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Asthma leads spending on avoidable pediatric inpatient stays
according to the Agency for Healthcare Research and Quality.
The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions “that evidence suggests may be avoidable, in part, through timely and quality primary and preventive care,” Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, said in an AHRQ statistical brief.
Those three other conditions are diabetes short-term complications, gastroenteritis, and urinary tract infections (UTIs). Neonatal stays were excluded from the analysis, Dr. McDermott of IBM Watson Health and Dr. Jiang of the AHRQ noted.
The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable. Hospital charges for the preventable stays came to $561.6 million, or 3% of the $20 billion in total costs for all nonneonatal stays, they said.
Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said.
Black children had a much higher rate of potentially avoidable stays for asthma (218 per 100,000) than did Hispanic children (74), Asian/Pacific Islander children (46), or white children (43), but children classified as other race/ethnicity were higher still: 380 per 100,000. Rates for children classified as other race/ethnicity were highest for the other three conditions as well, they reported.
Comparisons by sex for the four conditions ended up in a 2-2 tie: Girls had higher rates for diabetes (28 vs. 23) and UTIs (35 vs. 8), and boys had higher rates for asthma (96 vs. 67) and gastroenteritis (38 vs. 35), Dr. McDermott and Dr. Jiang reported.
SOURCE: McDermott KW, Jiang HJ. HCUP Statistical Brief #259. June 2020.
according to the Agency for Healthcare Research and Quality.
The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions “that evidence suggests may be avoidable, in part, through timely and quality primary and preventive care,” Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, said in an AHRQ statistical brief.
Those three other conditions are diabetes short-term complications, gastroenteritis, and urinary tract infections (UTIs). Neonatal stays were excluded from the analysis, Dr. McDermott of IBM Watson Health and Dr. Jiang of the AHRQ noted.
The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable. Hospital charges for the preventable stays came to $561.6 million, or 3% of the $20 billion in total costs for all nonneonatal stays, they said.
Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said.
Black children had a much higher rate of potentially avoidable stays for asthma (218 per 100,000) than did Hispanic children (74), Asian/Pacific Islander children (46), or white children (43), but children classified as other race/ethnicity were higher still: 380 per 100,000. Rates for children classified as other race/ethnicity were highest for the other three conditions as well, they reported.
Comparisons by sex for the four conditions ended up in a 2-2 tie: Girls had higher rates for diabetes (28 vs. 23) and UTIs (35 vs. 8), and boys had higher rates for asthma (96 vs. 67) and gastroenteritis (38 vs. 35), Dr. McDermott and Dr. Jiang reported.
SOURCE: McDermott KW, Jiang HJ. HCUP Statistical Brief #259. June 2020.
according to the Agency for Healthcare Research and Quality.
The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions “that evidence suggests may be avoidable, in part, through timely and quality primary and preventive care,” Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, said in an AHRQ statistical brief.
Those three other conditions are diabetes short-term complications, gastroenteritis, and urinary tract infections (UTIs). Neonatal stays were excluded from the analysis, Dr. McDermott of IBM Watson Health and Dr. Jiang of the AHRQ noted.
The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable. Hospital charges for the preventable stays came to $561.6 million, or 3% of the $20 billion in total costs for all nonneonatal stays, they said.
Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said.
Black children had a much higher rate of potentially avoidable stays for asthma (218 per 100,000) than did Hispanic children (74), Asian/Pacific Islander children (46), or white children (43), but children classified as other race/ethnicity were higher still: 380 per 100,000. Rates for children classified as other race/ethnicity were highest for the other three conditions as well, they reported.
Comparisons by sex for the four conditions ended up in a 2-2 tie: Girls had higher rates for diabetes (28 vs. 23) and UTIs (35 vs. 8), and boys had higher rates for asthma (96 vs. 67) and gastroenteritis (38 vs. 35), Dr. McDermott and Dr. Jiang reported.
SOURCE: McDermott KW, Jiang HJ. HCUP Statistical Brief #259. June 2020.
The evolution of “COVIDists”
Adapting to the demands placed on hospital resources by COVID-19
The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.1 The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.
The necessity of a new care model
Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications2 was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.
Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
The preparatory phase: From “Hospitalists” to “COVIDists”
As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.
COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.
In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).
The execution phase
All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.
Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,3 and helped with hospital capacity and patient flow (Tables 2 and 3).
This strategy also helped build solidarity and camaraderie between all these groups, making the COVIDists feel that they were never alone and that the whole hospital supported them. We are currently evaluating clinical outcomes and attempting to identify effects on mortality, length of stay, days on the ventilator, and days in ICU.
The maintenance phase
It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.
Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”4 In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
Conclusion
The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.
The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.
References
1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.
4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi
Adapting to the demands placed on hospital resources by COVID-19
Adapting to the demands placed on hospital resources by COVID-19
The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.1 The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.
The necessity of a new care model
Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications2 was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.
Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
The preparatory phase: From “Hospitalists” to “COVIDists”
As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.
COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.
In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).
The execution phase
All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.
Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,3 and helped with hospital capacity and patient flow (Tables 2 and 3).
This strategy also helped build solidarity and camaraderie between all these groups, making the COVIDists feel that they were never alone and that the whole hospital supported them. We are currently evaluating clinical outcomes and attempting to identify effects on mortality, length of stay, days on the ventilator, and days in ICU.
The maintenance phase
It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.
Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”4 In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
Conclusion
The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.
The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.
References
1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.
4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi
The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.1 The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.
The necessity of a new care model
Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications2 was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.
Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
The preparatory phase: From “Hospitalists” to “COVIDists”
As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.
COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.
In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).
The execution phase
All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.
Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,3 and helped with hospital capacity and patient flow (Tables 2 and 3).
This strategy also helped build solidarity and camaraderie between all these groups, making the COVIDists feel that they were never alone and that the whole hospital supported them. We are currently evaluating clinical outcomes and attempting to identify effects on mortality, length of stay, days on the ventilator, and days in ICU.
The maintenance phase
It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.
Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”4 In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
Conclusion
The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.
The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.
References
1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.
4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi
ID dermatology: Advancements, but new challenges, over 50 years
When Stephen Tyring, MD, PhD, an infectious disease dermatologist, started his career in the early 1980s, he said “we were diagnosing Kaposi’s sarcoma right and left. We would see a new case every day or two.”
It was the early days of the HIV/AIDS epidemic, and dermatologists were at the forefront because HIV/AIDS often presented with skin manifestations. Dr. Tyring, clinical professor in the departments of dermatology, microbiology & molecular genetics and internal medicine at the University of Texas Health Science Center, Houston, and his colleagues referred Kaposi’s patients for chemotherapy and radiation, but the outlook was often grim, especially if lesions developed in the lungs.
Dermatologist don’t see much Kaposi’s anymore because of highly effective treatments for HIV.
Members of the original editorial advisory board saw it coming. In a feature in which board members provided their prediction for the 1970s that appeared in the first issue, New York dermatologist Norman Orentreich, MD, counted the “probable introduction of virucidal agents” as one of the “significant advances or changes that I foresee in the next 10 years.” J. Lamar Callaway, MD, professor of dermatology at Duke University, Durham, N.C., predicted that “the next 10 years should develop effective anti-viral agents for warts, herpes simplex, and herpes zoster.”
To celebrate the 50th anniversary of Dermatology News, we are looking back at how the field has changed since that first issue. The focus this month is infectious disease. There’s a lot to be grateful for but there are also challenges like antibiotic resistance that weren’t on the radar screens of Dr. Orentreich, Dr. Callaway, and their peers in 1970.
All in all, “the only thing I wish we did the old way is sit at the bedside and talk to patients more. We rely so much on technology now that we sometimes lose the art of medicine, which is comforting to the patient,” said Theodore Rosen, MD, an ID dermatologist and professor of dermatology at Baylor College of Medicine, Houston, who’s been in practice for 42 years.
“A lot of advancements against herpes viruses”
One of the biggest wins for ID dermatology over the last 5 decades has been the management of herpes, both herpes simplex virus 1 and 2, as well as herpes zoster virus. It started with the approval of acyclovir in 1981. Before then, “we had no direct therapy for genital herpes, herpes zoster, or disseminated herpes in immunosuppressed or cancer patients,” Dr. Rosen said.
“I can remember doing an interview with Good Morning America when I gave the first IV dose of acyclovir in the city of Houston for really bad disseminated herpes” in an HIV patient, he said, and it worked.
Two derivatives, valacyclovir and famciclovir, became available in the mid-1990s, so today “we have three drugs and some others at the periphery that are all highly effective not only” against herpes, but also for preventing outbreaks; valacyclovir can even prevent asymptomatic shedding, therefore possibly preventing new infections. “That’s a concept we didn’t even have 40 years ago,” Dr. Rosen said.
