COVID-19 Updates

Hospitalized COVID-19 patients with hypertension and on treatment with an renin-angiotensin system inhibiting drug had significantly better survival, compared with similar hypertensive patients not on these drugs, in observational, propensity score–matched analyses that drew from a pool of more than 3,430 patients hospitalized at any of nine Chinese hospitals during December 2019–February 2020.

Courtesy CDC

“Among patients with hypertension hospitalized with COVID-19, inpatient treatment with ACEI [ACE inhibitor]/ARB [angiotensin receptor blocker] was associated with lower risk of all-cause mortality, compared with ACEI/ARB nonusers, during 28 days of follow-up. While study interpretation needs to consider the potential for residual confounders, it is unlikely that inpatient ACEI/ARB would be associated with an increased risk of mortality,” wrote Peng Zhang, MD, a cardiology researcher at Renmin Hospital of Wuhan University, China, and coauthors in Circulations Research, buttressing recent recommendations from several medical societies to maintain COVID-19 patients on these drugs.

“Our findings in this paper provide evidence supporting continuous use of ACEI/ARB for patients with hypertension infected with SARS-COV-2,” wrote the authors, backing up recent recommendations from cardiology societies that called for not stopping ACEI/ARB prescriptions in patients at risk for contracting or already have COVID-19 infection, including a statement from the American College of Cardiology, American Heart Association, and Heart Failure Society of America, and also guidance from the European Society of Cardiology.

The study included 1,128 patients with a history of hypertension, including 188 (17%) who received an ACEI/ARB drug during hospitalization. During 28-day follow-up, 99 died (9%), including 7 deaths among the 188 patients (4%) on an ACEI/ARB drug and 92 deaths among the 940 other hypertensive patients (10%).

The authors ran several analyses to try to adjust for the influence of possible confounders. A mixed-effect Cox model with four adjusted variables showed that treatment with an ACEI/ARB drug was tied to a statistically significant 58% lower death rate, compared with patients not receiving these drugs.

The researchers also ran several propensity score–adjusted analyses. One matched 174 of the patients who received an ACEI/ARB drug with 522 who did not, and comparing these two matched arms showed that ACEI/ARB use was linked with a statistically significant 63% cut in mortality, compared with patients not getting these drugs. A second propensity score–matched analysis first excluded the 383 patients who were hypertensive but received no antihypertensive medication during hospitalization. From the remaining 745 patients who received at least one antihypertensive medication, the authors identified 181 patients who received an ACEI/ARB and propensity-score matched them with 181 hypertensive patients on a different medication class, finding that ACEI/ARB use linked with a statistically significant 71% lower rate of all-cause mortality.

Additional analyses also showed that patients with hypertension had a statistically significant, 41% increased rate of all-cause death, compared with patients without hypertension, and another propensity score–matched analysis showed that among hypertensives treatment with an ACEI/ARB drug was linked with a statistically significant 68% reduced rate of septic shock.

Although this report was received with caution and some skepticism, it was also acknowledged as a step forward in the creation of an evidence base addressing ACEI/ARB treatment during COVID-19 infection.

“These drugs are lifesaving and should not be discontinued” for patients with hypertension, heart failure, and other cardiovascular disease, commented Gian Paolo Rossi, MD, professor and chair of medicine and director of the high blood pressure unit at the University of Padua (Italy). The analysis by Zhang and associates included the largest number of hospitalized COVID-19 patients with hypertension yet reported to assess the impact of treatment with ACEI/ARB drugs, and adds important evidence in favor of continuing these drugs in patients who develop COVID-19 infection, Dr. Rossi said in an interview. He recently coauthored a review that argued against ACEI/ARB discontinuation in COVID-19 patients based on previously reported evidence (Elife. 2020 Apr 6. doi: 10.7554/eLife.57278).

But other researchers take a wary view of the potential impact of ACEI/ARB agents. “If ACEI/ARB therapy increases ACE2 and the virus down-regulates it, and because ACE2 is the viral entry port into cells, why would ACE2-mediated down-regulation of the renin-angiotensin-aldosterone system lead to amelioration of [COVID-19] disease?” asked Laurence W. Busse, MD, a critical care physician at Emory University, Atlanta. “A number of issues could potentially confound the results, including the definition of COVID-19 and imbalance of antiviral therapy,” added Dr. Busse, who recently coauthored an editorial that posited using angiotensin II (Giapreza), an approved vasopressor drug, as an alternative renin-angiotensin system intervention for COVID-19 patients including both those in shock as well as potentially those not in shock (Crit Care. 2020 Apr 7. doi: 10.1186/s13054-020-02862-1). Despite these caveats, the new Chinese findings reported by Dr. Zhang and associates “are hypothesis generating and worth further exploration.”

The authors of an editorial that accompanied the Zhang study in Circulation Research made similar points. “While the investigators used standard techniques to attempt to reduce bias in this observational study via propensity matching, it is not a randomized study and the residual confounding inherent to this approach renders the conclusions hypothesis generating at best,” wrote Ravi V. Shah, MD, and two coauthors in the editorial (Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317174). They also agreed with the several society statements that have supported continued use of ACEI/ARB drugs in COVID-19 patients. “Withdrawal of these medications in the context of those conditions in which they have proven benefit (e.g., heart failure with reduced left ventricular ejection fraction) may actually inflict more harm than good,” they warned. “In the end we must rely on randomized clinical science,” and while this level of evidence is currently lacking, “the study by Zhang and colleagues is a direct step toward that goal.”

Dr. Zhang and coauthors had no commercial disclosures. Dr. Rossi and Dr. Busse had no disclosures. The authors of the Circulation Research editorial reported several disclosures.

mzoler@mdedge.com

SOURCE: Zhang P et al. Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317134.

