted for my patient and my team.”

This type of delay has become increasingly common in radiation oncology. One recent analysis estimated that 97% of radiation oncology services now require prior authorization under Medicare Advantage. And another analysis found that almost all radiation oncologists said prior authorization delays life-saving care for their patients.

The rise of prior authorization requirements may boil down to the fact that prior authorization is no longer reserved for uncertain or high-cost care. Terrence Cunningham, director of administrative simplification policy for the American Hospital Association, told this news organization last year that “prior authorization used to be applied only to new, costly, or high-risk services,” but now “many insurers require authorizations for even routine care, which is inappropriate.”

The growth of prior authorization requirements has forced many doctors, nurses, and pharmacists to dedicate part of their workday to handling requests and appealing denials and has forced many practices to hire staff exclusively for prior authorizations.

This additional work is costly.

One recent study found that the radiation oncology department of Vanderbilt University, Nashville, Tenn., spent nearly $500,000 annually in employee time to obtain prior authorization for radiation therapy treatments. Extrapolated nationally, the researchers estimated that physicians’ annual compensation for prior authorization duties came to an estimated $46 million. Overall, 86% of these costs were for treatments that were ultimately approved, the majority on initial request and some on appeal.

Dr. Kavadi has five full-time employees dedicated to managing prior authorization requests and challenges.

And after a week of delays and hours on the phone with the insurer, his patient’s radiation treatment was ultimately approved.

Dr. Kavadi wondered why something so simple needed to be so onerous.

Stretching out an approval for a standard radiation treatment “feels like a means of intentionally delaying care,” Dr. Kavadi said. “This is an example of a process that has run so far amok. It’s just a burden across the board.”

And even with his 30 years of experience, “I still have to ask my business supervisor what I am allowed to do,” he said. “I can’t just proceed with what’s best for my patient, what the patient has consented to, and what also happens to be the least expensive option.”

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

The first day of seeing patients without a mask was, for Sterling Ransone Jr., MD, “unsettling.” 

“I can’t tell you how weird it was the first day that I walked down the hall from my office to where my exam rooms are, to not have a mask on after 3 years of the habit,” said Dr. Ransone, a family physician in Deltaville, Va., and board chair of the American Academy of Family Physicians. 

The White House recently lifted the public health emergency order that overhauled the way health care providers operated and advised patients over the past 3 years. The new postpandemic era will require clinicians and staff to once again adjust. 

For Dr. Ransone, this transition entails getting used to his bare face, reminding patients of the latest and varying symptoms of the virus, and parting ways with sick patients if they refuse to wear a mask.

As states, hospitals, and health care systems around the country relax their mask mandates for care providers, clinicians will have to fall back on their own policies that patients with potential symptoms mask up. 

“Now that it’s up to our offices, we have to have a little bit more backbone,” Dr. Ransone said. “If they’re not willing to follow a health-related policy that will protect the vulnerable, we will not see them. And so for us, it’s been pretty straightforward.”

Despite the policy, Dr. Ransone has cared for patients who don’t disclose they are feeling sick until he enters the room. 

“And I wasn’t masked,” Dr. Ransone said. So, “I will wear masks for the rest of the day just to try to protect the rest of my patients in case I was exposed.”

Masks are optional for both patients and staff at the University of Maryland Medical System, but Niharika Khanna, MD, MBBS, said she still wears one with her patients, and her office advises staff to do the same. If patients are experiencing respiratory symptoms, like a cough, they are asked to wear one. 

“When the patient first walks up to you, you have no idea what they have,” Dr. Khanna said. 

Dr. Khanna is especially mindful of immunocompromised patients who have cancer, and Dr. Ransone cares for several patients who have received kidney transplants and are on potent immunosuppressive drugs. 

“I know they’re appreciating our efforts to protect them, and I think the other patients are realizing that it’s a wise thing to do,” Dr. Ransone said. 

Some patients have anxiety about the end of masking in doctor offices, but others have been excited about interacting more with their care teams, according to William Dahut, MD, chief scientific officer for the American Cancer Society. Many clinicians will advise their most immunocompromised patients the same as they did prior to the COVID-19 pandemic. 