Cidofovir has also made a difference. The IV formulation was approved for AIDS-associated cytomegalovirus retinitis in 1996 but discontinued a few years later amid concerns of severe renal toxicity. It’s found a new home in dermatology since then, explained ID dermatologist Carrie Kovarik, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia.
Dermatologists see acyclovir-resistant herpes “heaped up on the genitals in HIV patients,” and there weren’t many options in the past. A few years ago, “we [tried] injecting cidofovir directly into the skin lesions, and it’s been remarkably successful. It is a good way to treat these lesions” if dermatologists can get it compounded, she said.
Shingles vaccines, first the live attenuated zoster vaccine (Zostavax) approved by the Food and Drug Administration in 2006 and the more effective recombinant zoster vaccine (Shingrix) approved in 2017, have also had a significant impact.
Dr. Rosen remembers what it was like when he first started practicing over 40 years ago. Not uncommonly, “we saw horrible cases of shingles,” including one in his uncle, who was left with permanent hand pain long after the rash subsided.
Today, “I see much less shingles, and when I do see it, it’s in a much-attenuated form. [Shingrix], even if it doesn’t prevent the disease, often prevents postherpetic neuralgia,” he said.
Also, with pediatric vaccinations against chicken pox, “we’re probably going to see a whole new generation without shingles, which is huge. We’ve made a lot of advancements against herpes viruses,” Dr. Kovarik said.
“We finally found something that helps”
“We’ve [also] come a really long way with genital wart treatment,” Dr. Kovarik said.
It started with approval of topical imiquimod in 1997. “Before that, we were just killing one wart here and one wart there” but they would often come back and pop up in other areas. Injectable interferon was an option at the time, but people didn’t like all the needles.
With imiquimod, “we finally [had] a way to target HPV [human papillomavirus] and not just scrape” or freeze one wart at a time, and “we were able to generate an inflammatory response in the whole area to clear the virus.” Working with HIV patients, “I see sheets and sheets of confluent warts throughout the whole genital area; to try to freeze that is impossible. Now I have a way to get rid of [genital] warts and keep them away even if you have a big cluster,” she said.
“Sometimes, we’ll do both liquid nitrogen and imiquimod. That’s a good way to tackle people who have a high burden of warts,” Dr. Kovarik noted. Other effective treatments have come out as well, including an ointment formulation of sinecatechins, extracted from green tea, “but you have to put it on several times a day, and insurance companies don’t cover it often,” she said.
Intralesional cidofovir is also proving to be boon for potentially malignant refractory warts in HIV and transplant patients. “It’s an incredible treatment. We can inject that antiviral into warts and get rid of them. We finally found something that helps” these people, Dr. Kovarik said.
The HPV vaccine Gardasil is making a difference, as well. In addition to cervical dysplasia and anogenital cancers, it protects against two condyloma strains. Dr. Rosen said he’s seeing fewer cases of genital warts now than when he started practicing, likely because of the vaccine.
“Organisms that weren’t pathogens are now pathogens”
Antibiotic resistance probably tops the list for what’s changed in a bad way in ID dermatology since 1970. Dr. Rosen remembers at the start of his career that “we never worried about antibiotic resistance. We’d put people on antibiotics for acne, rosacea, and we’d keep them on them for 3 years, 6 years”; resistance wasn’t on the radar screen and was not mentioned once in the first issue of Dermatology News, which was packed with articles and ran 24 pages.
The situation is different now. Driven by decades of overuse in agriculture and the medical system, antibiotic resistance is a concern throughout medicine, and unfortunately, “we have not come nearly as far as fast with antibiotics,” at least the ones dermatologists use, “as we have with antivirals,” Dr. Tyring said.
For instance, methicillin-resistant Staphylococcus aureus (MRSA), first described in the United States in 1968, is “no longer the exception to the rule, but the rule” itself, he said, with carbuncles, furuncles, and abscesses not infrequently growing out MRSA. There are also new drug-resistant forms of old problems like gonorrhea and tuberculosis, among other developments, and impetigo has shifted since 1970 from mostly a Streptococcus infection easily treated with penicillin to often a Staphylococcus disease that’s resistant to it. There’s also been a steady march of new pathogens, including the latest one, SARS-CoV-2, the virus that causes COVID-19, which has been recognized as having a variety of skin manifestations.
“No matter how smart we think we are, nature has a way of putting us back in our place,” Dr. Rosen said.
The bright spot is that “we’ve become very adept at identifying and characterizing” microbes “based on techniques we didn’t even have when I started practicing,” such as polymerase chain reaction. “It has taken a lot of guess work out of treating infectious diseases,” he said.
The widespread use of immunosuppressives such as cyclophosphamide, mycophenolate, azathioprine, rituximab, and other agents used in conjunction with solid organ transplantation, has also been a challenge. “We are seeing infections with really odd organisms. Just recently, I had a patient with fusarium in the skin; it’s a fungus that lives in the dirt. I saw a patient with a species of algae” that normally lives in stagnant water, he commented. “We used to get [things like that] back on reports, and we’d throw them away. You can’t do that anymore. Organisms that weren’t pathogens in the past are now pathogens,” particularly in immunosuppressed people, Dr. Rosen said.
Venereologists no more
There’s been another big change in the field. “Back in the not too distant past, dermatologists in the U.S. were referred to as ‘dermatologist-venereologists.’ ” It goes back to the time when syphilis wasn’t diagnosed and treated early, so patients often presented with secondary skin complications and went to dermatologists for help. As a result, “dermatologists became the most experienced at treating it,” Dr. Tyring said.
That’s faded from practice. Part of the reason is that as late as 2000, syphilis seemed to be on the way out; the Centers for Disease and Control and Prevention even raised the possibility of elimination. Dermatologists turned their attention to other areas.
It might have been short-sighted, Dr. Rosen said. Syphilis has made a strong comeback, and drug-resistant gonorrhea has also emerged globally and in at least a few states. No other medical field has stepped in to take up the slack. “Ob.gyns. are busy delivering babies, ID [physicians are] concerned about HIV, and urologists are worried about kidney stones and cancer.” Other than herpes and genital warts, “we have not done well” with management of sexually transmitted diseases, he said.
“I could sense” his frustration
The first issue of Dermatology News carried an article and photospread about scabies that could run today, except that topical permethrin and oral ivermectin have largely replaced benzyl benzoate and sulfur ointments for treatment in the United States. In the article, Scottish dermatologist J. O’D. Alexander, MD, called scabies “the scourge of mankind” and blamed it’s prevalence on “an offhand attitude to the disease which makes control very difficult.”
“I could sense this man’s frustration that people were not recognizing scabies,” Dr. Kovarik said, and it’s no closer to being eradicated than it was in 1970. “It’s still around, and we see it in our clinics. It’s a horrible disease in kids we see in dermatology not infrequently,” and treatment has only advanced a bit.
The article highlights what hasn’t changed much in ID dermatology over the years. Common warts are another one. “With all the evolution in medicine, we don’t have any better treatments approved for common warts than we ever had.” Injecting cidofovir “works great,” but access is a problem, Dr. Tyring said.
Onychomycosis has also proven a tough nut to crack. Readers back in 1970 counted the introduction of the antifungal, griseofulvin, as a major advancement in the 1960s; it’s still a go-to for tinea capitis, but it didn’t work very well for toenail fungus. Terbinafine (Lamisil), approved in 1993, and subsequent developments have helped, but the field still awaits more effective options; a few potential new agents are in the pipeline.
Although there have been major advancements for serious systemic fungal infections, “we’ve mainly seen small steps forward” in ID dermatology, Dr. Tyring said.
Dr. Tyring, Dr. Kovarik, and Dr. Rosen said they had no relevant disclosures.
When Stephen Tyring, MD, PhD, an infectious disease dermatologist, started his career in the early 1980s, he said “we were diagnosing Kaposi’s sarcoma right and left. We would see a new case every day or two.”
It was the early days of the HIV/AIDS epidemic, and dermatologists were at the forefront because HIV/AIDS often presented with skin manifestations. Dr. Tyring, clinical professor in the departments of dermatology, microbiology & molecular genetics and internal medicine at the University of Texas Health Science Center, Houston, and his colleagues referred Kaposi’s patients for chemotherapy and radiation, but the outlook was often grim, especially if lesions developed in the lungs.
Dermatologist don’t see much Kaposi’s anymore because of highly effective treatments for HIV.
Members of the original editorial advisory board saw it coming. In a feature in which board members provided their prediction for the 1970s that appeared in the first issue, New York dermatologist Norman Orentreich, MD, counted the “probable introduction of virucidal agents” as one of the “significant advances or changes that I foresee in the next 10 years.” J. Lamar Callaway, MD, professor of dermatology at Duke University, Durham, N.C., predicted that “the next 10 years should develop effective anti-viral agents for warts, herpes simplex, and herpes zoster.”