Hospitalized COVID-19 patients with hypertension and on treatment with an renin-angiotensin system inhibiting drug had significantly better survival, compared with similar hypertensive patients not on these drugs, in observational, propensity score–matched analyses that drew from a pool of more than 3,430 patients hospitalized at any of nine Chinese hospitals during December 2019–February 2020.

Courtesy CDC

“Among patients with hypertension hospitalized with COVID-19, inpatient treatment with ACEI [ACE inhibitor]/ARB [angiotensin receptor blocker] was associated with lower risk of all-cause mortality, compared with ACEI/ARB nonusers, during 28 days of follow-up. While study interpretation needs to consider the potential for residual confounders, it is unlikely that inpatient ACEI/ARB would be associated with an increased risk of mortality,” wrote Peng Zhang, MD, a cardiology researcher at Renmin Hospital of Wuhan University, China, and coauthors in Circulations Research, buttressing recent recommendations from several medical societies to maintain COVID-19 patients on these drugs.

“Our findings in this paper provide evidence supporting continuous use of ACEI/ARB for patients with hypertension infected with SARS-COV-2,” wrote the authors, backing up recent recommendations from cardiology societies that called for not stopping ACEI/ARB prescriptions in patients at risk for contracting or already have COVID-19 infection, including a statement from the American College of Cardiology, American Heart Association, and Heart Failure Society of America, and also guidance from the European Society of Cardiology.

The study included 1,128 patients with a history of hypertension, including 188 (17%) who received an ACEI/ARB drug during hospitalization. During 28-day follow-up, 99 died (9%), including 7 deaths among the 188 patients (4%) on an ACEI/ARB drug and 92 deaths among the 940 other hypertensive patients (10%).

The authors ran several analyses to try to adjust for the influence of possible confounders. A mixed-effect Cox model with four adjusted variables showed that treatment with an ACEI/ARB drug was tied to a statistically significant 58% lower death rate, compared with patients not receiving these drugs.

The researchers also ran several propensity score–adjusted analyses. One matched 174 of the patients who received an ACEI/ARB drug with 522 who did not, and comparing these two matched arms showed that ACEI/ARB use was linked with a statistically significant 63% cut in mortality, compared with patients not getting these drugs. A second propensity score–matched analysis first excluded the 383 patients who were hypertensive but received no antihypertensive medication during hospitalization. From the remaining 745 patients who received at least one antihypertensive medication, the authors identified 181 patients who received an ACEI/ARB and propensity-score matched them with 181 hypertensive patients on a different medication class, finding that ACEI/ARB use linked with a statistically significant 71% lower rate of all-cause mortality.

Additional analyses also showed that patients with hypertension had a statistically significant, 41% increased rate of all-cause death, compared with patients without hypertension, and another propensity score–matched analysis showed that among hypertensives treatment with an ACEI/ARB drug was linked with a statistically significant 68% reduced rate of septic shock.

Although this report was received with caution and some skepticism, it was also acknowledged as a step forward in the creation of an evidence base addressing ACEI/ARB treatment during COVID-19 infection.

“These drugs are lifesaving and should not be discontinued” for patients with hypertension, heart failure, and other cardiovascular disease, commented Gian Paolo Rossi, MD, professor and chair of medicine and director of the high blood pressure unit at the University of Padua (Italy). The analysis by Zhang and associates included the largest number of hospitalized COVID-19 patients with hypertension yet reported to assess the impact of treatment with ACEI/ARB drugs, and adds important evidence in favor of continuing these drugs in patients who develop COVID-19 infection, Dr. Rossi said in an interview. He recently coauthored a review that argued against ACEI/ARB discontinuation in COVID-19 patients based on previously reported evidence (Elife. 2020 Apr 6. doi: 10.7554/eLife.57278).

But other researchers take a wary view of the potential impact of ACEI/ARB agents. “If ACEI/ARB therapy increases ACE2 and the virus down-regulates it, and because ACE2 is the viral entry port into cells, why would ACE2-mediated down-regulation of the renin-angiotensin-aldosterone system lead to amelioration of [COVID-19] disease?” asked Laurence W. Busse, MD, a critical care physician at Emory University, Atlanta. “A number of issues could potentially confound the results, including the definition of COVID-19 and imbalance of antiviral therapy,” added Dr. Busse, who recently coauthored an editorial that posited using angiotensin II (Giapreza), an approved vasopressor drug, as an alternative renin-angiotensin system intervention for COVID-19 patients including both those in shock as well as potentially those not in shock (Crit Care. 2020 Apr 7. doi: 10.1186/s13054-020-02862-1). Despite these caveats, the new Chinese findings reported by Dr. Zhang and associates “are hypothesis generating and worth further exploration.”

The authors of an editorial that accompanied the Zhang study in Circulation Research made similar points. “While the investigators used standard techniques to attempt to reduce bias in this observational study via propensity matching, it is not a randomized study and the residual confounding inherent to this approach renders the conclusions hypothesis generating at best,” wrote Ravi V. Shah, MD, and two coauthors in the editorial (Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317174). They also agreed with the several society statements that have supported continued use of ACEI/ARB drugs in COVID-19 patients. “Withdrawal of these medications in the context of those conditions in which they have proven benefit (e.g., heart failure with reduced left ventricular ejection fraction) may actually inflict more harm than good,” they warned. “In the end we must rely on randomized clinical science,” and while this level of evidence is currently lacking, “the study by Zhang and colleagues is a direct step toward that goal.”

Dr. Zhang and coauthors had no commercial disclosures. Dr. Rossi and Dr. Busse had no disclosures. The authors of the Circulation Research editorial reported several disclosures.

mzoler@mdedge.com

SOURCE: Zhang P et al. Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317134.

