Pandemic Public Health

Changes in Medical Practice

 

 “To expand capacity, hospitals have redirected physicians and nurses who were previously dedicated to elective treatments to help care for Covid-19 patients. Similarly, non-clinical staff have been pressed into duty to help with patient triage, and fourth-year medical students have been offered the opportunity to graduate early and join the front lines in unprecedented ways. In addition, as it did with telemedicine, the federal government took steps in late March to ease restrictions on the health care workforce and thereby expand capacity. For example, the government temporarily allowed nurse practitioners, physician assistants, and certified registered nurse anesthetists (CRNAs) to perform additional functions without physician supervision.”

 

Robert S. Huckman
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“[T]he effort to recover some of the tens of billions the industry says it lost from the cancellation of elective surgeries is colliding with a burst of new coronavirus cases in most of the country — and again putting economic recovery in conflict with disease prevention.

Hospitals until now were recession-proof and remain among the biggest employers in some communities. The pandemic brought historic levels of layoffs and furloughs among health care workers; the March jobs report showing the worst loss in health care jobs in at least 30 years.

If the hospitals close back down, it could drive up unemployment and the number of uninsured — as well as prolong delays in needed but non-emergency care. But trying to restore some postponed business could put more stresses on front-line health workers and possibly expose non-Covid patients in wards to the virus.”

Rachel Roubein
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In The Office

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 “Faced with an unprecedented crisis, hospitals have rapidly adapted to restructuring workforces and increasing surge capacity. While the most obvious examples are setting up medical tents and converting other spaces into areas capable of intensive care, staffing restructuring is also apparent.

‘We learned to build pyramids with experienced individuals on top and pulling individuals from multiple backgrounds, often working outside their field of practice to scale up care in response to the crisis. In doing so, we’ve developed the capacity to flex in a way we have never tested before,’ said Dr. Michael Grosso, chief medical officer at Huntington Hospital in Northwell Health in New York.”

Delaram J. Taghipour and Vinayak Kumar
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 “Already, the coronavirus has led to sweeping changes in who can receive care and how they access it. Millions of Americans, newly out of work, are also newly uninsured. Millions more who still have insurance have been forced to delay necessary but noncritical treatments. At the same time, doctors across the country have been granted broad flexibility to treat patients remotely, using telemedicine, instantly reshaping services ranging from routine checkups to addiction treatment.”
 

Lev Facher
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“In a very real sense, the spread of Covid-19 is a product of the digital and technological revolution that has transformed our world over the past century. Unlike the “Spanish flu” of 1918, which became an international epidemic over the course of a year, Covid-19 has spread to every inhabitable continent within weeks, outpacing our health system’s ability to test, track, and contain people with suspected infection. To continue functioning, private companies and institutions of higher education have made an abrupt transition to remote videoconferencing and other digital solutions, while the health care system is still managing this crisis largely through risky brick-and-mortar visits…

With the first emergency Covid-19 authorization, Congress lifted provisions that limited telemedicine services to rural areas, allowing the use of telemedicine services for all beneficiaries of fee-for-service Medicare.4 To enhance the technology infrastructure available to clinicians to support these visits, the Office of Civil Rights (OCR) at the Department of Health and Human Services (HHS) has announced that it is using its enforcement discretion and will not impose penalties for using HIPAA-noncompliant private communications technologies to provide telehealth services during this public health emergency.5 These are important initial responses, but the crisis demands a broader strategy to address three specific areas: reimbursement for new digital services, expanded regulatory relief, and evaluation of clinical care provided by means of these technologies.”

Sirina Keesara, Andrea Jonas, & Kevin Schulman
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Telehealth

Protection, Tests, 
& Treatment

 
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Personal Protective
Equipment

“Shortages of personal protective equipment and medical supplies could persist for years without strategic government intervention, officials from health care and manufacturing industries have predicted…

Although the disarray is not as widespread as it was this spring, hospitals said rolling shortages of supplies range from specialized beds to disposable isolation gowns to thermometers…

For the past two decades, personal protective equipment was supplied to health care institutions in lean supply chains in the same way toilet paper was to grocery stores. Chains between major manufacturers and end users were so efficient, there was no need to stockpile goods.

But in March, the supply chain broke when major Asian PPE exporters embargoed materials or shut down just as demand increased exponentially. Thus, health care institutions were in much the same position as regular grocery shoppers, who were trying to buy great quantities of a product they never needed to stockpile before.”

Jessica Glenza
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“Due to the high demand for PPEs all around the world, it is important to optimize the use of protective gear and ration the supplies so that the demand are met. However, there are guidelines recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) to maintain the supply in the wake of this increased demand of PPE, how the manufacturers should track their supplies, and how the recipients should manage them. Various strategies can be used to increase the re-use of PPEs during the COVID-19 pandemic that has modified the donning and doffing procedure.”

Syed Uzair Mahmood, Faine Crimbly, Sheharyar Khan, Erum Choudry, and Syeda Mehwish
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Testing

“Two kinds of tests are available for COVID-19: (1) viral tests to detect current infections, and (2) antibody tests to identify previous infections. CDC provides an overview of categories of people for SARS-CoV-2 testing with viral tests (i.e., nucleic acid or antigen tests). Viral testing can be used to inform actions necessary to keep SARS-CoV-2 out of the workplace, detect COVID-19 cases quickly, and stop transmission. Testing practices should aim for rapid turnaround times in order to facilitate effective action. Viral testing detects infection at the time the sample is collected; very early infection at the time of sample collection or exposure (e.g., workplace or community) after sample collection can result in undetected infection. Testing at different points in time, also referred to as serial testing, may be more likely to detect acute infection among workers with repeat exposures than testing done at a single point in time.”