To celebrate the 50th anniversary of Dermatology News, we are looking back at how the field has changed since that first issue. The focus this month is infectious disease. There’s a lot to be grateful for but there are also challenges like antibiotic resistance that weren’t on the radar screens of Dr. Orentreich, Dr. Callaway, and their peers in 1970.
All in all, “the only thing I wish we did the old way is sit at the bedside and talk to patients more. We rely so much on technology now that we sometimes lose the art of medicine, which is comforting to the patient,” said Theodore Rosen, MD, an ID dermatologist and professor of dermatology at Baylor College of Medicine, Houston, who’s been in practice for 42 years.
“A lot of advancements against herpes viruses”
One of the biggest wins for ID dermatology over the last 5 decades has been the management of herpes, both herpes simplex virus 1 and 2, as well as herpes zoster virus. It started with the approval of acyclovir in 1981. Before then, “we had no direct therapy for genital herpes, herpes zoster, or disseminated herpes in immunosuppressed or cancer patients,” Dr. Rosen said.
“I can remember doing an interview with Good Morning America when I gave the first IV dose of acyclovir in the city of Houston for really bad disseminated herpes” in an HIV patient, he said, and it worked.
Two derivatives, valacyclovir and famciclovir, became available in the mid-1990s, so today “we have three drugs and some others at the periphery that are all highly effective not only” against herpes, but also for preventing outbreaks; valacyclovir can even prevent asymptomatic shedding, therefore possibly preventing new infections. “That’s a concept we didn’t even have 40 years ago,” Dr. Rosen said.
Cidofovir has also made a difference. The IV formulation was approved for AIDS-associated cytomegalovirus retinitis in 1996 but discontinued a few years later amid concerns of severe renal toxicity. It’s found a new home in dermatology since then, explained ID dermatologist Carrie Kovarik, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia.
Dermatologists see acyclovir-resistant herpes “heaped up on the genitals in HIV patients,” and there weren’t many options in the past. A few years ago, “we [tried] injecting cidofovir directly into the skin lesions, and it’s been remarkably successful. It is a good way to treat these lesions” if dermatologists can get it compounded, she said.
Shingles vaccines, first the live attenuated zoster vaccine (Zostavax) approved by the Food and Drug Administration in 2006 and the more effective recombinant zoster vaccine (Shingrix) approved in 2017, have also had a significant impact.
Dr. Rosen remembers what it was like when he first started practicing over 40 years ago. Not uncommonly, “we saw horrible cases of shingles,” including one in his uncle, who was left with permanent hand pain long after the rash subsided.
Today, “I see much less shingles, and when I do see it, it’s in a much-attenuated form. [Shingrix], even if it doesn’t prevent the disease, often prevents postherpetic neuralgia,” he said.
Also, with pediatric vaccinations against chicken pox, “we’re probably going to see a whole new generation without shingles, which is huge. We’ve made a lot of advancements against herpes viruses,” Dr. Kovarik said.
“We finally found something that helps”
“We’ve [also] come a really long way with genital wart treatment,” Dr. Kovarik said.
It started with approval of topical imiquimod in 1997. “Before that, we were just killing one wart here and one wart there” but they would often come back and pop up in other areas. Injectable interferon was an option at the time, but people didn’t like all the needles.
With imiquimod, “we finally [had] a way to target HPV [human papillomavirus] and not just scrape” or freeze one wart at a time, and “we were able to generate an inflammatory response in the whole area to clear the virus.” Working with HIV patients, “I see sheets and sheets of confluent warts throughout the whole genital area; to try to freeze that is impossible. Now I have a way to get rid of [genital] warts and keep them away even if you have a big cluster,” she said.
“Sometimes, we’ll do both liquid nitrogen and imiquimod. That’s a good way to tackle people who have a high burden of warts,” Dr. Kovarik noted. Other effective treatments have come out as well, including an ointment formulation of sinecatechins, extracted from green tea, “but you have to put it on several times a day, and insurance companies don’t cover it often,” she said.
Intralesional cidofovir is also proving to be boon for potentially malignant refractory warts in HIV and transplant patients. “It’s an incredible treatment. We can inject that antiviral into warts and get rid of them. We finally found something that helps” these people, Dr. Kovarik said.
The HPV vaccine Gardasil is making a difference, as well. In addition to cervical dysplasia and anogenital cancers, it protects against two condyloma strains. Dr. Rosen said he’s seeing fewer cases of genital warts now than when he started practicing, likely because of the vaccine.
“Organisms that weren’t pathogens are now pathogens”
Antibiotic resistance probably tops the list for what’s changed in a bad way in ID dermatology since 1970. Dr. Rosen remembers at the start of his career that “we never worried about antibiotic resistance. We’d put people on antibiotics for acne, rosacea, and we’d keep them on them for 3 years, 6 years”; resistance wasn’t on the radar screen and was not mentioned once in the first issue of Dermatology News, which was packed with articles and ran 24 pages.
The situation is different now. Driven by decades of overuse in agriculture and the medical system, antibiotic resistance is a concern throughout medicine, and unfortunately, “we have not come nearly as far as fast with antibiotics,” at least the ones dermatologists use, “as we have with antivirals,” Dr. Tyring said.
For instance, methicillin-resistant Staphylococcus aureus (MRSA), first described in the United States in 1968, is “no longer the exception to the rule, but the rule” itself, he said, with carbuncles, furuncles, and abscesses not infrequently growing out MRSA. There are also new drug-resistant forms of old problems like gonorrhea and tuberculosis, among other developments, and impetigo has shifted since 1970 from mostly a Streptococcus infection easily treated with penicillin to often a Staphylococcus disease that’s resistant to it. There’s also been a steady march of new pathogens, including the latest one, SARS-CoV-2, the virus that causes COVID-19, which has been recognized as having a variety of skin manifestations.
“No matter how smart we think we are, nature has a way of putting us back in our place,” Dr. Rosen said.
The bright spot is that “we’ve become very adept at identifying and characterizing” microbes “based on techniques we didn’t even have when I started practicing,” such as polymerase chain reaction. “It has taken a lot of guess work out of treating infectious diseases,” he said.
The widespread use of immunosuppressives such as cyclophosphamide, mycophenolate, azathioprine, rituximab, and other agents used in conjunction with solid organ transplantation, has also been a challenge. “We are seeing infections with really odd organisms. Just recently, I had a patient with fusarium in the skin; it’s a fungus that lives in the dirt. I saw a patient with a species of algae” that normally lives in stagnant water, he commented. “We used to get [things like that] back on reports, and we’d throw them away. You can’t do that anymore. Organisms that weren’t pathogens in the past are now pathogens,” particularly in immunosuppressed people, Dr. Rosen said.
Venereologists no more
There’s been another big change in the field. “Back in the not too distant past, dermatologists in the U.S. were referred to as ‘dermatologist-venereologists.’ ” It goes back to the time when syphilis wasn’t diagnosed and treated early, so patients often presented with secondary skin complications and went to dermatologists for help. As a result, “dermatologists became the most experienced at treating it,” Dr. Tyring said.
That’s faded from practice. Part of the reason is that as late as 2000, syphilis seemed to be on the way out; the Centers for Disease and Control and Prevention even raised the possibility of elimination. Dermatologists turned their attention to other areas.
It might have been short-sighted, Dr. Rosen said. Syphilis has made a strong comeback, and drug-resistant gonorrhea has also emerged globally and in at least a few states. No other medical field has stepped in to take up the slack. “Ob.gyns. are busy delivering babies, ID [physicians are] concerned about HIV, and urologists are worried about kidney stones and cancer.” Other than herpes and genital warts, “we have not done well” with management of sexually transmitted diseases, he said.
“I could sense” his frustration
The first issue of Dermatology News carried an article and photospread about scabies that could run today, except that topical permethrin and oral ivermectin have largely replaced benzyl benzoate and sulfur ointments for treatment in the United States. In the article, Scottish dermatologist J. O’D. Alexander, MD, called scabies “the scourge of mankind” and blamed it’s prevalence on “an offhand attitude to the disease which makes control very difficult.”
“I could sense this man’s frustration that people were not recognizing scabies,” Dr. Kovarik said, and it’s no closer to being eradicated than it was in 1970. “It’s still around, and we see it in our clinics. It’s a horrible disease in kids we see in dermatology not infrequently,” and treatment has only advanced a bit.
The article highlights what hasn’t changed much in ID dermatology over the years. Common warts are another one. “With all the evolution in medicine, we don’t have any better treatments approved for common warts than we ever had.” Injecting cidofovir “works great,” but access is a problem, Dr. Tyring said.
Onychomycosis has also proven a tough nut to crack. Readers back in 1970 counted the introduction of the antifungal, griseofulvin, as a major advancement in the 1960s; it’s still a go-to for tinea capitis, but it didn’t work very well for toenail fungus. Terbinafine (Lamisil), approved in 1993, and subsequent developments have helped, but the field still awaits more effective options; a few potential new agents are in the pipeline.