Hospitalized COVID-19 patients with hypertension and on treatment with an renin-angiotensin system inhibiting drug had significantly better survival, compared with similar hypertensive patients not on these drugs, in observational, propensity score–matched analyses that drew from a pool of more than 3,430 patients hospitalized at any of nine Chinese hospitals during December 2019–February 2020.

Courtesy CDC

“Among patients with hypertension hospitalized with COVID-19, inpatient treatment with ACEI [ACE inhibitor]/ARB [angiotensin receptor blocker] was associated with lower risk of all-cause mortality, compared with ACEI/ARB nonusers, during 28 days of follow-up. While study interpretation needs to consider the potential for residual confounders, it is unlikely that inpatient ACEI/ARB would be associated with an increased risk of mortality,” wrote Peng Zhang, MD, a cardiology researcher at Renmin Hospital of Wuhan University, China, and coauthors in Circulations Research, buttressing recent recommendations from several medical societies to maintain COVID-19 patients on these drugs.

“Our findings in this paper provide evidence supporting continuous use of ACEI/ARB for patients with hypertension infected with SARS-COV-2,” wrote the authors, backing up recent recommendations from cardiology societies that called for not stopping ACEI/ARB prescriptions in patients at risk for contracting or already have COVID-19 infection, including a statement from the American College of Cardiology, American Heart Association, and Heart Failure Society of America, and also guidance from the European Society of Cardiology.

The study included 1,128 patients with a history of hypertension, including 188 (17%) who received an ACEI/ARB drug during hospitalization. During 28-day follow-up, 99 died (9%), including 7 deaths among the 188 patients (4%) on an ACEI/ARB drug and 92 deaths among the 940 other hypertensive patients (10%).

The authors ran several analyses to try to adjust for the influence of possible confounders. A mixed-effect Cox model with four adjusted variables showed that treatment with an ACEI/ARB drug was tied to a statistically significant 58% lower death rate, compared with patients not receiving these drugs.

The researchers also ran several propensity score–adjusted analyses. One matched 174 of the patients who received an ACEI/ARB drug with 522 who did not, and comparing these two matched arms showed that ACEI/ARB use was linked with a statistically significant 63% cut in mortality, compared with patients not getting these drugs. A second propensity score–matched analysis first excluded the 383 patients who were hypertensive but received no antihypertensive medication during hospitalization. From the remaining 745 patients who received at least one antihypertensive medication, the authors identified 181 patients who received an ACEI/ARB and propensity-score matched them with 181 hypertensive patients on a different medication class, finding that ACEI/ARB use linked with a statistically significant 71% lower rate of all-cause mortality.

Additional analyses also showed that patients with hypertension had a statistically significant, 41% increased rate of all-cause death, compared with patients without hypertension, and another propensity score–matched analysis showed that among hypertensives treatment with an ACEI/ARB drug was linked with a statistically significant 68% reduced rate of septic shock.

Although this report was received with caution and some skepticism, it was also acknowledged as a step forward in the creation of an evidence base addressing ACEI/ARB treatment during COVID-19 infection.

“These drugs are lifesaving and should not be discontinued” for patients with hypertension, heart failure, and other cardiovascular disease, commented Gian Paolo Rossi, MD, professor and chair of medicine and director of the high blood pressure unit at the University of Padua (Italy). The analysis by Zhang and associates included the largest number of hospitalized COVID-19 patients with hypertension yet reported to assess the impact of treatment with ACEI/ARB drugs, and adds important evidence in favor of continuing these drugs in patients who develop COVID-19 infection, Dr. Rossi said in an interview. He recently coauthored a review that argued against ACEI/ARB discontinuation in COVID-19 patients based on previously reported evidence (Elife. 2020 Apr 6. doi: 10.7554/eLife.57278).

But other researchers take a wary view of the potential impact of ACEI/ARB agents. “If ACEI/ARB therapy increases ACE2 and the virus down-regulates it, and because ACE2 is the viral entry port into cells, why would ACE2-mediated down-regulation of the renin-angiotensin-aldosterone system lead to amelioration of [COVID-19] disease?” asked Laurence W. Busse, MD, a critical care physician at Emory University, Atlanta. “A number of issues could potentially confound the results, including the definition of COVID-19 and imbalance of antiviral therapy,” added Dr. Busse, who recently coauthored an editorial that posited using angiotensin II (Giapreza), an approved vasopressor drug, as an alternative renin-angiotensin system intervention for COVID-19 patients including both those in shock as well as potentially those not in shock (Crit Care. 2020 Apr 7. doi: 10.1186/s13054-020-02862-1). Despite these caveats, the new Chinese findings reported by Dr. Zhang and associates “are hypothesis generating and worth further exploration.”

The authors of an editorial that accompanied the Zhang study in Circulation Research made similar points. “While the investigators used standard techniques to attempt to reduce bias in this observational study via propensity matching, it is not a randomized study and the residual confounding inherent to this approach renders the conclusions hypothesis generating at best,” wrote Ravi V. Shah, MD, and two coauthors in the editorial (Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317174). They also agreed with the several society statements that have supported continued use of ACEI/ARB drugs in COVID-19 patients. “Withdrawal of these medications in the context of those conditions in which they have proven benefit (e.g., heart failure with reduced left ventricular ejection fraction) may actually inflict more harm than good,” they warned. “In the end we must rely on randomized clinical science,” and while this level of evidence is currently lacking, “the study by Zhang and colleagues is a direct step toward that goal.”

Dr. Zhang and coauthors had no commercial disclosures. Dr. Rossi and Dr. Busse had no disclosures. The authors of the Circulation Research editorial reported several disclosures.

mzoler@mdedge.com

SOURCE: Zhang P et al. Circ Res. 2020 Apr 17. doi: 10.1161/CIRCRESAHA.120.317134.

Lung cancer patients should be prioritized for COVID-19 testing, according to an editorial published in Annals of Oncology.