“There’s always been guidelines that oncologists have given to patients who are immunocompromised – we always told them to avoid crowded places, crowded scenes, be outside more than inside,” Dr. Dahut said. “Those general recommendations will continue.”

The AAFP supports masking to limit COVID’s spread, but the “most important thing people can do is to get vaccinated,” Tochi Iroku-Malize, MD, MPH, MBA, president of the AAFP, said.

But the accessibility of vaccinations is also shifting.
 

Testing shifts

The government will continue to provide free COVID-19 vaccines because it still has supplies on hand. When this stock runs out, commercial insurance providers will be required to cover the immunizations, as they are considered preventive, but people without insurance will have to pay out of pocket. 

The AAFP is pushing the Biden administration and Congress to keep the purchase price of those vaccines low enough that clinicians can keep them in stock, according to Dr. Iroku-Malize. Once the federal government transitions COVID-19 vaccines to the commercial market – as early as later in 2023 – it may pose some challenges for providers. 

“If the price of the vaccines is too high, physician practices may struggle to make the upfront investment in COVID-19 vaccines,” Dr. Iroku-Malize said. “Patients often prefer to receive vaccine counseling and administration from their usual source of primary care, like their family physician.” 

The federal government has also said it still has a supply of treatments for the public to access for free, but has not revealed how much it has on hand or given a timeline for the transition to the private market. 

COVID-19 tests, meanwhile, are no longer covered because of the end of the public health emergency, and cost about $45 per kit on average, according to an analysis by the Kaiser Family Foundation.

Pediatrician Lisa Costello, MD, MPH, knows that price point will be a challenge for some families she cares for at West Virginia University Medicine Children’s Hospital in Morgantown. Many still ask her where they can access free tests. 

“Testing if you’re a higher risk person is something we need to ensure that people continue to be educated about,” Dr. Costello said. 

She’s hopeful that COVID-19 vaccines and treatments such as Paxlovid will stay free in the coming months so patients can continue to easily access them.
 

Future of telehealth

Relaxed regulations of prescribing controlled substances via telehealth and across state lines allowed clinicians to treat patients near and far during the pandemic. But many providers were worried about a proposal from the Drug Enforcement Administration to clamp down on the prescribing of controlled substances via telehealth, according to A. Mark Fendrick, MD, an internal medicine physician at the University of Michigan, Ann Arbor.

“We were all panicking about what was going to happen to what is for many clinicians a very valuable policy,” Dr. Fendrick said of the telehealth flexibilities introduced during COVID-19. 

The DEA, after getting 38,000 comments on their proposed regulations, pulled back on that plan, delaying the cliff until November. 

Dr. Fendrick said that telehealth has allowed clinicians to reach patients who have historically faced barriers to care, such as lacking transportation. 

“The benefits of that outweigh the potential harms,” he said. “Every policy you make that tightens access because you want to decrease the untoward and unfortunate outcomes will also decrease access to clinical indications.”

The AAFP said it hopes for clear guidance from the DEA in the coming months on what the new telehealth landscape for prescribing will look like.
 

Medicaid changes

About half of the patients who see Dr. Khanna have insurance through Medicaid. 

During the public health emergency, states were not allowed to remove anyone from Medicaid, regardless of whether they no longer qualified for the program or not. But a law passed by Congress last year requires states to once again check Medicaid eligibility. As many as 15 million people could lose their Medicaid coverage. 

That could affect the treatments Dr. Khanna recommends for her patients who get kicked off because those who become uninsured or transition to private insurance will have to pay more out of pocket. Maryland will start removals in June. 

“When you have an uninsured patient versus Medicaid, it’s a huge difference in what you can ask the patient to do – the medications you can provide, the testing you can provide,” Dr. Khanna said. 

States were authorized to remove people from Medicaid as of April 1, with Arkansas, New Hampshire, and South Dakota starting right away. But many states are just now getting the review process going. About a dozen states, including Indiana, Ohio, Utah, and West Virginia, started removing people in May 2023. 

Uninsurance rates hit record lows across the United States during the pandemic. Keeping Americans on health insurance is a top priority for the AAFP, Dr. Iroku-Malize said. “We know health care coverage disruptions prevent people from seeking and accessing the care they need.”