Although there have been major advancements for serious systemic fungal infections, “we’ve mainly seen small steps forward” in ID dermatology, Dr. Tyring said.
Dr. Tyring, Dr. Kovarik, and Dr. Rosen said they had no relevant disclosures.
When Stephen Tyring, MD, PhD, an infectious disease dermatologist, started his career in the early 1980s, he said “we were diagnosing Kaposi’s sarcoma right and left. We would see a new case every day or two.”
It was the early days of the HIV/AIDS epidemic, and dermatologists were at the forefront because HIV/AIDS often presented with skin manifestations. Dr. Tyring, clinical professor in the departments of dermatology, microbiology & molecular genetics and internal medicine at the University of Texas Health Science Center, Houston, and his colleagues referred Kaposi’s patients for chemotherapy and radiation, but the outlook was often grim, especially if lesions developed in the lungs.
Dermatologist don’t see much Kaposi’s anymore because of highly effective treatments for HIV.
Members of the original editorial advisory board saw it coming. In a feature in which board members provided their prediction for the 1970s that appeared in the first issue, New York dermatologist Norman Orentreich, MD, counted the “probable introduction of virucidal agents” as one of the “significant advances or changes that I foresee in the next 10 years.” J. Lamar Callaway, MD, professor of dermatology at Duke University, Durham, N.C., predicted that “the next 10 years should develop effective anti-viral agents for warts, herpes simplex, and herpes zoster.”
To celebrate the 50th anniversary of Dermatology News, we are looking back at how the field has changed since that first issue. The focus this month is infectious disease. There’s a lot to be grateful for but there are also challenges like antibiotic resistance that weren’t on the radar screens of Dr. Orentreich, Dr. Callaway, and their peers in 1970.
All in all, “the only thing I wish we did the old way is sit at the bedside and talk to patients more. We rely so much on technology now that we sometimes lose the art of medicine, which is comforting to the patient,” said Theodore Rosen, MD, an ID dermatologist and professor of dermatology at Baylor College of Medicine, Houston, who’s been in practice for 42 years.
“A lot of advancements against herpes viruses”
One of the biggest wins for ID dermatology over the last 5 decades has been the management of herpes, both herpes simplex virus 1 and 2, as well as herpes zoster virus. It started with the approval of acyclovir in 1981. Before then, “we had no direct therapy for genital herpes, herpes zoster, or disseminated herpes in immunosuppressed or cancer patients,” Dr. Rosen said.
“I can remember doing an interview with Good Morning America when I gave the first IV dose of acyclovir in the city of Houston for really bad disseminated herpes” in an HIV patient, he said, and it worked.
Two derivatives, valacyclovir and famciclovir, became available in the mid-1990s, so today “we have three drugs and some others at the periphery that are all highly effective not only” against herpes, but also for preventing outbreaks; valacyclovir can even prevent asymptomatic shedding, therefore possibly preventing new infections. “That’s a concept we didn’t even have 40 years ago,” Dr. Rosen said.
Cidofovir has also made a difference. The IV formulation was approved for AIDS-associated cytomegalovirus retinitis in 1996 but discontinued a few years later amid concerns of severe renal toxicity. It’s found a new home in dermatology since then, explained ID dermatologist Carrie Kovarik, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia.
Dermatologists see acyclovir-resistant herpes “heaped up on the genitals in HIV patients,” and there weren’t many options in the past. A few years ago, “we [tried] injecting cidofovir directly into the skin lesions, and it’s been remarkably successful. It is a good way to treat these lesions” if dermatologists can get it compounded, she said.
Shingles vaccines, first the live attenuated zoster vaccine (Zostavax) approved by the Food and Drug Administration in 2006 and the more effective recombinant zoster vaccine (Shingrix) approved in 2017, have also had a significant impact.
Dr. Rosen remembers what it was like when he first started practicing over 40 years ago. Not uncommonly, “we saw horrible cases of shingles,” including one in his uncle, who was left with permanent hand pain long after the rash subsided.
Today, “I see much less shingles, and when I do see it, it’s in a much-attenuated form. [Shingrix], even if it doesn’t prevent the disease, often prevents postherpetic neuralgia,” he said.
Also, with pediatric vaccinations against chicken pox, “we’re probably going to see a whole new generation without shingles, which is huge. We’ve made a lot of advancements against herpes viruses,” Dr. Kovarik said.
“We finally found something that helps”
“We’ve [also] come a really long way with genital wart treatment,” Dr. Kovarik said.
It started with approval of topical imiquimod in 1997. “Before that, we were just killing one wart here and one wart there” but they would often come back and pop up in other areas. Injectable interferon was an option at the time, but people didn’t like all the needles.
With imiquimod, “we finally [had] a way to target HPV [human papillomavirus] and not just scrape” or freeze one wart at a time, and “we were able to generate an inflammatory response in the whole area to clear the virus.” Working with HIV patients, “I see sheets and sheets of confluent warts throughout the whole genital area; to try to freeze that is impossible. Now I have a way to get rid of [genital] warts and keep them away even if you have a big cluster,” she said.
“Sometimes, we’ll do both liquid nitrogen and imiquimod. That’s a good way to tackle people who have a high burden of warts,” Dr. Kovarik noted. Other effective treatments have come out as well, including an ointment formulation of sinecatechins, extracted from green tea, “but you have to put it on several times a day, and insurance companies don’t cover it often,” she said.
Intralesional cidofovir is also proving to be boon for potentially malignant refractory warts in HIV and transplant patients. “It’s an incredible treatment. We can inject that antiviral into warts and get rid of them. We finally found something that helps” these people, Dr. Kovarik said.
The HPV vaccine Gardasil is making a difference, as well. In addition to cervical dysplasia and anogenital cancers, it protects against two condyloma strains. Dr. Rosen said he’s seeing fewer cases of genital warts now than when he started practicing, likely because of the vaccine.
“Organisms that weren’t pathogens are now pathogens”
Antibiotic resistance probably tops the list for what’s changed in a bad way in ID dermatology since 1970. Dr. Rosen remembers at the start of his career that “we never worried about antibiotic resistance. We’d put people on antibiotics for acne, rosacea, and we’d keep them on them for 3 years, 6 years”; resistance wasn’t on the radar screen and was not mentioned once in the first issue of Dermatology News, which was packed with articles and ran 24 pages.
The situation is different now. Driven by decades of overuse in agriculture and the medical system, antibiotic resistance is a concern throughout medicine, and unfortunately, “we have not come nearly as far as fast with antibiotics,” at least the ones dermatologists use, “as we have with antivirals,” Dr. Tyring said.
For instance, methicillin-resistant Staphylococcus aureus (MRSA), first described in the United States in 1968, is “no longer the exception to the rule, but the rule” itself, he said, with carbuncles, furuncles, and abscesses not infrequently growing out MRSA. There are also new drug-resistant forms of old problems like gonorrhea and tuberculosis, among other developments, and impetigo has shifted since 1970 from mostly a Streptococcus infection easily treated with penicillin to often a Staphylococcus disease that’s resistant to it. There’s also been a steady march of new pathogens, including the latest one, SARS-CoV-2, the virus that causes COVID-19, which has been recognized as having a variety of skin manifestations.
“No matter how smart we think we are, nature has a way of putting us back in our place,” Dr. Rosen said.
The bright spot is that “we’ve become very adept at identifying and characterizing” microbes “based on techniques we didn’t even have when I started practicing,” such as polymerase chain reaction. “It has taken a lot of guess work out of treating infectious diseases,” he said.
The widespread use of immunosuppressives such as cyclophosphamide, mycophenolate, azathioprine, rituximab, and other agents used in conjunction with solid organ transplantation, has also been a challenge. “We are seeing infections with really odd organisms. Just recently, I had a patient with fusarium in the skin; it’s a fungus that lives in the dirt. I saw a patient with a species of algae” that normally lives in stagnant water, he commented. “We used to get [things like that] back on reports, and we’d throw them away. You can’t do that anymore. Organisms that weren’t pathogens in the past are now pathogens,” particularly in immunosuppressed people, Dr. Rosen said.
Venereologists no more
There’s been another big change in the field. “Back in the not too distant past, dermatologists in the U.S. were referred to as ‘dermatologist-venereologists.’ ” It goes back to the time when syphilis wasn’t diagnosed and treated early, so patients often presented with secondary skin complications and went to dermatologists for help. As a result, “dermatologists became the most experienced at treating it,” Dr. Tyring said.
That’s faded from practice. Part of the reason is that as late as 2000, syphilis seemed to be on the way out; the Centers for Disease and Control and Prevention even raised the possibility of elimination. Dermatologists turned their attention to other areas.