In fact, treatment recommendations should call for baseline COVID-19 testing for all patients with lung cancer, Antonio Passaro, MD, PhD, of the European Institute of Oncology in Milan, Italy, and colleagues argued in the editorial.

“While all types of malignancies seem to be associated with high COVID-19 prevalence, morbidity, and mortality, lung cancer represents a specific scenario of cumulative risk factors for COVID-19 complications,” the authors wrote.

“[Lung cancer patients] are at a uniquely escalated risk of complications from COVID-19 due to the common features of smoking history, respiratory and cardiac disease, advanced age, and often predisposing risks from treatment, such as lung surgery and immunosuppressive chemotherapy,” said Howard (Jack) West, MD, of City of Hope Comprehensive Cancer Center in Duarte, Calif., who was not involved in the editorial.

“They also routinely experience a cough as well as chest imaging that may overlap between their underlying lung cancer, possible side effects of treatment, and potential COVID-19, leading to troubling ambiguity that can only be addressed by proactive and widespread testing of patients with lung cancer at the earliest opportunity and as a very high priority,” Dr. West added.

Dr. Passaro and colleagues’ editorial outlined these and other issues that suggest a need to prioritize testing in lung cancer patients.

Disease characteristics, treatment, and imaging

Lung cancer patients may have “defective pulmonary architecture,” such as mechanical obstruction from a tumor or previous lung surgery, that predisposes them to infection and can increase the risk of cytokine release. This is a concern because massive cytokine release during SARS-CoV-2 infection “has been postulated to be the major step in leading to the development of ARDS [acute respiratory distress syndrome],” Dr. Passaro and colleagues wrote.

The authors also argued that similar clinical symptoms among lung cancer patients and those with COVID-19 – such as cough, fever, and dyspnea – underscore the need for an accurate screening model to allow for early COVID-19 detection and potentially improve outcomes.

Similarly, lung cancer patients and COVID-19 patients may have overlapping findings on imaging. The radiologic effects of some common treatments for lung cancer can lead to the same kind of ground glass opacities and other findings seen in COVID-19 patients. Therefore, the authors predict an increase in “COVID-19-suspicious imaging, even in the absence of new symptoms” in the coming weeks.

Another issue to consider is the frequent use of corticosteroids in cancer patients. Corticosteroids may be harmful when used for COVID-19–related acute respiratory distress syndrome and could mask early symptoms of infection. Therefore, routine COVID-19 testing in patients receiving steroids may be warranted, according to Dr. Passaro and colleagues.

In addition, immunosuppression associated with cancer treatment “may impose specific consideration on the schedule and dose of cytotoxic chemotherapy for lung cancer patients in epidemic areas,” the authors wrote.

Increasing awareness: A registry and guidelines

“In the era of COVID-19, the optimal management of patients with lung cancer remains unknown, and the oncology community should have increased awareness to prevent the emergence of an increase in cancer-related and infectious mortality,” Dr. Passaro and colleagues wrote.

To that end, a novel global registry (TERAVOLT) has been launched and is collecting data worldwide with an aim of developing a tailored risk assessment strategy for lung cancer patients. The authors noted that developing international consensus with respect to COVID-19 testing in lung cancer is essential for achieving that goal.

The European Society for Medical Oncology recently released guidelines for treating lung cancer patients during the COVID-19 pandemic, but those guidelines do not include recommendations on COVID-19 testing.

“Baseline SARS-CoV-2 testing for all patients affected by lung cancer should be recommended,” Dr. Passaro and colleagues wrote. “In addition, for those patients with a negative swab test and new ground glass opacities detected on CT scan, with or without new respiratory symptoms, bronchoscopy should be considered to increase testing sensitivity.”

This work was partially supported by the Italian Ministry of Health. The authors reported having no relevant conflicts of interest. Dr. West is a regular correspondent for Medscape, which is owned by the same parent company as MDedge.

sworcester@mdedge.com

SOURCE: Passaro A et al. Annals of Oncology. doi: 10.1016/j.annonc.2020.04.002.

Lung cancer patients should be prioritized for COVID-19 testing, according to an editorial published in Annals of Oncology.

In fact, treatment recommendations should call for baseline COVID-19 testing for all patients with lung cancer, Antonio Passaro, MD, PhD, of the European Institute of Oncology in Milan, Italy, and colleagues argued in the editorial.

“While all types of malignancies seem to be associated with high COVID-19 prevalence, morbidity, and mortality, lung cancer represents a specific scenario of cumulative risk factors for COVID-19 complications,” the authors wrote.

“[Lung cancer patients] are at a uniquely escalated risk of complications from COVID-19 due to the common features of smoking history, respiratory and cardiac disease, advanced age, and often predisposing risks from treatment, such as lung surgery and immunosuppressive chemotherapy,” said Howard (Jack) West, MD, of City of Hope Comprehensive Cancer Center in Duarte, Calif., who was not involved in the editorial.

“They also routinely experience a cough as well as chest imaging that may overlap between their underlying lung cancer, possible side effects of treatment, and potential COVID-19, leading to troubling ambiguity that can only be addressed by proactive and widespread testing of patients with lung cancer at the earliest opportunity and as a very high priority,” Dr. West added.

Dr. Passaro and colleagues’ editorial outlined these and other issues that suggest a need to prioritize testing in lung cancer patients.

Disease characteristics, treatment, and imaging

Lung cancer patients may have “defective pulmonary architecture,” such as mechanical obstruction from a tumor or previous lung surgery, that predisposes them to infection and can increase the risk of cytokine release. This is a concern because massive cytokine release during SARS-CoV-2 infection “has been postulated to be the major step in leading to the development of ARDS [acute respiratory distress syndrome],” Dr. Passaro and colleagues wrote.