Many people who are removed from Medicaid will be eligible for health insurance through employers, or through the Affordable Care Act’s private marketplace. But premiums and deductibles are often higher in these plans, which studies have shown result in patients delaying medical visits and not filling prescriptions or receiving treatment.
 

Staying mindful

Hospitals that receive federal funds will still have to report COVID-19 test results to the Centers for Medicare & Medicaid Services through 2024, although private labs will no longer be obligated to do so. The Centers for Disease Control and Prevention will also continue to monitor virus levels in communities through wastewater. But some states will no longer collect data. 

Gone are the days when clinicians and others would watch for daily totals of case counts with the type of fervor typically reserved for live scoring updates during sports games, according to Dr. Costello.

“We just have to be mindful of the numbers that might be coming in,” Dr. Costello said.

Dr. Ransone, however, cautioned that clinicians not become complacent. In early May, Dr. Ransone saw two patients with conjunctivitis, what patients thought was simply pink eye – a symptom of the latest COVID-19 variant. Both patients told him it wasn’t possible they had COVID-19 because they didn’t have coughs. 

“I don’t want to see physician offices fall into that trap that it’s over and be a potential nidus for infection for other patients,” Dr. Ransone said. “It’s incumbent upon us to remind people of the current symptoms so that folks will know when they need to wear a mask when they’re around their grandmother.”

The move away from universal masking in the office has benefits. Many of his older patients have difficulty hearing and had used lip reading to help understand him, he said. During the pandemic, masks got in the way of that form of communication. Now they can see his mouth again and better decipher what he says.

“Being able to have that face-to-face contact, without a mask intervening, has been really beneficial for a lot of my older patients,” he said.

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

The first day of seeing patients without a mask was, for Sterling Ransone Jr., MD, “unsettling.” 

“I can’t tell you how weird it was the first day that I walked down the hall from my office to where my exam rooms are, to not have a mask on after 3 years of the habit,” said Dr. Ransone, a family physician in Deltaville, Va., and board chair of the American Academy of Family Physicians. 

The White House recently lifted the public health emergency order that overhauled the way health care providers operated and advised patients over the past 3 years. The new postpandemic era will require clinicians and staff to once again adjust. 

For Dr. Ransone, this transition entails getting used to his bare face, reminding patients of the latest and varying symptoms of the virus, and parting ways with sick patients if they refuse to wear a mask.

As states, hospitals, and health care systems around the country relax their mask mandates for care providers, clinicians will have to fall back on their own policies that patients with potential symptoms mask up. 

“Now that it’s up to our offices, we have to have a little bit more backbone,” Dr. Ransone said. “If they’re not willing to follow a health-related policy that will protect the vulnerable, we will not see them. And so for us, it’s been pretty straightforward.”

Despite the policy, Dr. Ransone has cared for patients who don’t disclose they are feeling sick until he enters the room. 

“And I wasn’t masked,” Dr. Ransone said. So, “I will wear masks for the rest of the day just to try to protect the rest of my patients in case I was exposed.”

Masks are optional for both patients and staff at the University of Maryland Medical System, but Niharika Khanna, MD, MBBS, said she still wears one with her patients, and her office advises staff to do the same. If patients are experiencing respiratory symptoms, like a cough, they are asked to wear one. 

“When the patient first walks up to you, you have no idea what they have,” Dr. Khanna said. 

Dr. Khanna is especially mindful of immunocompromised patients who have cancer, and Dr. Ransone cares for several patients who have received kidney transplants and are on potent immunosuppressive drugs. 

“I know they’re appreciating our efforts to protect them, and I think the other patients are realizing that it’s a wise thing to do,” Dr. Ransone said. 

Some patients have anxiety about the end of masking in doctor offices, but others have been excited about interacting more with their care teams, according to William Dahut, MD, chief scientific officer for the American Cancer Society. Many clinicians will advise their most immunocompromised patients the same as they did prior to the COVID-19 pandemic. 

“There’s always been guidelines that oncologists have given to patients who are immunocompromised – we always told them to avoid crowded places, crowded scenes, be outside more than inside,” Dr. Dahut said. “Those general recommendations will continue.”