It might have been short-sighted, Dr. Rosen said. Syphilis has made a strong comeback, and drug-resistant gonorrhea has also emerged globally and in at least a few states. No other medical field has stepped in to take up the slack. “Ob.gyns. are busy delivering babies, ID [physicians are] concerned about HIV, and urologists are worried about kidney stones and cancer.” Other than herpes and genital warts, “we have not done well” with management of sexually transmitted diseases, he said.
“I could sense” his frustration
The first issue of Dermatology News carried an article and photospread about scabies that could run today, except that topical permethrin and oral ivermectin have largely replaced benzyl benzoate and sulfur ointments for treatment in the United States. In the article, Scottish dermatologist J. O’D. Alexander, MD, called scabies “the scourge of mankind” and blamed it’s prevalence on “an offhand attitude to the disease which makes control very difficult.”
“I could sense this man’s frustration that people were not recognizing scabies,” Dr. Kovarik said, and it’s no closer to being eradicated than it was in 1970. “It’s still around, and we see it in our clinics. It’s a horrible disease in kids we see in dermatology not infrequently,” and treatment has only advanced a bit.
The article highlights what hasn’t changed much in ID dermatology over the years. Common warts are another one. “With all the evolution in medicine, we don’t have any better treatments approved for common warts than we ever had.” Injecting cidofovir “works great,” but access is a problem, Dr. Tyring said.
Onychomycosis has also proven a tough nut to crack. Readers back in 1970 counted the introduction of the antifungal, griseofulvin, as a major advancement in the 1960s; it’s still a go-to for tinea capitis, but it didn’t work very well for toenail fungus. Terbinafine (Lamisil), approved in 1993, and subsequent developments have helped, but the field still awaits more effective options; a few potential new agents are in the pipeline.
Although there have been major advancements for serious systemic fungal infections, “we’ve mainly seen small steps forward” in ID dermatology, Dr. Tyring said.
Dr. Tyring, Dr. Kovarik, and Dr. Rosen said they had no relevant disclosures.
Learning the ICU
Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.1 “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.
A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.
“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”
Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.
References
1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.
Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.1 “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.
A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.
“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”
Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.
References
1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.
Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.1 “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.
A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.
“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”
Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.
References
1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.
It’s official: COVID-19 was bad for the health care business
COVID-19 took a huge cut of clinicians’ business in March and April
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
COVID-19 took a huge cut of clinicians’ business in March and April
COVID-19 took a huge cut of clinicians’ business in March and April
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
It’s official: COVID-19 was bad for the health care business
COVID-19 took a huge cut of clinicians’ business in March and April
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
COVID-19 took a huge cut of clinicians’ business in March and April
COVID-19 took a huge cut of clinicians’ business in March and April
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
In the first 2 months of the COVID-19 pandemic, health care professionals experienced sharp drops in both utilization and revenue, according to an analysis of the nation’s largest collection of private health care claims data.
For the months of March and April 2020, use of medical professional services dropped by 65% and 68%, respectively, compared with last year, and estimated revenue fell by 45% and 48%, FAIR Health, a nonprofit organization that manages a database of 31 billion claim records, said in a new report.
For the Northeast states – the epicenter of the pandemic in March and April – patient volume was down by 60% in March and 80% in April, while revenue fell by 55% in March and 79% in April, the organization said.
For this analysis, “a professional service was defined as any service provided by an individual (e.g., physician, nurse, nurse practitioner, physician assistant) instead of being billed by a facility,” FAIR Health noted. Figures for 2019 were adjusted using the Consumer Price Index.
The size of the pandemic-related decreases in utilization and income varied by specialty. Of the seven specialties included in the study, oral surgery was hit the hardest, followed by gastroenterology, cardiology, orthopedics, dermatology, adult primary care, and pediatric primary care, FAIR Health said.
After experiencing a 2% drop in utilization this January and an increase of 4% in February, compared with 2019, gastroenterology saw corresponding drops of 73% in March and 77% in April. Estimated revenue for the specialty was flat in January and rose by 10% in February, but plummeted by 75% in March and 80% in April, the FAIR Health data show.
In cardiology, patient volume from 2019 to 2020 looked like this: Down by 4% in January, up 5% in February, down by 62% in March, and down by 71% in April. The earnings numbers tell a similar story: Down by 2% in January, up by 15% in February, down by 57% in March, and down by 73% in April, the organization reported.
Dermatology did the best among the non–primary care specialties, but that was just a relative success. Utilization still dropped by 62% and 68% in March and April of 2020, compared with last year, and revenue declined by 50% in March and 59% in April, FAIR Health said.
For adult primary care, the utilization numbers were similar, but revenue took a somewhat smaller hit. Patient volume from 2019 to 2020 was fairly steady in January and February, then nosedived in March (down 60%) and April (down 68%). Earnings were up initially, rising 1% in January and 2% in February, but fell 47% in March and 54% in April, FAIR Health said.
Pediatric primary care, it appears, may have been buoyed somewhat by its younger patients. The specialty as a whole saw utilization tumble by 52% in March and 58% in April, but revenue dropped by just 32% and 35%, respectively, according to the report.
A little extra data diving showed that the figures for preventive care visits for patients aged 0-4 years in March and April were –2% and 0% for volume and –2% and 1% for revenue. Meanwhile, the volume of immunizations only dropped by 14% and 10% and vaccine-related revenue slipped by just 7% and 2%, FAIR Health noted.
“Across many specialties from January to April 2020, office or other outpatient [evaluation and management] visits became more common relative to other procedures. ... This may have been due in part to the fact that many of these E&M services could be rendered via telehealth,” FAIR Health said.
Telehealth, however, was no panacea, the report explained: “Even when medical practices have continued to function via telehealth, many have experienced lower reimbursements for telehealth visits than for in-person visits and more time educating patients on how to use the technology.”
Secondary infections common in COVID-19, implications unclear
but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.
“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.
“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.
One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.
“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”
That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.
“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.
Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.
“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.
Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.
“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.
“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.
“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.
One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.
“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”
That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.
“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.
Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.
“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.
Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.
“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.
“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.
“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.
One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.
“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”
That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.
“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.
Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.
“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.
Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.
“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
Racism joins COVID-19 at the primary care table
Primary care clinicians, already experiencing all-time high stress levels related to COVID-19, are now struggling to cope with the fallout from racism and the death of George Floyd, according to a survey conducted June 5-8.
When asked how the situation has affected their practices, two-thirds of the survey’s 586 respondents said that George Floyd’s death and related events had been the subject of practice conversations and 12% “drew clear connections between the current racial unrest and the health of their patients,” the Larry A. Green Center said in a recent statement.
One-third of the clinicians also said that recent racism-related events have had a negative effect on their own well-being, and that connection was expressed even more strongly in a related survey of 1,111 patients that was conducted June 8.
In that survey, about 65% of patients said that racism affected emotional, psychological, and behavioral health, and 40% noted that George Floyd’s death had a negative impact on the well-being of friends, the Larry A. Green Center said in partnership with the Primary Care Collaborative and 3rd Conversation.
“The fact that so many patients and clinicians agree that racism is a driver of health points to the incredible role primary care plays in creating safe spaces to process deep societal and personal issues,” said Christine Bechtel, cofounder of 3rd Conversation, a community of patients and providers.
COVID-19, in the meantime, is still doing its thing. Almost two-thirds (63%) of respondents to the clinician survey said that stress levels at their practices had reached all-time-high levels in the last 4 weeks.
Just 1.4% of the primary care clinicians said that the pandemic had put no strain on their practices (see graph), and just 10% rated that strain as a 2 on a scale of 1-5, the center said. Among the stressors:
About 49% continue to lack PPE.
About 40% still have no or limited ability for testing.
About 37% of practice settings still report layoffs and furloughs.
About 31% report that clinician salaries are still being skipped or deferred.
“Both public and private policy makers must take immediate steps to stabilize primary care,” said Ann Greiner, president and CEO of the Primary Care Collaborative. “This financial support is necessary but not sufficient. Instead, we need wholesale reform of payment in order to achieve the kind of high-performing primary care that truly meets patient needs.”
Primary care clinicians, already experiencing all-time high stress levels related to COVID-19, are now struggling to cope with the fallout from racism and the death of George Floyd, according to a survey conducted June 5-8.
When asked how the situation has affected their practices, two-thirds of the survey’s 586 respondents said that George Floyd’s death and related events had been the subject of practice conversations and 12% “drew clear connections between the current racial unrest and the health of their patients,” the Larry A. Green Center said in a recent statement.
One-third of the clinicians also said that recent racism-related events have had a negative effect on their own well-being, and that connection was expressed even more strongly in a related survey of 1,111 patients that was conducted June 8.
In that survey, about 65% of patients said that racism affected emotional, psychological, and behavioral health, and 40% noted that George Floyd’s death had a negative impact on the well-being of friends, the Larry A. Green Center said in partnership with the Primary Care Collaborative and 3rd Conversation.