The authors also argued that similar clinical symptoms among lung cancer patients and those with COVID-19 – such as cough, fever, and dyspnea – underscore the need for an accurate screening model to allow for early COVID-19 detection and potentially improve outcomes.

Similarly, lung cancer patients and COVID-19 patients may have overlapping findings on imaging. The radiologic effects of some common treatments for lung cancer can lead to the same kind of ground glass opacities and other findings seen in COVID-19 patients. Therefore, the authors predict an increase in “COVID-19-suspicious imaging, even in the absence of new symptoms” in the coming weeks.

Another issue to consider is the frequent use of corticosteroids in cancer patients. Corticosteroids may be harmful when used for COVID-19–related acute respiratory distress syndrome and could mask early symptoms of infection. Therefore, routine COVID-19 testing in patients receiving steroids may be warranted, according to Dr. Passaro and colleagues.

In addition, immunosuppression associated with cancer treatment “may impose specific consideration on the schedule and dose of cytotoxic chemotherapy for lung cancer patients in epidemic areas,” the authors wrote.

Increasing awareness: A registry and guidelines

“In the era of COVID-19, the optimal management of patients with lung cancer remains unknown, and the oncology community should have increased awareness to prevent the emergence of an increase in cancer-related and infectious mortality,” Dr. Passaro and colleagues wrote.

To that end, a novel global registry (TERAVOLT) has been launched and is collecting data worldwide with an aim of developing a tailored risk assessment strategy for lung cancer patients. The authors noted that developing international consensus with respect to COVID-19 testing in lung cancer is essential for achieving that goal.

The European Society for Medical Oncology recently released guidelines for treating lung cancer patients during the COVID-19 pandemic, but those guidelines do not include recommendations on COVID-19 testing.

“Baseline SARS-CoV-2 testing for all patients affected by lung cancer should be recommended,” Dr. Passaro and colleagues wrote. “In addition, for those patients with a negative swab test and new ground glass opacities detected on CT scan, with or without new respiratory symptoms, bronchoscopy should be considered to increase testing sensitivity.”

This work was partially supported by the Italian Ministry of Health. The authors reported having no relevant conflicts of interest. Dr. West is a regular correspondent for Medscape, which is owned by the same parent company as MDedge.

sworcester@mdedge.com

SOURCE: Passaro A et al. Annals of Oncology. doi: 10.1016/j.annonc.2020.04.002.

Lung cancer patients should be prioritized for COVID-19 testing, according to an editorial published in Annals of Oncology.

In fact, treatment recommendations should call for baseline COVID-19 testing for all patients with lung cancer, Antonio Passaro, MD, PhD, of the European Institute of Oncology in Milan, Italy, and colleagues argued in the editorial.

“While all types of malignancies seem to be associated with high COVID-19 prevalence, morbidity, and mortality, lung cancer represents a specific scenario of cumulative risk factors for COVID-19 complications,” the authors wrote.

“[Lung cancer patients] are at a uniquely escalated risk of complications from COVID-19 due to the common features of smoking history, respiratory and cardiac disease, advanced age, and often predisposing risks from treatment, such as lung surgery and immunosuppressive chemotherapy,” said Howard (Jack) West, MD, of City of Hope Comprehensive Cancer Center in Duarte, Calif., who was not involved in the editorial.

“They also routinely experience a cough as well as chest imaging that may overlap between their underlying lung cancer, possible side effects of treatment, and potential COVID-19, leading to troubling ambiguity that can only be addressed by proactive and widespread testing of patients with lung cancer at the earliest opportunity and as a very high priority,” Dr. West added.

Dr. Passaro and colleagues’ editorial outlined these and other issues that suggest a need to prioritize testing in lung cancer patients.

Disease characteristics, treatment, and imaging

Lung cancer patients may have “defective pulmonary architecture,” such as mechanical obstruction from a tumor or previous lung surgery, that predisposes them to infection and can increase the risk of cytokine release. This is a concern because massive cytokine release during SARS-CoV-2 infection “has been postulated to be the major step in leading to the development of ARDS [acute respiratory distress syndrome],” Dr. Passaro and colleagues wrote.

The authors also argued that similar clinical symptoms among lung cancer patients and those with COVID-19 – such as cough, fever, and dyspnea – underscore the need for an accurate screening model to allow for early COVID-19 detection and potentially improve outcomes.

Similarly, lung cancer patients and COVID-19 patients may have overlapping findings on imaging. The radiologic effects of some common treatments for lung cancer can lead to the same kind of ground glass opacities and other findings seen in COVID-19 patients. Therefore, the authors predict an increase in “COVID-19-suspicious imaging, even in the absence of new symptoms” in the coming weeks.

Another issue to consider is the frequent use of corticosteroids in cancer patients. Corticosteroids may be harmful when used for COVID-19–related acute respiratory distress syndrome and could mask early symptoms of infection. Therefore, routine COVID-19 testing in patients receiving steroids may be warranted, according to Dr. Passaro and colleagues.

In addition, immunosuppression associated with cancer treatment “may impose specific consideration on the schedule and dose of cytotoxic chemotherapy for lung cancer patients in epidemic areas,” the authors wrote.

Increasing awareness: A registry and guidelines

“In the era of COVID-19, the optimal management of patients with lung cancer remains unknown, and the oncology community should have increased awareness to prevent the emergence of an increase in cancer-related and infectious mortality,” Dr. Passaro and colleagues wrote.

To that end, a novel global registry (TERAVOLT) has been launched and is collecting data worldwide with an aim of developing a tailored risk assessment strategy for lung cancer patients. The authors noted that developing international consensus with respect to COVID-19 testing in lung cancer is essential for achieving that goal.