The AAFP supports masking to limit COVID’s spread, but the “most important thing people can do is to get vaccinated,” Tochi Iroku-Malize, MD, MPH, MBA, president of the AAFP, said.

But the accessibility of vaccinations is also shifting.
 

Testing shifts

The government will continue to provide free COVID-19 vaccines because it still has supplies on hand. When this stock runs out, commercial insurance providers will be required to cover the immunizations, as they are considered preventive, but people without insurance will have to pay out of pocket. 

The AAFP is pushing the Biden administration and Congress to keep the purchase price of those vaccines low enough that clinicians can keep them in stock, according to Dr. Iroku-Malize. Once the federal government transitions COVID-19 vaccines to the commercial market – as early as later in 2023 – it may pose some challenges for providers. 

“If the price of the vaccines is too high, physician practices may struggle to make the upfront investment in COVID-19 vaccines,” Dr. Iroku-Malize said. “Patients often prefer to receive vaccine counseling and administration from their usual source of primary care, like their family physician.” 

The federal government has also said it still has a supply of treatments for the public to access for free, but has not revealed how much it has on hand or given a timeline for the transition to the private market. 

COVID-19 tests, meanwhile, are no longer covered because of the end of the public health emergency, and cost about $45 per kit on average, according to an analysis by the Kaiser Family Foundation.

Pediatrician Lisa Costello, MD, MPH, knows that price point will be a challenge for some families she cares for at West Virginia University Medicine Children’s Hospital in Morgantown. Many still ask her where they can access free tests. 

“Testing if you’re a higher risk person is something we need to ensure that people continue to be educated about,” Dr. Costello said. 

She’s hopeful that COVID-19 vaccines and treatments such as Paxlovid will stay free in the coming months so patients can continue to easily access them.
 

Future of telehealth

Relaxed regulations of prescribing controlled substances via telehealth and across state lines allowed clinicians to treat patients near and far during the pandemic. But many providers were worried about a proposal from the Drug Enforcement Administration to clamp down on the prescribing of controlled substances via telehealth, according to A. Mark Fendrick, MD, an internal medicine physician at the University of Michigan, Ann Arbor.

“We were all panicking about what was going to happen to what is for many clinicians a very valuable policy,” Dr. Fendrick said of the telehealth flexibilities introduced during COVID-19. 

The DEA, after getting 38,000 comments on their proposed regulations, pulled back on that plan, delaying the cliff until November. 

Dr. Fendrick said that telehealth has allowed clinicians to reach patients who have historically faced barriers to care, such as lacking transportation. 

“The benefits of that outweigh the potential harms,” he said. “Every policy you make that tightens access because you want to decrease the untoward and unfortunate outcomes will also decrease access to clinical indications.”

The AAFP said it hopes for clear guidance from the DEA in the coming months on what the new telehealth landscape for prescribing will look like.
 

Medicaid changes

About half of the patients who see Dr. Khanna have insurance through Medicaid. 

During the public health emergency, states were not allowed to remove anyone from Medicaid, regardless of whether they no longer qualified for the program or not. But a law passed by Congress last year requires states to once again check Medicaid eligibility. As many as 15 million people could lose their Medicaid coverage. 

That could affect the treatments Dr. Khanna recommends for her patients who get kicked off because those who become uninsured or transition to private insurance will have to pay more out of pocket. Maryland will start removals in June. 

“When you have an uninsured patient versus Medicaid, it’s a huge difference in what you can ask the patient to do – the medications you can provide, the testing you can provide,” Dr. Khanna said. 

States were authorized to remove people from Medicaid as of April 1, with Arkansas, New Hampshire, and South Dakota starting right away. But many states are just now getting the review process going. About a dozen states, including Indiana, Ohio, Utah, and West Virginia, started removing people in May 2023. 

Uninsurance rates hit record lows across the United States during the pandemic. Keeping Americans on health insurance is a top priority for the AAFP, Dr. Iroku-Malize said. “We know health care coverage disruptions prevent people from seeking and accessing the care they need.”

