It’s amazing that the word “medication” is not mentioned in a recent Morbidity and Mortality Weekly Report from the US Centers for Disease Control and Prevention (CDC). The research states that a staggering 90% of people hospitalized for COVID-19 have underlying conditions, including hypertension, diabetes mellitus and cardiovascular disease, all of which require drug treatments for patients to remain healthy.
Yet nowhere in the report is there mention of how
patients can potentially prevent COVID-19 related health decline through better
medication use for their underlying disease.
Are the COVID-19 hospitalization rates truly caused by the underlying
disease and insufficient use of preventive measures like social distancing? Or
are these underlying conditions unmanaged due to medication optimization issues
placing these patients at higher risk for hospitalizations?
Medication optimization is how the healthcare system
supports the patient from the initial prescription to follow up and ongoing
review. It aims to improve the safety, effectiveness, and affordable use of
The invisible threat enabling the spread of COVID-19
that no one seems to be talking about is that barriers to medication use are
accelerating infections for these high-risk populations. Buried within the “People Who Need Extra Precautions”
section of its website, the CDC states people with high-risk for severe illness
from COVID-19 are “people of all ages with underlying medical conditions,
particularly if not well controlled”. Clearly, optimizing medications is one of
the most important aspects to controlling chronic illness. Optimization
supports patients through medication therapy that aims to improve safety,
effectiveness, and affordable use of prescribed drugs.
As healthcare systems around the world grapple with the coronavirus, ‘virtual-first healthcare’ is fast becoming the global response of private and public healthcare systems alike. In Australia, the federal government recently committed to investing $500M to built out its country’s ‘virtual-first’ healthcare infrastructure, so we caught up with Louise Schaper, CEO of the Australasian Institute of Digital Health (AIDH), to find out what that means for telehealth, remote monitoring, and digital health companies looking to capitalize on the market opportunity in Australia.
With a population of 25 million people (roughly the number of people in Florida) and a set of newly-minted reimbursement codes that makes telehealth available to all of them via the government-funded public healthcare system, the appetite for investing in new health tech solutions has grown ravenous.
Says Louise, “Anyone who has solutions that are already market-tested and approved, I’d actually expand your networks globally now. There’s not a section of the globe that hasn’t been impacted by [covid19] and we’re all needing to work out how to deliver healthcare differently.”
As in other parts of the world, the government codes reimbursing telehealth and other virtual-first services are temporary (Australia’s are set to expire September 30, 2020), but organizations like the AIDH, the Australian Medical Association, and others are advocating for their permanence and are optimistic.
The prevailing sentiment is that, like in the US, the benefits of virtual care to healthcare consumers and clinicians are going to be difficult for the government to ignore. Add to that the potential of linking virtual care to the Aussie government’s AUD$2 billion dollar build of its MyHealthRecord system — a centralized, cloud-based EMR that holds the healthcare data of 90% of all Australians — and the prospect grows even more appealing.
Join us as we talk through the basics of the Australian healthcare system and get an insider’s look at the demand for digital health, remote monitoring, and telehealth Down Under.
After my posts on telemedicine were published recently, (this one on Manly Wellness before the pandemic and this one after it erupted, on A Country Doctor Writes, then reblogged on The Health Care Blog, KevinMD and many others), I have been asked about my views on telemedicine’s role in the future of primary care.
Things have changed quickly, and a bit chaotically, and there is a lot of experimentation happening right now in practices I work or speak with.
Before thinking about telemedicine in Primary Care, we need to agree on some sort of definition of primary care, because there are so many functions and services we lump together under that term.
Many people think of primary care mostly as treating minor, episodic illnesses like colds, rashes, minor sprains and the like. This is an area that has attracted a lot of interest because it is easy money for the providers, since the visits tend to be quick and straightforward and such televisits are also attractive for the insurance companies if they can keep insured patients out of the emergency room. With the technical limitations of video quality and objective data such as heart rate and rhythm, I think this is an absolute growth area for telemedicine. However, with all the other forms but mostly here, fragmentation of care could become a complicated problem. To put it bluntly, if we still expect a medical professional or a health care organization to keep an eye on reports from various sources, such as hospital specialists, walk-in clinics or independent telemedicine providers, they are going to want to get paid for it.