The European Society for Medical Oncology recently released guidelines for treating lung cancer patients during the COVID-19 pandemic, but those guidelines do not include recommendations on COVID-19 testing.

“Baseline SARS-CoV-2 testing for all patients affected by lung cancer should be recommended,” Dr. Passaro and colleagues wrote. “In addition, for those patients with a negative swab test and new ground glass opacities detected on CT scan, with or without new respiratory symptoms, bronchoscopy should be considered to increase testing sensitivity.”

This work was partially supported by the Italian Ministry of Health. The authors reported having no relevant conflicts of interest. Dr. West is a regular correspondent for Medscape, which is owned by the same parent company as MDedge.

sworcester@mdedge.com

SOURCE: Passaro A et al. Annals of Oncology. doi: 10.1016/j.annonc.2020.04.002.

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com. He has no disclosures.

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com. He has no disclosures.

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com. He has no disclosures.

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

sworcester@mdedge.com

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

sworcester@mdedge.com

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

sworcester@mdedge.com

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.

As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.

karandaev/iStock/Getty Images

No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.

Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here. That trying period in your life forged the strength, courage, which serves you today. It also made you more compassionate. Here lies the biggest take-away for COVID survival.

Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.

Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!

This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.


“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.

karandaev/iStock/Getty Images

No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.

Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here. That trying period in your life forged the strength, courage, which serves you today. It also made you more compassionate. Here lies the biggest take-away for COVID survival.

Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.

Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!

This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.


“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.

karandaev/iStock/Getty Images

No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.

Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here. That trying period in your life forged the strength, courage, which serves you today. It also made you more compassionate. Here lies the biggest take-away for COVID survival.

Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.

Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!

This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.


“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

The Food and Drug Administration has authorized the first diagnostic test with a home collection option for COVID-19, a reissue of the emergency use authorization allowing for testing of samples self-collected by patients at home with the Pixel by LabCorp COVID-19 RT-PCR Test.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The reissued authorization allows for testing of a sample taken from the nose by way of a self-collection kit that contains nasal swabs and saline, according to the FDA press release. After self-swabbing, users should send the samples in an insulated package to a LabCorp laboratory for testing. LabCorp intends to make the Pixel test available to consumers in most states, accessible through doctors’ orders.

The Pixel test includes a specific Q-tip–style cotton swab for patients to use to collect their samples, the FDA noted. Because of concerns with sterility and cross-reactivity caused by inherent genetic material in cotton swabs, generic cotton swabs should not be used as a substitute. The FDA will work with test developers to determine if generic cotton swabs can be used safely and effectively with other tests.

“Throughout this pandemic we have been facilitating test development to ensure patients’ access to accurate diagnostics, which includes supporting the development of reliable and accurate at-home sample collection options. ... [The FDA] worked with LabCorp to ensure the data demonstrated from at-home patient sample collection is as safe and accurate as sample collection at a doctor’s office, hospital, or other testing site. With this action, there is now a convenient and reliable option for patient sample collection from the comfort and safety of their home,” FDA Commissioner Stephen M. Hahn, MD, said in the press release.

lfranki@mdedge.com

The Food and Drug Administration has authorized the first diagnostic test with a home collection option for COVID-19, a reissue of the emergency use authorization allowing for testing of samples self-collected by patients at home with the Pixel by LabCorp COVID-19 RT-PCR Test.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The reissued authorization allows for testing of a sample taken from the nose by way of a self-collection kit that contains nasal swabs and saline, according to the FDA press release. After self-swabbing, users should send the samples in an insulated package to a LabCorp laboratory for testing. LabCorp intends to make the Pixel test available to consumers in most states, accessible through doctors’ orders.

The Pixel test includes a specific Q-tip–style cotton swab for patients to use to collect their samples, the FDA noted. Because of concerns with sterility and cross-reactivity caused by inherent genetic material in cotton swabs, generic cotton swabs should not be used as a substitute. The FDA will work with test developers to determine if generic cotton swabs can be used safely and effectively with other tests.

“Throughout this pandemic we have been facilitating test development to ensure patients’ access to accurate diagnostics, which includes supporting the development of reliable and accurate at-home sample collection options. ... [The FDA] worked with LabCorp to ensure the data demonstrated from at-home patient sample collection is as safe and accurate as sample collection at a doctor’s office, hospital, or other testing site. With this action, there is now a convenient and reliable option for patient sample collection from the comfort and safety of their home,” FDA Commissioner Stephen M. Hahn, MD, said in the press release.

lfranki@mdedge.com

The Food and Drug Administration has authorized the first diagnostic test with a home collection option for COVID-19, a reissue of the emergency use authorization allowing for testing of samples self-collected by patients at home with the Pixel by LabCorp COVID-19 RT-PCR Test.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The reissued authorization allows for testing of a sample taken from the nose by way of a self-collection kit that contains nasal swabs and saline, according to the FDA press release. After self-swabbing, users should send the samples in an insulated package to a LabCorp laboratory for testing. LabCorp intends to make the Pixel test available to consumers in most states, accessible through doctors’ orders.

The Pixel test includes a specific Q-tip–style cotton swab for patients to use to collect their samples, the FDA noted. Because of concerns with sterility and cross-reactivity caused by inherent genetic material in cotton swabs, generic cotton swabs should not be used as a substitute. The FDA will work with test developers to determine if generic cotton swabs can be used safely and effectively with other tests.

“Throughout this pandemic we have been facilitating test development to ensure patients’ access to accurate diagnostics, which includes supporting the development of reliable and accurate at-home sample collection options. ... [The FDA] worked with LabCorp to ensure the data demonstrated from at-home patient sample collection is as safe and accurate as sample collection at a doctor’s office, hospital, or other testing site. With this action, there is now a convenient and reliable option for patient sample collection from the comfort and safety of their home,” FDA Commissioner Stephen M. Hahn, MD, said in the press release.

lfranki@mdedge.com

With health care systems becoming increasingly stretched as the COVID-19 pandemic sweeps the globe, the European Society for Medical Oncology (ESMO) has produced practical recommendations for prioritizing the management of cancer patients, including those with gynecologic cancers.