“The fact that so many patients and clinicians agree that racism is a driver of health points to the incredible role primary care plays in creating safe spaces to process deep societal and personal issues,” said Christine Bechtel, cofounder of 3rd Conversation, a community of patients and providers.
COVID-19, in the meantime, is still doing its thing. Almost two-thirds (63%) of respondents to the clinician survey said that stress levels at their practices had reached all-time-high levels in the last 4 weeks.
Just 1.4% of the primary care clinicians said that the pandemic had put no strain on their practices (see graph), and just 10% rated that strain as a 2 on a scale of 1-5, the center said. Among the stressors:
About 49% continue to lack PPE.
About 40% still have no or limited ability for testing.
About 37% of practice settings still report layoffs and furloughs.
About 31% report that clinician salaries are still being skipped or deferred.
“Both public and private policy makers must take immediate steps to stabilize primary care,” said Ann Greiner, president and CEO of the Primary Care Collaborative. “This financial support is necessary but not sufficient. Instead, we need wholesale reform of payment in order to achieve the kind of high-performing primary care that truly meets patient needs.”
Primary care clinicians, already experiencing all-time high stress levels related to COVID-19, are now struggling to cope with the fallout from racism and the death of George Floyd, according to a survey conducted June 5-8.
When asked how the situation has affected their practices, two-thirds of the survey’s 586 respondents said that George Floyd’s death and related events had been the subject of practice conversations and 12% “drew clear connections between the current racial unrest and the health of their patients,” the Larry A. Green Center said in a recent statement.
One-third of the clinicians also said that recent racism-related events have had a negative effect on their own well-being, and that connection was expressed even more strongly in a related survey of 1,111 patients that was conducted June 8.
In that survey, about 65% of patients said that racism affected emotional, psychological, and behavioral health, and 40% noted that George Floyd’s death had a negative impact on the well-being of friends, the Larry A. Green Center said in partnership with the Primary Care Collaborative and 3rd Conversation.
“The fact that so many patients and clinicians agree that racism is a driver of health points to the incredible role primary care plays in creating safe spaces to process deep societal and personal issues,” said Christine Bechtel, cofounder of 3rd Conversation, a community of patients and providers.
COVID-19, in the meantime, is still doing its thing. Almost two-thirds (63%) of respondents to the clinician survey said that stress levels at their practices had reached all-time-high levels in the last 4 weeks.
Just 1.4% of the primary care clinicians said that the pandemic had put no strain on their practices (see graph), and just 10% rated that strain as a 2 on a scale of 1-5, the center said. Among the stressors:
About 49% continue to lack PPE.
About 40% still have no or limited ability for testing.
About 37% of practice settings still report layoffs and furloughs.
About 31% report that clinician salaries are still being skipped or deferred.
“Both public and private policy makers must take immediate steps to stabilize primary care,” said Ann Greiner, president and CEO of the Primary Care Collaborative. “This financial support is necessary but not sufficient. Instead, we need wholesale reform of payment in order to achieve the kind of high-performing primary care that truly meets patient needs.”
80% of US counties have no ID specialists
Nearly 80% of US counties have no infectious disease (ID) specialists, and 80% of counties in the top quartile of COVID-19 cases have no ID physicians or a below-average ratio of ID specialists to the population, according to a study published online in Annals of Internal Medicine.
Although the majority of these counties are rural, nearly two-thirds of Americans live in the 80% of counties that have a below-average ID specialist density or no access to ID physicians at all.
There are no data yet on the association between ID physician care and COVID-19 outcomes, the researchers note. “However, for many other infectious diseases, a robust evidence base supports the association between ID physician intervention and improved outcomes, including lower mortality, shorter length of stay, fewer readmissions, and lower total health care spending,” the authors explain.
The national average density of ID specialists was 1.76 ID physicians per 100,000 people in 2017. However, the authors say this distribution “was geographically skewed”: Of the 3142 US counties, 331 (10.5%) had above-average ID physician densities and 312 (9.9%) had below-average ID physician densities. Not a single ID physician practiced in the other 2499 counties.
A US map accompanying the study shows the distribution of ID specialists across the country. The areas with the most ID specialists were in the Northeast and Florida. Below-average densities of ID physicians were shown in the Southwest and on the West Coast. Large swathes of the South, the Midwest, and the Mountain West had no ID specialists.
Among the 785 counties with the highest quartile of COVID-19 burden as of mid-May, 147 (18.7%) and 117 (14.9%) had above- and below-average ID physician densities, respectively. More than two-thirds (521) of these counties had no ID specialist coverage.
Although the literature does not indicate the “right” ratio of ID specialists to a population, the authors conclude, “our current distribution during pandemic times is probably far too sparse. The deficits in our ID physician workforce today have left us poorly prepared for the unprecedented demand ahead.”
The overall shortage of ID specialists is becoming more severe, the researchers note. In 2019 to 2020, ID fellowship programs had fewer than one applicant for every open position, on average. Thirty-eight percent of ID programs were unable to fill their training slots, and 19% could fill no slots at all.
This deficit of interest in the ID field continues a long-term trend. A 2019 Merritt Hawkins report found that between the 2009-2010 and 2016-2017 fellowship matches the number of adult ID programs filling all their positions dropped by 41% and the number of applicants decreased by 31%, according to Medscape Medical News.
The authors tie the decline of interest in the field to the compensation of ID specialists, which is lower than that of procedural specialists. Because their field focuses on cognitive skills, these highly trained physicians are paid about the same as primary care physicians.
Loan Repayment
Young physicians have an average of $200,000 in loans when they graduate from medical school, coauthor Rochelle Walensky, MD, MPH, said in an interview. With the fellowship training required to become an infectious disease specialist, they fall even further in debt. In effect, they earn less than primary care doctors do, she said.
Consequently, any strategy to bolster the ID specialist workforce should include a government loan repayment program, Dr. Walensky explained, adding that perhaps the loan repayment could be tied to practicing in underserved areas where ID specialists are especially needed.
Telehealth is the key to stretching the resources of ID specialists for the duration of the COVID-19 pandemic, she said. “The way to expand [the specialty] in the short run is to reimburse for telehealth.”
Dr. Walensky is also concerned about the rollback of funding for infectious disease research. “I have a whole corps of researchers ... who are really worried about their research future,” she said. “These are Harvard scientists who don’t know if they’ll be funded. If they’re not, we could lose a whole generation of researchers, and where will we be 10-15 years from now?”
Dr. Walensky is Chief of the Infectious Diseases Division at Massachusetts General Hospital and a professor of medicine at Harvard Medical School, both in Boston.
Frontline Roles
On the front line of fighting COVID-19 today, ID specialists are also critical to the research required to create a vaccine and find new treatments, Dr. Walensky explained. They are knowledgeable about current drugs such as hydroxychloroquine and can set up protocols for clinical trials.
At Massachusetts General Hospital, she continued, she and her colleagues developed infectious disease control policies to keep patients and health workers safe; they also triage patients to determine which ones should be tested for COVID-19 and give advice to treating doctors when patients who appear to have COVID-19 test negative. In addition, ID specialists are skilled in the management of complex cases, such as COVID patients who have comorbidities.
“We’re not [gastrointestinal] docs or cardiology docs,” Dr. Walensky noted. “We don’t manage a single organ system. We’re trained to worry about the entire patient. Given that this disease manifests itself in so many different ways to so many different patients and affects many different organs that nobody was anticipating — that’s our sweet spot in terms of how we care for patients.”
Dr. Walensky reports grants from Steve and Deborah Gorlin MGH Research Scholar Award, outside the submitted work. The remaining authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Nearly 80% of US counties have no infectious disease (ID) specialists, and 80% of counties in the top quartile of COVID-19 cases have no ID physicians or a below-average ratio of ID specialists to the population, according to a study published online in Annals of Internal Medicine.
Although the majority of these counties are rural, nearly two-thirds of Americans live in the 80% of counties that have a below-average ID specialist density or no access to ID physicians at all.
There are no data yet on the association between ID physician care and COVID-19 outcomes, the researchers note. “However, for many other infectious diseases, a robust evidence base supports the association between ID physician intervention and improved outcomes, including lower mortality, shorter length of stay, fewer readmissions, and lower total health care spending,” the authors explain.
The national average density of ID specialists was 1.76 ID physicians per 100,000 people in 2017. However, the authors say this distribution “was geographically skewed”: Of the 3142 US counties, 331 (10.5%) had above-average ID physician densities and 312 (9.9%) had below-average ID physician densities. Not a single ID physician practiced in the other 2499 counties.
A US map accompanying the study shows the distribution of ID specialists across the country. The areas with the most ID specialists were in the Northeast and Florida. Below-average densities of ID physicians were shown in the Southwest and on the West Coast. Large swathes of the South, the Midwest, and the Mountain West had no ID specialists.
