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Tag: Anish Koka

Testing Won’t Get Us Where We Need to Go

By ANISH KOKA, MD

The great pandemic is wreaking havoc, we are told, because the nation is not testing enough.  The consensus from a diverse group that includes public health experts, economists, and silicon valley investors is that more testing will allow the country to restart the economy and do it safely. 

The White House has been a mini laboratory for this testing strategy.  Everyone who comes into contact with the President and Vice President is tested daily.  This is supposedly what allows everyone to sit in meetings together and generally carry out the essential business of the country.  But over this Mother’s Day weekend members of the White House spent their time scrambling to track down contacts of Katie Miller, the press secretary of the Vice president who tested positive.  And contacts were left unclear about what exactly to do.  One official started self-quarantining, while another did not. 

If the White House has trouble with a mass testing, and contact tracing strategy, one wonders how this may work nationwide with thousands of new cases per day.  While it would be tempting to blame administrative incompetence for the difficulties in the most important household in the land, the real difficulties lies with inherent limitations to tests that need to be understood before getting on the testing bandwagon.

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COVID-19: Physicians in Shackles

By ANISH KOKA, MD

A number of politically tinged narratives have divided physicians during the pandemic. It would be unfortunate if politics obscured the major problem brought into stark relief by the pandemic: a system that marginalizes physicians and strips them of agency.

In practices big and small, hospital-employed or private practice, nursing homes or hospitals, there are serious issues raising their heads for doctors and their patients.

No masks for you

When I walked into my office Thursday, March 12th, I assembled the office staff for the first time to talk about COVID.  The prior weekend had been awash with scenes of mayhem in Italy, and I had come away with the dawning realization that my wishful thinking on the virus from Wuhan skipping us was dead wrong.  The US focus had been on travel from China and other Far East hotspots.  There was no such limitation on travel from Europe.  The virus had clearly seeded Italy and possibly other parts of Europe heavily, and now the US was faced with the very real possibility that there was significant community spread that had occurred from travelers from Europe and Italy over the last month. I had assumed that seeing no cases in our hospitals and ICUs by early March meant the virus had been contained in China.  That was clearly not the case.

Our testing apparatus had also largely been limited in the US to symptomatic patients who had been to high-risk countries.  If Europe was seeded, this meant we had not been screening nearly enough people.  When I heard the first few cases pop up in my county, it was clear the jig was up.  It was pandemic panic mode time.  There was a chance that there were thousands of cases in the community we didn’t know about and that we were weeks away from the die-off happening in hospitals in China and Italy.  So what I told the staff the morning of March 12th was that we needed to start acting now as if there was significant spread of COVID in the community.  This meant canceling clinic visits for all but urgent patients, wearing masks, trying to buy masks, attention to hand hygiene, cleaning rooms between patients, screening everyone for flu-like symptoms before coming to the office, and moving to a skeleton staff in the office.  I left the office that day wearing a mask as I headed to the ER.

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COVID-19: The Nursing Home Tragedy

By ANISH KOKA, MD

Our strategy with nursing homes in the midst of the current pandemic is bad.  Nursing homes and other long term care facilities house some of our sickest patients in and it is apparent we have no cogent strategy to protect them. 

I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home.  I was worried too, but optimistic.

I figured the larger medical community would be on the same page if someone did get COVID.  It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home.  So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.

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The COVID Pandemic: WHO Dunnit?

By ANISH KOKA, MD

COVID is here. A little strand of RNA that used to live in bats has a new host.  And that strand is clearly not the flu.  New York is overrun, with more than half of the nation’s new cases per day, and refrigerated 18-wheelers parked outside hospitals serve as makeshift morgues.  Detroit, New Orleans, Miami, and Philadelphia await an inevitable surge of their own with bated breath.  America’s health care workers are scrambling to hold the line against a deluge of sick patients arriving hourly at a rate that’s hard to fathom. 