Many people who are removed from Medicaid will be eligible for health insurance through employers, or through the Affordable Care Act’s private marketplace. But premiums and deductibles are often higher in these plans, which studies have shown result in patients delaying medical visits and not filling prescriptions or receiving treatment.
 

Staying mindful

Hospitals that receive federal funds will still have to report COVID-19 test results to the Centers for Medicare & Medicaid Services through 2024, although private labs will no longer be obligated to do so. The Centers for Disease Control and Prevention will also continue to monitor virus levels in communities through wastewater. But some states will no longer collect data. 

Gone are the days when clinicians and others would watch for daily totals of case counts with the type of fervor typically reserved for live scoring updates during sports games, according to Dr. Costello.

“We just have to be mindful of the numbers that might be coming in,” Dr. Costello said.

Dr. Ransone, however, cautioned that clinicians not become complacent. In early May, Dr. Ransone saw two patients with conjunctivitis, what patients thought was simply pink eye – a symptom of the latest COVID-19 variant. Both patients told him it wasn’t possible they had COVID-19 because they didn’t have coughs. 

“I don’t want to see physician offices fall into that trap that it’s over and be a potential nidus for infection for other patients,” Dr. Ransone said. “It’s incumbent upon us to remind people of the current symptoms so that folks will know when they need to wear a mask when they’re around their grandmother.”

The move away from universal masking in the office has benefits. Many of his older patients have difficulty hearing and had used lip reading to help understand him, he said. During the pandemic, masks got in the way of that form of communication. Now they can see his mouth again and better decipher what he says.

“Being able to have that face-to-face contact, without a mask intervening, has been really beneficial for a lot of my older patients,” he said.

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

The first day of seeing patients without a mask was, for Sterling Ransone Jr., MD, “unsettling.” 

“I can’t tell you how weird it was the first day that I walked down the hall from my office to where my exam rooms are, to not have a mask on after 3 years of the habit,” said Dr. Ransone, a family physician in Deltaville, Va., and board chair of the American Academy of Family Physicians. 

The White House recently lifted the public health emergency order that overhauled the way health care providers operated and advised patients over the past 3 years. The new postpandemic era will require clinicians and staff to once again adjust. 

For Dr. Ransone, this transition entails getting used to his bare face, reminding patients of the latest and varying symptoms of the virus, and parting ways with sick patients if they refuse to wear a mask.

As states, hospitals, and health care systems around the country relax their mask mandates for care providers, clinicians will have to fall back on their own policies that patients with potential symptoms mask up. 

“Now that it’s up to our offices, we have to have a little bit more backbone,” Dr. Ransone said. “If they’re not willing to follow a health-related policy that will protect the vulnerable, we will not see them. And so for us, it’s been pretty straightforward.”

Despite the policy, Dr. Ransone has cared for patients who don’t disclose they are feeling sick until he enters the room. 

“And I wasn’t masked,” Dr. Ransone said. So, “I will wear masks for the rest of the day just to try to protect the rest of my patients in case I was exposed.”

Masks are optional for both patients and staff at the University of Maryland Medical System, but Niharika Khanna, MD, MBBS, said she still wears one with her patients, and her office advises staff to do the same. If patients are experiencing respiratory symptoms, like a cough, they are asked to wear one. 

“When the patient first walks up to you, you have no idea what they have,” Dr. Khanna said. 

Dr. Khanna is especially mindful of immunocompromised patients who have cancer, and Dr. Ransone cares for several patients who have received kidney transplants and are on potent immunosuppressive drugs. 

“I know they’re appreciating our efforts to protect them, and I think the other patients are realizing that it’s a wise thing to do,” Dr. Ransone said. 

Some patients have anxiety about the end of masking in doctor offices, but others have been excited about interacting more with their care teams, according to William Dahut, MD, chief scientific officer for the American Cancer Society. Many clinicians will advise their most immunocompromised patients the same as they did prior to the COVID-19 pandemic. 

“There’s always been guidelines that oncologists have given to patients who are immunocompromised – we always told them to avoid crowded places, crowded scenes, be outside more than inside,” Dr. Dahut said. “Those general recommendations will continue.”

The AAFP supports masking to limit COVID’s spread, but the “most important thing people can do is to get vaccinated,” Tochi Iroku-Malize, MD, MPH, MBA, president of the AAFP, said.