Center for Disease Control
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“A key component to managing the Covid-19 pandemic is frequent, rapid, and routine testing of a large number of Americans — including those without symptoms. With public discussion of this issue has come increased scrutiny of the accuracy of Covid-19 tests, especially the rapid point-of-care tests whose results can come back in a matter of minutes.

Yet these discussions rarely explain what test accuracy actually means, and how it should be used in clinical decision-making. Without this understanding, it is impossible to make truly informed decisions about whether and how these rapid point-of-care tests should be used. And the focus on accuracy obscures an important point: even tests that aren’t perfect can play important roles in controlling this pandemic.”

Jeffrey L. Schnipper and Paul E. Sax
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“In the past month, the number of tests conducted in the United States has actually drifted down—and that may be partly because of Trump-administration policy.

The United States now reports about 100,000 fewer daily tests than it did in late July, according to the COVID Tracking Project at The Atlantic. Some of this decline is due to reduced demand: The surge of infections across the South and West has subsided, and when fewer people are sick, fewer people seek out tests. Yet this cannot explain all of it. In the Midwest, the number of confirmed cases is growing faster than the number of tests, which has been a sign of a growing outbreak throughout the pandemic.

The decline in reported tests has come just as other changes have hit the testing system. In recent weeks, the Trump administration has taken unprecedented steps to interfere with guidance from the Centers for Disease Control and Prevention...At the same time, new antigen-testing technology is rolling out nationwide. While quicker tests in greater numbers should help curb the virus, they are also decentralizing data collection.”

Alexis C. Madrigal and Robinson Meyer

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Treatment

“Ventilators have become the single most important piece of medical equipment for critically ill coronavirus patients whose damaged lungs prevent them from getting enough oxygen to vital organs. The machines work by forcing air deep into the lungs, dislodging the fluid and accumulated pus that interfere with the exchange of oxygen, a process orchestrated by tiny air sacs known as alveoli…

Ventilators are not a cure for Covid-19 patients, but mechanical breathing assistance can keep patients alive while they battle the infection.”

Mika Gröndahl, Andrew Jacobs & Larry Buchanan
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“Current estimates of the number of ventilators in the United States range from 60,000 to 160,000, depending on whether those that have only partial functionality are included.2 The national strategic reserve of ventilators is small and far from sufficient for the projected gap.2 No matter which estimate we use, there are not enough ventilators for patients with Covid-19 in the upcoming months.”

Megan L. Ranney, Valerie Griffeth, & Ashish K. Jha
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Heath care & Impact Disparities

 

“But the Covid-19 pandemic has exposed a truth we can no longer ignore. It’s clearer than ever before that our health — indeed, our survival as a species — depends on the health of the most vulnerable among us.”

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“The COVID-19 pandemic will exacerbate the financial situations of the millions of Americans who struggle to afford their medical care. Driven in part by rising health plan deductibles, 1 in 3 Americans reported not receiving medical care due to cost in 2019.1 This number is even higher for those who are financially insecure or chronically ill.”

Mark Fendrick & Beth Shrosbree
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 “As figures emerge about the disproportionate toll that COVID-19 is taking on people of colour in the United States, scientists are suggesting measures to help mitigate the inequalities…

Many of the causes for these health disparities are systemic and well known. “We’re getting infected more because we are exposed more and less protected,” says Camara Phyllis Jones, an epidemiologist at the Rollins School of Public Health at Emory University in Atlanta, Georgia. Existing socio-economic and health disparities — caused by historical segregation and endemic racism in the United States — can at least partially explain why people of colour are getting sick and dying at disproportionate rates.”

Nidhi Subbaraman
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“The worsening coronavirus epidemic in the U.S. has upended the country’s medical system. It has led to system-wide disruptions that physicians say are necessary for combatting the immediate, un-ignorable threat of COVID-19—but that may, by default, force patients who do not have coronavirus to shoulder a heavy burden. Those with chronic conditions will have to fight harder to get the care they need, not only now but also after the outbreak ends, when hospitals are left to deal with backlogs from appointments canceled en masse. Anyone with the misfortune to get into a car accident or have a heart attack during the outbreak will be at the mercy of a strained system. And in this environment, the gulf between people who can and cannot afford to spend the time and money to seek out good care will become ever-more apparent…

Research has shown that the richest 1% of Americans can expect to live more than a decade longer than the poorest 1%—and that’s without a pandemic in the mix. COVID-19 has drawn a clear line between people with white-collar jobs that allow them to follow public-health advice and work from home, and those in service-focused jobs who must be physically present—thereby risking infection—to collect a paycheck. The country’s most vulnerable populations, such as those who are homeless or living below the poverty line, are the least able to stock up on groceries, prescription medication and other supplies and hunker down inside; they’re also less likely to own a car, or otherwise have the means to safely travel to a doctor’s office if needed.

The class-based health care gap is likely only to widen, Sathya says. “As the unemployment rate rises because of this, people are going to have less and less access to health insurance,” he says. If health care is in high demand and short supply, wealth, and access to pricey private doctors, will play an increasingly ugly role in who gets it.”

Jamie Ducharme
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