I pause here to attest to the heroic response of the medical community and the countless more working to support them. At the time of this writing, despite 368,000 confirmed cases in the United States, 11,000 deaths have been reported.  A horrid number, but still a far cry from Italy with 130,000 cases, and 16,523 deaths, and Spain with 14,000 deaths amidst 140,000 cases.  Italy and Spain may be a few weeks ahead of the United States, but at the moment, Italy and Spain have case fatality rates (12.5%, 10%) that are multiples of the United States (2.5%). If this rate does stand, it will be a testament to the tenacity of medical workers toiling under extenuating circumstances.

With the scale of the tragedy now obvious, the take from some very smart people is that the people who should have been paying attention were asleep at the wheel.  The easy target is the bombastic New York real estate developer and current President of the United States who repeatedly assured raucous campaign crowds and the nation that the virus was under control before it wasn’t. 

The charge is made that the President ignored warnings and painted a rosy picture of an unfolding crisis in a short-sighted attempt to preserve the economy and a beloved stock market.  He may be guilty of the latter charge, but the real question relates to ignored warnings.  Where were the warnings? Who was sounding the alarm that was ultimately ignored?

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The THCB Gang Episode 4

Episode 4 of “The THCB Gang” was live-streamed Thursday April 9. You can see it below and it’s also preserved as a weekly podcast available on our iTunes & Spotify channels. Every Thursday at 1pm PT-4pm ET, 4-6 semi-regular guests drawn from THCB authors and other assorted old friends of mine will shoot the shit about health care business, politics, practice, and tech. It tries to be fun but serious and informative!

This week, joining me were Jane Sarasohn Kahn (@healthythinker), Anish Koka (@anish_koka), Saurabh Jha (@roguerad), Elizabeth Clayborne (@DrElizPC), and Ian Morrison (@seccurve). A fun and very informative discussion about where the COVID-19 crisis is right now and what it’s going to mean both now and in the near future — Matthew Holt

Pandemic Fears: What the AIDS Battle Should Teach Us About COVID-19

By ANISH KOKA, MD

As the globe faces a novel, highly transmissible, lethal virus, I am most struck by a medicine cabinet that is embarrassingly empty for doctors in this battle.  This means much of the debate centers on mitigation of spread of the virus.  Tempers flare over discussions on travel bans, social distancing, and self quarantines, yet the inescapable fact remains that the medical community can do little more than support the varying fractions of patients who progress from mild to severe and life threatening disease.  This isn’t meant to minimize the massive efforts brought to bear to keep patients alive by health care workers but those massive efforts to support failing organs in the severely ill are in large part because we lack any effective therapy to combat the virus.  It is akin to taking care of patients with bacterial infections in an era before antibiotics, or HIV/AIDS in an era before anti-retroviral therapy.  

It should be a familiar feeling for at least one of the leading physicians charged with managing the current crisis – Dr. Anthony Fauci.  Dr. Fauci started as an immunologist at the NIH in the 1960s and quickly made breakthroughs in previously fatal diseases marked by an overactive immune response.  Strange reports of a new disease that was sweeping through the gay community in the early 1980’s caused him to shift focus to join the great battle against the AIDS epidemic. 

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Low Value Testing and Unmet Cascades

By ANISH KOKA, MD

Mr. Smith has a problem. 

He can’t see. 

Even this cardiologist knows why.  The not so subtle evidence lies in the cloudy lens in front of his pupils.  He is afflicted with cataracts that obstruct his vision to the point he can’t really do his job refurbishing antique furniture safely.  His other problem is that he hates doctors. He hasn’t had reason to see one for more than a decade.  He’s 68, takes no medications, smokes a pack of cigarettes a day, and is a master of one word answers. He’s in my office because he needs a medical evaluation prior to his cataract procedure. Someone needs to attest to medical safety. I’m it.

He just wants to get out of here.