Among the 785 counties with the highest quartile of COVID-19 burden as of mid-May, 147 (18.7%) and 117 (14.9%) had above- and below-average ID physician densities, respectively. More than two-thirds (521) of these counties had no ID specialist coverage.
Although the literature does not indicate the “right” ratio of ID specialists to a population, the authors conclude, “our current distribution during pandemic times is probably far too sparse. The deficits in our ID physician workforce today have left us poorly prepared for the unprecedented demand ahead.”
The overall shortage of ID specialists is becoming more severe, the researchers note. In 2019 to 2020, ID fellowship programs had fewer than one applicant for every open position, on average. Thirty-eight percent of ID programs were unable to fill their training slots, and 19% could fill no slots at all.
This deficit of interest in the ID field continues a long-term trend. A 2019 Merritt Hawkins report found that between the 2009-2010 and 2016-2017 fellowship matches the number of adult ID programs filling all their positions dropped by 41% and the number of applicants decreased by 31%, according to Medscape Medical News.
The authors tie the decline of interest in the field to the compensation of ID specialists, which is lower than that of procedural specialists. Because their field focuses on cognitive skills, these highly trained physicians are paid about the same as primary care physicians.
Loan Repayment
Young physicians have an average of $200,000 in loans when they graduate from medical school, coauthor Rochelle Walensky, MD, MPH, said in an interview. With the fellowship training required to become an infectious disease specialist, they fall even further in debt. In effect, they earn less than primary care doctors do, she said.
Consequently, any strategy to bolster the ID specialist workforce should include a government loan repayment program, Dr. Walensky explained, adding that perhaps the loan repayment could be tied to practicing in underserved areas where ID specialists are especially needed.
Telehealth is the key to stretching the resources of ID specialists for the duration of the COVID-19 pandemic, she said. “The way to expand [the specialty] in the short run is to reimburse for telehealth.”
Dr. Walensky is also concerned about the rollback of funding for infectious disease research. “I have a whole corps of researchers ... who are really worried about their research future,” she said. “These are Harvard scientists who don’t know if they’ll be funded. If they’re not, we could lose a whole generation of researchers, and where will we be 10-15 years from now?”
Dr. Walensky is Chief of the Infectious Diseases Division at Massachusetts General Hospital and a professor of medicine at Harvard Medical School, both in Boston.
Frontline Roles
On the front line of fighting COVID-19 today, ID specialists are also critical to the research required to create a vaccine and find new treatments, Dr. Walensky explained. They are knowledgeable about current drugs such as hydroxychloroquine and can set up protocols for clinical trials.
At Massachusetts General Hospital, she continued, she and her colleagues developed infectious disease control policies to keep patients and health workers safe; they also triage patients to determine which ones should be tested for COVID-19 and give advice to treating doctors when patients who appear to have COVID-19 test negative. In addition, ID specialists are skilled in the management of complex cases, such as COVID patients who have comorbidities.
“We’re not [gastrointestinal] docs or cardiology docs,” Dr. Walensky noted. “We don’t manage a single organ system. We’re trained to worry about the entire patient. Given that this disease manifests itself in so many different ways to so many different patients and affects many different organs that nobody was anticipating — that’s our sweet spot in terms of how we care for patients.”
Dr. Walensky reports grants from Steve and Deborah Gorlin MGH Research Scholar Award, outside the submitted work. The remaining authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Nearly 80% of US counties have no infectious disease (ID) specialists, and 80% of counties in the top quartile of COVID-19 cases have no ID physicians or a below-average ratio of ID specialists to the population, according to a study published online in Annals of Internal Medicine.
Although the majority of these counties are rural, nearly two-thirds of Americans live in the 80% of counties that have a below-average ID specialist density or no access to ID physicians at all.
There are no data yet on the association between ID physician care and COVID-19 outcomes, the researchers note. “However, for many other infectious diseases, a robust evidence base supports the association between ID physician intervention and improved outcomes, including lower mortality, shorter length of stay, fewer readmissions, and lower total health care spending,” the authors explain.
The national average density of ID specialists was 1.76 ID physicians per 100,000 people in 2017. However, the authors say this distribution “was geographically skewed”: Of the 3142 US counties, 331 (10.5%) had above-average ID physician densities and 312 (9.9%) had below-average ID physician densities. Not a single ID physician practiced in the other 2499 counties.
A US map accompanying the study shows the distribution of ID specialists across the country. The areas with the most ID specialists were in the Northeast and Florida. Below-average densities of ID physicians were shown in the Southwest and on the West Coast. Large swathes of the South, the Midwest, and the Mountain West had no ID specialists.
Among the 785 counties with the highest quartile of COVID-19 burden as of mid-May, 147 (18.7%) and 117 (14.9%) had above- and below-average ID physician densities, respectively. More than two-thirds (521) of these counties had no ID specialist coverage.
Although the literature does not indicate the “right” ratio of ID specialists to a population, the authors conclude, “our current distribution during pandemic times is probably far too sparse. The deficits in our ID physician workforce today have left us poorly prepared for the unprecedented demand ahead.”
The overall shortage of ID specialists is becoming more severe, the researchers note. In 2019 to 2020, ID fellowship programs had fewer than one applicant for every open position, on average. Thirty-eight percent of ID programs were unable to fill their training slots, and 19% could fill no slots at all.
This deficit of interest in the ID field continues a long-term trend. A 2019 Merritt Hawkins report found that between the 2009-2010 and 2016-2017 fellowship matches the number of adult ID programs filling all their positions dropped by 41% and the number of applicants decreased by 31%, according to Medscape Medical News.
The authors tie the decline of interest in the field to the compensation of ID specialists, which is lower than that of procedural specialists. Because their field focuses on cognitive skills, these highly trained physicians are paid about the same as primary care physicians.
Loan Repayment
Young physicians have an average of $200,000 in loans when they graduate from medical school, coauthor Rochelle Walensky, MD, MPH, said in an interview. With the fellowship training required to become an infectious disease specialist, they fall even further in debt. In effect, they earn less than primary care doctors do, she said.
Consequently, any strategy to bolster the ID specialist workforce should include a government loan repayment program, Dr. Walensky explained, adding that perhaps the loan repayment could be tied to practicing in underserved areas where ID specialists are especially needed.
Telehealth is the key to stretching the resources of ID specialists for the duration of the COVID-19 pandemic, she said. “The way to expand [the specialty] in the short run is to reimburse for telehealth.”
Dr. Walensky is also concerned about the rollback of funding for infectious disease research. “I have a whole corps of researchers ... who are really worried about their research future,” she said. “These are Harvard scientists who don’t know if they’ll be funded. If they’re not, we could lose a whole generation of researchers, and where will we be 10-15 years from now?”
Dr. Walensky is Chief of the Infectious Diseases Division at Massachusetts General Hospital and a professor of medicine at Harvard Medical School, both in Boston.
Frontline Roles
On the front line of fighting COVID-19 today, ID specialists are also critical to the research required to create a vaccine and find new treatments, Dr. Walensky explained. They are knowledgeable about current drugs such as hydroxychloroquine and can set up protocols for clinical trials.
At Massachusetts General Hospital, she continued, she and her colleagues developed infectious disease control policies to keep patients and health workers safe; they also triage patients to determine which ones should be tested for COVID-19 and give advice to treating doctors when patients who appear to have COVID-19 test negative. In addition, ID specialists are skilled in the management of complex cases, such as COVID patients who have comorbidities.
“We’re not [gastrointestinal] docs or cardiology docs,” Dr. Walensky noted. “We don’t manage a single organ system. We’re trained to worry about the entire patient. Given that this disease manifests itself in so many different ways to so many different patients and affects many different organs that nobody was anticipating — that’s our sweet spot in terms of how we care for patients.”
Dr. Walensky reports grants from Steve and Deborah Gorlin MGH Research Scholar Award, outside the submitted work. The remaining authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Clinicians urged to use CURE ID to report COVID-19 cases
in conjunction with ongoing clinical trial efforts.
“By utilizing the CURE ID platform now for COVID-19 case collection – in conjunction with data gathered from other registries, EHR systems, and clinical trials – data collected during an outbreak can be improved and coordinated,” Heather A. Stone, MPH, said during a June 9 webinar sponsored by the Food and Drug Administration. “This may allow us to find possible treatments to help ease this pandemic, and prepare us better to fight the next one.”
During the hour-long webinar, Ms. Stone, a health science policy analyst in the office of medical policy at the FDA’s Center for Drug Evaluation and Research, demonstrated CURE ID, an Internet-based data repository first developed in 2013 as a collaboration between the FDA and the National Center for Advancing Translational Sciences, a part of the National Institutes of Health (NCATS/NIH). It provides licensed clinicians worldwide with an opportunity to report novel uses of existing drugs for patients with difficult-to-treat infectious diseases, including COVID-19, through a website, a smartphone, or other mobile device. The app can be downloaded for free at http://cure.ncats.io. It can also be downloaded from the Apple app store or the Google Play store by searching “CURE ID.”