But the accessibility of vaccinations is also shifting.
 

Testing shifts

The government will continue to provide free COVID-19 vaccines because it still has supplies on hand. When this stock runs out, commercial insurance providers will be required to cover the immunizations, as they are considered preventive, but people without insurance will have to pay out of pocket. 

The AAFP is pushing the Biden administration and Congress to keep the purchase price of those vaccines low enough that clinicians can keep them in stock, according to Dr. Iroku-Malize. Once the federal government transitions COVID-19 vaccines to the commercial market – as early as later in 2023 – it may pose some challenges for providers. 

“If the price of the vaccines is too high, physician practices may struggle to make the upfront investment in COVID-19 vaccines,” Dr. Iroku-Malize said. “Patients often prefer to receive vaccine counseling and administration from their usual source of primary care, like their family physician.” 

The federal government has also said it still has a supply of treatments for the public to access for free, but has not revealed how much it has on hand or given a timeline for the transition to the private market. 

COVID-19 tests, meanwhile, are no longer covered because of the end of the public health emergency, and cost about $45 per kit on average, according to an analysis by the Kaiser Family Foundation.

Pediatrician Lisa Costello, MD, MPH, knows that price point will be a challenge for some families she cares for at West Virginia University Medicine Children’s Hospital in Morgantown. Many still ask her where they can access free tests. 

“Testing if you’re a higher risk person is something we need to ensure that people continue to be educated about,” Dr. Costello said. 

She’s hopeful that COVID-19 vaccines and treatments such as Paxlovid will stay free in the coming months so patients can continue to easily access them.
 

Future of telehealth

Relaxed regulations of prescribing controlled substances via telehealth and across state lines allowed clinicians to treat patients near and far during the pandemic. But many providers were worried about a proposal from the Drug Enforcement Administration to clamp down on the prescribing of controlled substances via telehealth, according to A. Mark Fendrick, MD, an internal medicine physician at the University of Michigan, Ann Arbor.

“We were all panicking about what was going to happen to what is for many clinicians a very valuable policy,” Dr. Fendrick said of the telehealth flexibilities introduced during COVID-19. 

The DEA, after getting 38,000 comments on their proposed regulations, pulled back on that plan, delaying the cliff until November. 

Dr. Fendrick said that telehealth has allowed clinicians to reach patients who have historically faced barriers to care, such as lacking transportation. 

“The benefits of that outweigh the potential harms,” he said. “Every policy you make that tightens access because you want to decrease the untoward and unfortunate outcomes will also decrease access to clinical indications.”

The AAFP said it hopes for clear guidance from the DEA in the coming months on what the new telehealth landscape for prescribing will look like.
 

Medicaid changes

About half of the patients who see Dr. Khanna have insurance through Medicaid. 

During the public health emergency, states were not allowed to remove anyone from Medicaid, regardless of whether they no longer qualified for the program or not. But a law passed by Congress last year requires states to once again check Medicaid eligibility. As many as 15 million people could lose their Medicaid coverage. 

That could affect the treatments Dr. Khanna recommends for her patients who get kicked off because those who become uninsured or transition to private insurance will have to pay more out of pocket. Maryland will start removals in June. 

“When you have an uninsured patient versus Medicaid, it’s a huge difference in what you can ask the patient to do – the medications you can provide, the testing you can provide,” Dr. Khanna said. 

States were authorized to remove people from Medicaid as of April 1, with Arkansas, New Hampshire, and South Dakota starting right away. But many states are just now getting the review process going. About a dozen states, including Indiana, Ohio, Utah, and West Virginia, started removing people in May 2023. 

Uninsurance rates hit record lows across the United States during the pandemic. Keeping Americans on health insurance is a top priority for the AAFP, Dr. Iroku-Malize said. “We know health care coverage disruptions prevent people from seeking and accessing the care they need.”

Many people who are removed from Medicaid will be eligible for health insurance through employers, or through the Affordable Care Act’s private marketplace. But premiums and deductibles are often higher in these plans, which studies have shown result in patients delaying medical visits and not filling prescriptions or receiving treatment.
 