His annoyance of being in the office is justified.  Cataract surgery is very low risk.  Unless he’s having an acute medical problem, there is little to do.  The problem is that in an age of high volume, super specialized care, the eye doctor can’t attest to this, and the anesthesiologists have little interest in finding out the morning of his procedure that Mr. Smith has been having more frequent episodes of chest pain over the last two weeks.  Perhaps the chest pain is just acid reflux, or maybe it’s because of a pulmonary embolism related to the tobacco induced lung malignancy no one knows about. It’s possible, and highly likely, Mr. Smith will survive his cataract surgery even if he has a pulmonary embolism.  Cataract surgery really is pretty low risk.

But the doctor’s ethos has never been to ‘clear a patient for a cataract’, it is to commit to the health of the patient.  Mr. Smith deserves the opportunity to receive good medical care that isn’t made threadbare just because of the cataract surgery on the horizon.

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Presenting Complaint: Social Injustice

By ANISH KOKA, MD

Bobby

It took some doing, but I had finally made it to Bobby’s home.

It was a rowhome tucked into one of those little side streets in the city that non-city folks wouldn’t dream of driving down. As I step in, I’m met by the usual set up – wooden steps that hug the right side of the wall leading up to the second floor.  Bobby certainly hasn’t made it up to the second floor in some time. At the moment she is sitting in her hospital bed in the living room. The bed is the focal point to a room stuffed to the gills with all manners of stuff. At least three quarters of the stuff seems to be food. Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers, Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on display here.

Bobby weighs in at four hundred pounds, 5 foot 5 inches. She has a tracheostomy from multiple prior episodes of respiratory failure that have required ventilatory support. I’m here at the request of a devoted primary care physician that still makes home calls. I’ve looked through the last number of hospital stays. The last few discharge summaries are carbon copies of each other. Hypoxemic respiratory failure related to pulmonary edema complicated further by morbid obesity. Time on the vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The last echocardiogram done was 3 admissions ago. A poor study. Not much could be seen due to ‘body habitus’.

I sit on the side of the bed trying to acquire my own images of her heart. I talk to her as I struggle. Bobby is 58, the youngest of three sisters, and the only surviving member of the family. Her elder sisters died of respiratory complications as well. They both died with tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine before that. I explain that a prolonged period of time on the ventilator on a prior admission prompted the tracheostomy, and that the multiple recent admissions to the hospital that required a ventilator seemed to validate that decision. She doesn’t waver. Both her sisters died shortly after they got tracheostomies. Bobby thinks the physicians taking care of her sisters had a hand in their demise. “They didn’t care.” “We told them they were sick.”

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Economics Lessons from the Subcontinent: India’s Coronary Stent Policy

By ANISH KOKA MD

It is commonly believed that deliberate, careful price regulation by enlightened technocrats trumps the haphazard and chaotic regulation of prices imposed by the free market—especially when the market is subject to greed and corruption.

A most interesting case study challenging that belief comes courtesy of the largest Democracy in the world: India.

In 2017, an arm of the Indian Government, the National Pharmaceutical Pricing Authority (NPPA) took action to control the price of coronary stents in India by capping their retail price.  The problem that stimulated this action was their exorbitant price that made them unaffordable to many Indians.

The retail prices of US made drug-eluting stents ranged from Rs 80,000 – 150,000 (~$1000 – ~$2000), while the price of Indian made drug-eluting stents ranged from Rs 45,000 – 90,000 (~$600 – ~$1200).  Considering that a good job for 90% of the Indian labor force pays about Rs 180,000 per year, these prices put most coronary stents out of the reach of a vast swath of the populace.

What regulators knew, however, was that the price point at which coronary stents were being imported into India was a fraction of the price being charged to Indians.  The up-charge had everything to do with what happened after the stent was brought onto Indian soil: The Indian subsidiary of the US stent manufacturer would sell its product to a domestic distributor that would then employ all means necessary to ensure their stent was chosen by cardiologists to be implanted.

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Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

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