GuideWell has launched the COVID-19 Health Innovation Collaborative to identify and support solutions that can immediately increase the scope and scale of resources aimed at reducing the complex stress factors COVID-19 is bringing to bear on the U.S. health system.
There will be five categories of focus under
this collaborative, and proposed solutions must directly address at least one
of these categories:
Home-based self-testing solutions for the COVID-19 virus
Virtual, in-home care solutions for at-risk populations that have limited access to health care services
Solutions that reduce risk for health care providers in clinical settings, including approaches for increasing protection of clinical staff
Solutions focused on reducing social isolation due to COVID-19 diagnosis or social distancing
Solutions for delivering food and urgently needed supplies to at-risk populations and households with COVID-19 exposure or symptoms
The COVID-19 Collaborative’s overarching
objective is to source a diverse portfolio of innovative companies that
collectively have the potential to respond to the pandemic in the above
categories. For each category, a cohort of 3-5 companies will be selected to
work together to create a connected, high impact approach to addressing the
I am writing this blog post (the first after nearly two years!) in lockdown mode because of the rapidly spreading SARSCoV2 virus, the causative agent of the COVID19 disease (a poor choice of a name, since the disease itself is really SARS on steroids).
One interesting feature of this disease is that a large number of patients will manifest minimal or no symptoms (“asymptomatic” infections), a state which must clearly be distinguished from the presymptomatic phase of the infection. In the latter, many patients who will eventually go on to develop the more serious forms of the disease have minimal symptoms. This is contrast to asymptomatic patients who will never develop anything more bothersome than mild symptoms (“sniffles”), for which they will never seek medical attention. Ever since the early phases of the COVID19 pandemic, a prominent narrative postulated that asymptomatic infections are much more common than symptomatic ones. Therefore, calculations such as the Case Fatality Rate (CFR = deaths over all symptomatic cases) mislead about the Infection Fatality Rate (IFR = deaths over all cases). Subthreads of this narrative go on to postulate that the lockdowns which have been implemented widely around the world are overkill because COVID19 is no more lethal than the flu, when lethality is calculated over ALL infections.
Whereas the politicization of the lockdown argument is of no interest to the author of this blog (after all the virus does not care whether its victim is rich or poor, white or non-white, Westerner or Asian), estimating the prevalence of individuals who were exposed to the virus but never developed symptoms is important for public health, epidemiological and medical care reasons. Since these patients do not seek medical evaluation, they will not detected by acute care tests (viral loads in PCR based assays). However such patients, may be detected after the fact by looking for evidence of past infection, in the form of circulating antibodies in the patients’ serum. I was thus very excited to read about the release of a preprint describing a seroprevalence study in Santa Clara County, California. This preprint described the results of a cross-sectional examination of the residents in the county in Santa Clara, with a lateral flow immunoassay (similar to a home pregnancy kit) for the presence of antibodies against the SARSCoV2 virus. The presence of antibodies signifies that the patient was not only exposed at some point to the virus, but this exposure led to an actual infection to which the immune system responded by forming antibodies. These resulting antibodies persist for far longer than the actual infection and thus provide an indirect record of who was infected. More importantly, such antibodies may be the only way to detect asymptomatic infections, because these patients will not manifest any symptoms that will make them seek medical attention, when they were actively infected. Hence, the premise of the Santa Clara study is a solid one and in fact we need many more of these studies. But did the study actually deliver? Let’s take a deep dive into the preprint.
If you are a soccer fan, watching the FIFA World Cup is a
ritual that you don’t ever violate. Brazilians, arguably more than any other
fans in the world, live and breathe soccer—and they are always expected to be a
legitimate contender to win it all. Their expectations are magnified when they are
the host country, which was the case in 2014. Not only did the Germans destroy
Brazilian World Cup dreams, but less than a year after a humiliating loss
on their turf, Brazilians began dealing with another devastating blow: a viral
epidemic. Zika left the country scrambling to understand how to manage the
devastation caused by the virus and grappling with conspiracies theories of
whether the virus was linked to the tourism brought by hosting the FIFA World
How did I become so interested in what happened in Brazil five
years ago? Well, social distancing and being mostly at home in the era of
COVID-19 seems to energize reflection. Watching politicians on TV networks blaming
each other and struggling to appear more knowledgeable than scientists makes me
marvel at the hubris. My mind took me back to several prior epidemics that we
encountered from Swine Flu to Ebola, and I couldn’t help but think about the lessons
lost. What did we miss in these previous crises to land us in this current
state where Zoom is your best friend and you are more interested in commenting
on tweets than doing a peer-review? One cannot help but wonder what is so
different about this coronavirus that it has paralyzed the globe.