ESMO’s guidelines for cervical, endometrial, and epithelial ovarian cancer delineate which patients should be prioritized for treatment in the face of reduced resources and despite the risk of SARS-CoV-2 infection.

“Many European countries have already sorted their own guidelines, either nationally or through their own societies,” said Jonathan Ledermann, MD, a professor of medical oncology at the University College London Cancer Institute who was involved in developing ESMO’s recommendations for gynecologic cancers.

Dr. Ledermann noted that the British Gynaecological Cancer Society, for example, has published guidance on COVID-19 that reflects U.K. practice.

“ESMO obviously feels a responsibility, from the European perspective, to give some guidance to their membership about the COVID-19 situation in the same way that they would put out guidelines if a new drug became available,” Dr. Ledermann said.
 

Prioritizing care

All of the ESMO COVID-19 guidelines group cancer patients into high-, medium-, or low-priority categories to ensure that patients who may need the most care will be seen first as hospital services become affected by the pandemic.

Those in the high-priority category are patients whose condition is either immediately life-threatening or clinically unstable or who may benefit greatly from intervention. Those in the low-priority group are patients who may be stable enough to have treatment delayed while the COVID-19 pandemic is ongoing or for whom the benefit of the intervention is low, compared with the risks of SARS-CoV-2 infection.

Those in the medium-priority group are patients whose treatment is noncritical, but for whom delaying treatment for more than 6 weeks could potentially impact the overall outcome or care of the patient.

For all gynecologic cancers covered, the guidelines stress that decisions made by the multidisciplinary team need to be documented, taking the patient’s condition into account, assessing who may be the most vulnerable, and considering the available resources.
 

High-priority visits

Examples of patients with cervical cancer who are a high priority for outpatient visits, according to the guidelines, include patients who have acute abdominal symptoms, renal obstruction, or complications after surgery or radiotherapy. Persistent and severe symptomatic pelvic or vaginal bleeding is another reason to be categorized as high priority for an outpatient visit, alongside anuria or symptoms of deep vein thrombosis.

New patients with histologically confirmed cervical changes should also be seen as a high priority to stage their cancer, but the guidelines stress that any blood tests and imaging should be done as close to the patient’s home as possible.

Similar recommendations are made for women with endometrial cancer, with those who have potentially unstable symptoms, severe bleeding from their tumors, and signs of venous thromboembolism or anuria being at the highest priority for outpatient visits.

Women with potentially unstable epithelial ovarian cancer – who have acute abdominal pain, intestinal obstruction, or complications after surgery – are also a high priority for an outpatient visit, as are new patients who have symptomatic ascites, pleural effusion, or intestinal obstruction.
 

Applying guidelines in practice

Knowing that ESMO and other organizations have carefully considered the management of cancer patients specifically in relation to COVID-19 could offer oncologists “a feeling of support and some security when they make difficult decisions,” Dr. Ledermann said.

“With all guidelines, particularly in this sort of situation, we have to be very careful in terms of their interpretation, because what fits one country may not fit another, and what fits one hospital may not necessarily fit another. So they should be taken as guidance rather than prescriptive documents,” Dr. Ledermann said.

As vice president of the European Society for Gynecologic Oncology, Dr. Ledermann noted that ESGO has taken a slightly different approach than ESMO. ESGO decided to collect and post links to existing COVID-19 resources on its website rather than create its own specific recommendations.

ESGO is also producing an expert webinar series, which has, so far, covered the management of ovarian and uterine cancers, giving clinicians the chance to learn from those who have experienced dramatic changes to their services during the COVID-19 pandemic.

Dr. Ledermann has no conflicts of interest.

With health care systems becoming increasingly stretched as the COVID-19 pandemic sweeps the globe, the European Society for Medical Oncology (ESMO) has produced practical recommendations for prioritizing the management of cancer patients, including those with gynecologic cancers.

ESMO’s guidelines for cervical, endometrial, and epithelial ovarian cancer delineate which patients should be prioritized for treatment in the face of reduced resources and despite the risk of SARS-CoV-2 infection.

“Many European countries have already sorted their own guidelines, either nationally or through their own societies,” said Jonathan Ledermann, MD, a professor of medical oncology at the University College London Cancer Institute who was involved in developing ESMO’s recommendations for gynecologic cancers.

Dr. Ledermann noted that the British Gynaecological Cancer Society, for example, has published guidance on COVID-19 that reflects U.K. practice.

“ESMO obviously feels a responsibility, from the European perspective, to give some guidance to their membership about the COVID-19 situation in the same way that they would put out guidelines if a new drug became available,” Dr. Ledermann said.
 

Prioritizing care

All of the ESMO COVID-19 guidelines group cancer patients into high-, medium-, or low-priority categories to ensure that patients who may need the most care will be seen first as hospital services become affected by the pandemic.

Those in the high-priority category are patients whose condition is either immediately life-threatening or clinically unstable or who may benefit greatly from intervention. Those in the low-priority group are patients who may be stable enough to have treatment delayed while the COVID-19 pandemic is ongoing or for whom the benefit of the intervention is low, compared with the risks of SARS-CoV-2 infection.

Those in the medium-priority group are patients whose treatment is noncritical, but for whom delaying treatment for more than 6 weeks could potentially impact the overall outcome or care of the patient.

For all gynecologic cancers covered, the guidelines stress that decisions made by the multidisciplinary team need to be documented, taking the patient’s condition into account, assessing who may be the most vulnerable, and considering the available resources.
 