According to Ms. Stone, the platform’s three main goals are to enhance the understanding of new uses of approved medical products, to facilitate clinical trials and drug development, and to serve as a resource for physicians to share information where no FDA-approved product (which has been proven to be safe and effective) exists for the new use. CURE ID enables users to report their own cases as well as read cases of neglected infectious diseases with no sufficient approved therapies from other clinicians around the world. “It also enables clinicians to engage directly with communities of disease experts around the world, breaking down geographic and specialty silos,” Ms. Stone said. “It also enables them to access information on approved therapies for each disease and as well on active clinical trials.”
To date, CURE-ID contains information on 325 infectious diseases, including 1,580 case reports and 18,907 clinical trials. Initial pilot priority diseases include COVID-19, mycetoma, atypical mycobacteria, drug-resistant gonorrhea, rare and resistant fungal infections, as well as multidrug resistant gram-negative bacteria.
As of June 9, COVID-19-related data on the platform includes 151 case reports that have been extracted from the published literature or entered by clinician users, 80 discussion posts, and links to 694 clinical trials, 303 journal articles, 212 news articles, and 34 events. A total of 65 repurposed drugs have been identified as potential treatments for the virus, including 15 drugs with 10 or more cases.
“This facilitates clinicians reporting their real-world experiences treating COVID-19 patients, when patients are unable to be enrolled in a clinical trial,” Ms. Stone said. “It includes an updated case report form tailored to COVID-19 and data fields that have been harmonized with other real-world data and clinical trial platforms.” She pointed out that voluntary submission of cases to CURE ID is not a substitute for filing information with regulatory and public health authorities, where required. The platform also enables data to be entered and adverse events to be automatically shared with the FDA’s MedWatch Adverse Reporting System.
Ms. Stone concluded the webinar by announcing the formation of a new private-public partnership between the Critical Path Institute and the FDA and NCATS/NIH known as the CURE Drug Repurposing Collaboratory. The effort will begin with a pilot project focused on furthering drug development for COVID-19 through use of the CURE ID platform. “The Collaboratory will demonstrate how data shared from clinicians in real-time can be used to inform ongoing and future clinical trials, and potentially drug labeling,” Ms. Stone said. She reported having no financial disclosures.
in conjunction with ongoing clinical trial efforts.
“By utilizing the CURE ID platform now for COVID-19 case collection – in conjunction with data gathered from other registries, EHR systems, and clinical trials – data collected during an outbreak can be improved and coordinated,” Heather A. Stone, MPH, said during a June 9 webinar sponsored by the Food and Drug Administration. “This may allow us to find possible treatments to help ease this pandemic, and prepare us better to fight the next one.”
During the hour-long webinar, Ms. Stone, a health science policy analyst in the office of medical policy at the FDA’s Center for Drug Evaluation and Research, demonstrated CURE ID, an Internet-based data repository first developed in 2013 as a collaboration between the FDA and the National Center for Advancing Translational Sciences, a part of the National Institutes of Health (NCATS/NIH). It provides licensed clinicians worldwide with an opportunity to report novel uses of existing drugs for patients with difficult-to-treat infectious diseases, including COVID-19, through a website, a smartphone, or other mobile device. The app can be downloaded for free at http://cure.ncats.io. It can also be downloaded from the Apple app store or the Google Play store by searching “CURE ID.”
According to Ms. Stone, the platform’s three main goals are to enhance the understanding of new uses of approved medical products, to facilitate clinical trials and drug development, and to serve as a resource for physicians to share information where no FDA-approved product (which has been proven to be safe and effective) exists for the new use. CURE ID enables users to report their own cases as well as read cases of neglected infectious diseases with no sufficient approved therapies from other clinicians around the world. “It also enables clinicians to engage directly with communities of disease experts around the world, breaking down geographic and specialty silos,” Ms. Stone said. “It also enables them to access information on approved therapies for each disease and as well on active clinical trials.”
To date, CURE-ID contains information on 325 infectious diseases, including 1,580 case reports and 18,907 clinical trials. Initial pilot priority diseases include COVID-19, mycetoma, atypical mycobacteria, drug-resistant gonorrhea, rare and resistant fungal infections, as well as multidrug resistant gram-negative bacteria.
As of June 9, COVID-19-related data on the platform includes 151 case reports that have been extracted from the published literature or entered by clinician users, 80 discussion posts, and links to 694 clinical trials, 303 journal articles, 212 news articles, and 34 events. A total of 65 repurposed drugs have been identified as potential treatments for the virus, including 15 drugs with 10 or more cases.
“This facilitates clinicians reporting their real-world experiences treating COVID-19 patients, when patients are unable to be enrolled in a clinical trial,” Ms. Stone said. “It includes an updated case report form tailored to COVID-19 and data fields that have been harmonized with other real-world data and clinical trial platforms.” She pointed out that voluntary submission of cases to CURE ID is not a substitute for filing information with regulatory and public health authorities, where required. The platform also enables data to be entered and adverse events to be automatically shared with the FDA’s MedWatch Adverse Reporting System.
Ms. Stone concluded the webinar by announcing the formation of a new private-public partnership between the Critical Path Institute and the FDA and NCATS/NIH known as the CURE Drug Repurposing Collaboratory. The effort will begin with a pilot project focused on furthering drug development for COVID-19 through use of the CURE ID platform. “The Collaboratory will demonstrate how data shared from clinicians in real-time can be used to inform ongoing and future clinical trials, and potentially drug labeling,” Ms. Stone said. She reported having no financial disclosures.
in conjunction with ongoing clinical trial efforts.
“By utilizing the CURE ID platform now for COVID-19 case collection – in conjunction with data gathered from other registries, EHR systems, and clinical trials – data collected during an outbreak can be improved and coordinated,” Heather A. Stone, MPH, said during a June 9 webinar sponsored by the Food and Drug Administration. “This may allow us to find possible treatments to help ease this pandemic, and prepare us better to fight the next one.”
During the hour-long webinar, Ms. Stone, a health science policy analyst in the office of medical policy at the FDA’s Center for Drug Evaluation and Research, demonstrated CURE ID, an Internet-based data repository first developed in 2013 as a collaboration between the FDA and the National Center for Advancing Translational Sciences, a part of the National Institutes of Health (NCATS/NIH). It provides licensed clinicians worldwide with an opportunity to report novel uses of existing drugs for patients with difficult-to-treat infectious diseases, including COVID-19, through a website, a smartphone, or other mobile device. The app can be downloaded for free at http://cure.ncats.io. It can also be downloaded from the Apple app store or the Google Play store by searching “CURE ID.”
According to Ms. Stone, the platform’s three main goals are to enhance the understanding of new uses of approved medical products, to facilitate clinical trials and drug development, and to serve as a resource for physicians to share information where no FDA-approved product (which has been proven to be safe and effective) exists for the new use. CURE ID enables users to report their own cases as well as read cases of neglected infectious diseases with no sufficient approved therapies from other clinicians around the world. “It also enables clinicians to engage directly with communities of disease experts around the world, breaking down geographic and specialty silos,” Ms. Stone said. “It also enables them to access information on approved therapies for each disease and as well on active clinical trials.”
To date, CURE-ID contains information on 325 infectious diseases, including 1,580 case reports and 18,907 clinical trials. Initial pilot priority diseases include COVID-19, mycetoma, atypical mycobacteria, drug-resistant gonorrhea, rare and resistant fungal infections, as well as multidrug resistant gram-negative bacteria.
As of June 9, COVID-19-related data on the platform includes 151 case reports that have been extracted from the published literature or entered by clinician users, 80 discussion posts, and links to 694 clinical trials, 303 journal articles, 212 news articles, and 34 events. A total of 65 repurposed drugs have been identified as potential treatments for the virus, including 15 drugs with 10 or more cases.
“This facilitates clinicians reporting their real-world experiences treating COVID-19 patients, when patients are unable to be enrolled in a clinical trial,” Ms. Stone said. “It includes an updated case report form tailored to COVID-19 and data fields that have been harmonized with other real-world data and clinical trial platforms.” She pointed out that voluntary submission of cases to CURE ID is not a substitute for filing information with regulatory and public health authorities, where required. The platform also enables data to be entered and adverse events to be automatically shared with the FDA’s MedWatch Adverse Reporting System.
Ms. Stone concluded the webinar by announcing the formation of a new private-public partnership between the Critical Path Institute and the FDA and NCATS/NIH known as the CURE Drug Repurposing Collaboratory. The effort will begin with a pilot project focused on furthering drug development for COVID-19 through use of the CURE ID platform. “The Collaboratory will demonstrate how data shared from clinicians in real-time can be used to inform ongoing and future clinical trials, and potentially drug labeling,” Ms. Stone said. She reported having no financial disclosures.