I decided to take a deep dive into the Zika epidemic in a
hopeful effort to better understand the present public health crisis. I started
by reading Zika: The Emerging Epidemic, by Donald G. McNeil Jr, who also
covers global epidemics for the New York Times. The book is a
fascinating read and offers illuminating parallels to the current failings we
are seeing with national and global health protection agencies during the COVID-19
Health tech has suddenly found its new focus in coronavirus – but are we at risk of doing more harm than good by rushing to use unproven solutions? To avoid chaos in the aftermath, we should focus on tried-and tested tech, and only use novel solutions where need is deemed greater than the acceptable risk.
The COVID pandemic is categorically not a black swan event.
Black swans are by definition unknowable and unpredictable. In contrast, a global viral pandemic was predicted by scientists decades before, from the potential impact, right down to the source of the virus. In fact, only last year The Johns Hopkins Center for Health Security in partnership with the World Economic Forum and the Bill and Melinda Gates Foundation hosted Event 201 (video below), a high-level pandemic exercise on October 18, 2019, in New York, NY to simulate and plan for this exact scenario involving a life-threatening respiratory agent. They accurately predicted the exponential spread of disease, the sudden economic crash, and the desolation it would impose on healthcare systems. Indeed, Bill Gates himself is on record in 2015 predicting at a TED event that it would be ‘microbes, not missiles’ that would would be the next existential threat to humanity.
As a psychiatrist, my role in COVID-19 has included that of a therapist for my colleagues. I helped start Physician Support Line, a peer-to-peer hotline for physicians staffed by more than 500 volunteer psychiatrists. Through the hotline and social media, physicians are revealing their emotional fatigue. One doctor shared her sense of powerlessness when she couldn’t provide comfort but instead had to watch her young patient with COVID-19 die alone from behind a glass window. Another shared his sorrow after his 72-year-old patient died by suicide. She was socially isolated and didn’t want to be a burden on anyone if she contracted COVID-19. An internist felt deep distress and alarm that her hospital was quickly running out of ventilators and had 12 codes in 24 hours.
Through a brief survey I
conducted across the U.S., 269 physicians reported moderate to severe symptoms
of anxiety (53%), depression (43%), and insomnia (16%). About 46% wanted to see
or would consider seeing a mental health clinician for severe anxiety (30%),
not feeling like themselves (27%), or being unhappy (21%). These are all similar statistics to
the front line health care workers in Wuhan.
While President Trump mulls whether to reopen the country again in May, and as Fox & Friends host Brian Kilmeade suggests that “only” 60,000 people will die from the coronavirus, there are some warning signs that the White House COVID-19 Task Force’s prediction of 100,000-240,000 deaths may be way too low.
That isn’t surprising, considering that Administration
officials said this projection depended on us doing everything right. Of
course, it appears that large sections of the country have done many things
wrong—whether it’s Florida Governor Ron DeSantis’ reluctance to close houses of
worship or the refusal of several state governors to issue stay at home orders.
That doesn’t include Trump’s own refusal to admit the seriousness of the
COVID-19 outbreak until mid-March and the continuing failure of the federal
government to ensure an adequate supply of test kits, PPE and ventilators.
So here’s what all of this may be leading up to: a minimum
of 600,000 COVID-related deaths in the U.S. over the next two years.
We have seen and heard about the classic symptoms of
COVID-19 at UCSF Medical Center, where I work as a cardiologist. Patients keep
coming in with pulmonary distress, pneumonia, and ultimately, Acute Respiratory
Distress Syndrome (ARDS) – the life-and-death situation that requires
However, I’m beginning to learn about other symptoms that some
doctors are noticing. There are numerous reports of other complications, especially
in advanced disease.
Elevation in D-Dimer, (a biomarker of coagulation system activation) has been associated with dramatically increased risk of death from COVID-19. This has led some to speculate that empiric treatment with anticoagulants might improve outcomes in these critically ill patients. Indeed, there was this recent publication of a retrospective analysis of anticoagulation with heparin or low molecular weight heparin showing an association with improved outcomes in COVID-19 patients in China.