Staying mindful

Hospitals that receive federal funds will still have to report COVID-19 test results to the Centers for Medicare & Medicaid Services through 2024, although private labs will no longer be obligated to do so. The Centers for Disease Control and Prevention will also continue to monitor virus levels in communities through wastewater. But some states will no longer collect data. 

Gone are the days when clinicians and others would watch for daily totals of case counts with the type of fervor typically reserved for live scoring updates during sports games, according to Dr. Costello.

“We just have to be mindful of the numbers that might be coming in,” Dr. Costello said.

Dr. Ransone, however, cautioned that clinicians not become complacent. In early May, Dr. Ransone saw two patients with conjunctivitis, what patients thought was simply pink eye – a symptom of the latest COVID-19 variant. Both patients told him it wasn’t possible they had COVID-19 because they didn’t have coughs. 

“I don’t want to see physician offices fall into that trap that it’s over and be a potential nidus for infection for other patients,” Dr. Ransone said. “It’s incumbent upon us to remind people of the current symptoms so that folks will know when they need to wear a mask when they’re around their grandmother.”

The move away from universal masking in the office has benefits. Many of his older patients have difficulty hearing and had used lip reading to help understand him, he said. During the pandemic, masks got in the way of that form of communication. Now they can see his mouth again and better decipher what he says.

“Being able to have that face-to-face contact, without a mask intervening, has been really beneficial for a lot of my older patients,” he said.

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

Depression rates among U.S. adults have reached the highest levels ever recorded since the national public opinion firm Gallup started tracking the mental illness in 2015.
 

In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.

Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.

“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”

The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:

• Has a doctor or nurse ever told you that you have depression?
• Do you currently have or are you currently being treated for depression?

Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).

The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.

The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.

When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.

Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.

“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”

If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.

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

Depression rates among U.S. adults have reached the highest levels ever recorded since the national public opinion firm Gallup started tracking the mental illness in 2015.
 

In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.

Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.

“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”

The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:

• Has a doctor or nurse ever told you that you have depression?
• Do you currently have or are you currently being treated for depression?

Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).

The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.

The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.

When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.

Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.

“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”

If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.

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

Depression rates among U.S. adults have reached the highest levels ever recorded since the national public opinion firm Gallup started tracking the mental illness in 2015.
 

In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.

Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.

“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”

The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:

• Has a doctor or nurse ever told you that you have depression?
• Do you currently have or are you currently being treated for depression?

Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).

The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.

The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.

When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.

Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.

“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”

If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.

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

Key clinical point: Adjuvant supplementation with single-strain probiotic lactobacilli significantly reduced the SCORing Atopic Dermatitis (SCORAD) index in young patients with atopic dermatitis (AD).

Major finding: The single-strain probiotic lactobacilli vs placebo group had a significant reduction in the SCORAD index (mean difference −4.50; P  =  .003).

Study details: Findings are from a meta-analysis of 14 studies involving 1124 patients aged 0-18 years with AD who received single-strain probiotic lactobacilli (n = 574) or placebo (n = 550).

Disclosures: This study was funded by the Slovenian Research Agency. The authors declared no conflicts of interest.

Source: Fijan S et al. Single-strain probiotic lactobacilli for the treatment of atopic dermatitis in children: A systematic review and meta-analysis. Pharmaceutics. 2023;15(4):1256 (Apr 17). Doi: 10.3390/pharmaceutics15041256

Key clinical point: Adjuvant supplementation with single-strain probiotic lactobacilli significantly reduced the SCORing Atopic Dermatitis (SCORAD) index in young patients with atopic dermatitis (AD).

Major finding: The single-strain probiotic lactobacilli vs placebo group had a significant reduction in the SCORAD index (mean difference −4.50; P  =  .003).

Study details: Findings are from a meta-analysis of 14 studies involving 1124 patients aged 0-18 years with AD who received single-strain probiotic lactobacilli (n = 574) or placebo (n = 550).

Disclosures: This study was funded by the Slovenian Research Agency. The authors declared no conflicts of interest.