High-priority visits

Examples of patients with cervical cancer who are a high priority for outpatient visits, according to the guidelines, include patients who have acute abdominal symptoms, renal obstruction, or complications after surgery or radiotherapy. Persistent and severe symptomatic pelvic or vaginal bleeding is another reason to be categorized as high priority for an outpatient visit, alongside anuria or symptoms of deep vein thrombosis.

New patients with histologically confirmed cervical changes should also be seen as a high priority to stage their cancer, but the guidelines stress that any blood tests and imaging should be done as close to the patient’s home as possible.

Similar recommendations are made for women with endometrial cancer, with those who have potentially unstable symptoms, severe bleeding from their tumors, and signs of venous thromboembolism or anuria being at the highest priority for outpatient visits.

Women with potentially unstable epithelial ovarian cancer – who have acute abdominal pain, intestinal obstruction, or complications after surgery – are also a high priority for an outpatient visit, as are new patients who have symptomatic ascites, pleural effusion, or intestinal obstruction.
 

Applying guidelines in practice

Knowing that ESMO and other organizations have carefully considered the management of cancer patients specifically in relation to COVID-19 could offer oncologists “a feeling of support and some security when they make difficult decisions,” Dr. Ledermann said.

“With all guidelines, particularly in this sort of situation, we have to be very careful in terms of their interpretation, because what fits one country may not fit another, and what fits one hospital may not necessarily fit another. So they should be taken as guidance rather than prescriptive documents,” Dr. Ledermann said.

As vice president of the European Society for Gynecologic Oncology, Dr. Ledermann noted that ESGO has taken a slightly different approach than ESMO. ESGO decided to collect and post links to existing COVID-19 resources on its website rather than create its own specific recommendations.

ESGO is also producing an expert webinar series, which has, so far, covered the management of ovarian and uterine cancers, giving clinicians the chance to learn from those who have experienced dramatic changes to their services during the COVID-19 pandemic.

Dr. Ledermann has no conflicts of interest.

With health care systems becoming increasingly stretched as the COVID-19 pandemic sweeps the globe, the European Society for Medical Oncology (ESMO) has produced practical recommendations for prioritizing the management of cancer patients, including those with gynecologic cancers.

ESMO’s guidelines for cervical, endometrial, and epithelial ovarian cancer delineate which patients should be prioritized for treatment in the face of reduced resources and despite the risk of SARS-CoV-2 infection.

“Many European countries have already sorted their own guidelines, either nationally or through their own societies,” said Jonathan Ledermann, MD, a professor of medical oncology at the University College London Cancer Institute who was involved in developing ESMO’s recommendations for gynecologic cancers.

Dr. Ledermann noted that the British Gynaecological Cancer Society, for example, has published guidance on COVID-19 that reflects U.K. practice.

“ESMO obviously feels a responsibility, from the European perspective, to give some guidance to their membership about the COVID-19 situation in the same way that they would put out guidelines if a new drug became available,” Dr. Ledermann said.
 

Prioritizing care

All of the ESMO COVID-19 guidelines group cancer patients into high-, medium-, or low-priority categories to ensure that patients who may need the most care will be seen first as hospital services become affected by the pandemic.

Those in the high-priority category are patients whose condition is either immediately life-threatening or clinically unstable or who may benefit greatly from intervention. Those in the low-priority group are patients who may be stable enough to have treatment delayed while the COVID-19 pandemic is ongoing or for whom the benefit of the intervention is low, compared with the risks of SARS-CoV-2 infection.

Those in the medium-priority group are patients whose treatment is noncritical, but for whom delaying treatment for more than 6 weeks could potentially impact the overall outcome or care of the patient.

For all gynecologic cancers covered, the guidelines stress that decisions made by the multidisciplinary team need to be documented, taking the patient’s condition into account, assessing who may be the most vulnerable, and considering the available resources.
 

High-priority visits

Examples of patients with cervical cancer who are a high priority for outpatient visits, according to the guidelines, include patients who have acute abdominal symptoms, renal obstruction, or complications after surgery or radiotherapy. Persistent and severe symptomatic pelvic or vaginal bleeding is another reason to be categorized as high priority for an outpatient visit, alongside anuria or symptoms of deep vein thrombosis.

New patients with histologically confirmed cervical changes should also be seen as a high priority to stage their cancer, but the guidelines stress that any blood tests and imaging should be done as close to the patient’s home as possible.

Similar recommendations are made for women with endometrial cancer, with those who have potentially unstable symptoms, severe bleeding from their tumors, and signs of venous thromboembolism or anuria being at the highest priority for outpatient visits.

Women with potentially unstable epithelial ovarian cancer – who have acute abdominal pain, intestinal obstruction, or complications after surgery – are also a high priority for an outpatient visit, as are new patients who have symptomatic ascites, pleural effusion, or intestinal obstruction.
 

Applying guidelines in practice

Knowing that ESMO and other organizations have carefully considered the management of cancer patients specifically in relation to COVID-19 could offer oncologists “a feeling of support and some security when they make difficult decisions,” Dr. Ledermann said.

“With all guidelines, particularly in this sort of situation, we have to be very careful in terms of their interpretation, because what fits one country may not fit another, and what fits one hospital may not necessarily fit another. So they should be taken as guidance rather than prescriptive documents,” Dr. Ledermann said.

As vice president of the European Society for Gynecologic Oncology, Dr. Ledermann noted that ESGO has taken a slightly different approach than ESMO. ESGO decided to collect and post links to existing COVID-19 resources on its website rather than create its own specific recommendations.

ESGO is also producing an expert webinar series, which has, so far, covered the management of ovarian and uterine cancers, giving clinicians the chance to learn from those who have experienced dramatic changes to their services during the COVID-19 pandemic.

Dr. Ledermann has no conflicts of interest.