Source: Fijan S et al. Single-strain probiotic lactobacilli for the treatment of atopic dermatitis in children: A systematic review and meta-analysis. Pharmaceutics. 2023;15(4):1256 (Apr 17). Doi: 10.3390/pharmaceutics15041256

Key clinical point: Adjuvant supplementation with single-strain probiotic lactobacilli significantly reduced the SCORing Atopic Dermatitis (SCORAD) index in young patients with atopic dermatitis (AD).

Major finding: The single-strain probiotic lactobacilli vs placebo group had a significant reduction in the SCORAD index (mean difference −4.50; P  =  .003).

Study details: Findings are from a meta-analysis of 14 studies involving 1124 patients aged 0-18 years with AD who received single-strain probiotic lactobacilli (n = 574) or placebo (n = 550).

Disclosures: This study was funded by the Slovenian Research Agency. The authors declared no conflicts of interest.

Source: Fijan S et al. Single-strain probiotic lactobacilli for the treatment of atopic dermatitis in children: A systematic review and meta-analysis. Pharmaceutics. 2023;15(4):1256 (Apr 17). Doi: 10.3390/pharmaceutics15041256

Key clinical point: A lower alpha diversity in infancy is associated with an increased risk for atopic dermatitis (AD) in children of parents with atopy.

Major finding: Overall, the skin microbiome at birth and 2 months of age was not associated with the subsequent development of AD (P  =  .2). However, a lower alpha diversity at 2 months of age was significantly associated with an increased risk for AD during the first 2 years in children with at least 1 parent (adjusted hazard ratio [aHR] 1.67; P  =  .03) or both parents (aHR 4.44; P  =  .04) with a history of atopy.

Study details: Findings are from a prospective analysis of 300 children born to term, of which 153 had a parental history of atopy.

Disclosures: This study was funded by The Leo Foundation and others. Some authors declared serving as speakers, advisors, or consultants for or receiving research grants or speaker or consulting honoraria from various organizations, including the study funders.

Source: Halling AS et al. Reduced skin microbiome diversity in infancy is associated with increased risk of atopic dermatitis in high-risk children. J Invest Dermatol. 2023 (Apr 19). Doi: 10.1016/j.jid.2023.03.1682

Key clinical point: A lower alpha diversity in infancy is associated with an increased risk for atopic dermatitis (AD) in children of parents with atopy.

Major finding: Overall, the skin microbiome at birth and 2 months of age was not associated with the subsequent development of AD (P  =  .2). However, a lower alpha diversity at 2 months of age was significantly associated with an increased risk for AD during the first 2 years in children with at least 1 parent (adjusted hazard ratio [aHR] 1.67; P  =  .03) or both parents (aHR 4.44; P  =  .04) with a history of atopy.

Study details: Findings are from a prospective analysis of 300 children born to term, of which 153 had a parental history of atopy.

Disclosures: This study was funded by The Leo Foundation and others. Some authors declared serving as speakers, advisors, or consultants for or receiving research grants or speaker or consulting honoraria from various organizations, including the study funders.

Source: Halling AS et al. Reduced skin microbiome diversity in infancy is associated with increased risk of atopic dermatitis in high-risk children. J Invest Dermatol. 2023 (Apr 19). Doi: 10.1016/j.jid.2023.03.1682

Key clinical point: A lower alpha diversity in infancy is associated with an increased risk for atopic dermatitis (AD) in children of parents with atopy.

Major finding: Overall, the skin microbiome at birth and 2 months of age was not associated with the subsequent development of AD (P  =  .2). However, a lower alpha diversity at 2 months of age was significantly associated with an increased risk for AD during the first 2 years in children with at least 1 parent (adjusted hazard ratio [aHR] 1.67; P  =  .03) or both parents (aHR 4.44; P  =  .04) with a history of atopy.

Study details: Findings are from a prospective analysis of 300 children born to term, of which 153 had a parental history of atopy.

Disclosures: This study was funded by The Leo Foundation and others. Some authors declared serving as speakers, advisors, or consultants for or receiving research grants or speaker or consulting honoraria from various organizations, including the study funders.

Source: Halling AS et al. Reduced skin microbiome diversity in infancy is associated with increased risk of atopic dermatitis in high-risk children. J Invest Dermatol. 2023 (Apr 19). Doi: 10.1016/j.jid.2023.03.1682