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A compelling link between severe COVID and immune system response
https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8
One of the most perplexing elements of the novel coronavirus is its variability. It’s common knowledge that while many infected people will experience mild symptoms, those who are older, male and have underlying chronic disease are at much higher risk of severe disease and death.
Two recent papers published in Science provide some of the most compelling evidence behind the impaired immune response seen in severely affected patients—and a potential link to the gender disparities in outcomes.
Both papers are centered on the role of Type I interferon, an immune protein that provides a first line of defense in viral illness.
The first study analyzed the DNA of over 650 patients with severe COVID to assess mutations in the genes that code for interferon-1. Some 3.5 percent of patients with life-threatening COVID carried mutations, but these were found in none of the control patients who only had mild disease.
The second paper evaluated the presence of antibodies to the patient’s own interferon, finding that 14 percent of patients with severe disease had these “auto-antibodies”, which are extremely rare in the general population. Interestingly, 12.5 percent of severely ill men had the antibodies, compared to just 2.6 percent of women with severe disease. Previous work linked poor interferon response to the X chromosome, highlighting the potential increased risk for men.
Taken together, these studies indicate that impaired Type I interferon could contribute to 1 in 7 severe COVID cases. Scientists are hopeful this work could lead to new diagnostics that estimate a patient’s risk of poor outcomes. This growing body of work, with new insights published every week in Science and other journals, underscores the rapid advances being made in understanding and treating this novel and complex disease.
America’s most prestigious medical journal makes a political statement
https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8
For its first 208 years, the New England Journal of Medicine has never endorsed a political candidate. But this week the journal published an editorial outlining its political position in the upcoming Presidential election, signed unanimously by all editors who are US citizens.
The editors did not explicitly endorse former Vice President Biden, but rather offered a scathing condemnation of the current administration’s performance during the COVID pandemic: “Reasonable people will certainly disagree about the many political positions taken by candidates.
But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.” (Formally endorsing Biden last month, Scientific American also made the first political endorsement in its 175-year history.)
Much of the media coverage of the NEJM statement has centered on the question of whether medicine should involve itself in politics, or “live above it”.
Medicine has been drawn into political disputes before, but now the nature of the involvement has changed. In the past, debates largely centered around regulation, payment or policy—but now the science itself has become a fundamentally political issue.
The very nature of the coronavirus has become a matter of political belief, not just an indisputable scientific fact.
Public trust in both scientific institutions and the government, and their ability to work together, has been damaged. We fear this will lead to poorer health outcomes regardless of who wins the upcoming election.
Into the COVID fray again, or for the first time
https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8
While it sometimes seems like the coronavirus has been with us forever, it’s worth remembering that there are still parts of the country that are only now experiencing their first big spike in cases—that’s the nature of a “patchwork” pandemic working its way across a vast country.
One of our health system members in the Midwest, with whom we recently spent time, is in just this situation: they’re seeing their highest inpatient COVID census to date, just this month. As they shared with us, there are advantages and drawbacks to being a “late follower” on the epidemic curve. The good news is that they’re ready.
Back in March, like most systems, they stood up an “incident command center”, and began preparing for a wave of COVID patients, designating a floor of the hospital as a “hot zone”, creating negative pressure rooms, cross-training staff, developing treatment protocols, stockpiling protective equipment, and securing a pipeline of critical therapeutics and testing supplies. There was a moderate but manageable number of cases across the late spring and summer, but never to an extent that stressed the system.
Eventually, recognizing that they couldn’t ask their doctors, nurses, and administrators to stay on high alert indefinitely, they “stood down” to a more normal operational tempo, only to watch with dismay as the surrounding community seemingly forgot about the virus, and lessened precautions (masking, distancing, and so forth), wanting life to return to “normal”. And now, the post-Labor Day, post-return-to-school spike has arrived.
The challenge now is getting everyone, inside and outside the system, to stop talking about COVID in the past tense, as though they’ve already “gotten through it.” The preparations they’ve made are paying off now. Hospital operations continue to run smoothly even with a high COVID census, but the workforce is exhausted, and citizens aren’t stepping outside to bang gratefully on pots every night anymore.
Asking the team to return to war footing is no easy task, given the fatigue of the past seven months. A question looms: what is the trigger to restart “incident command”? As cases begin to increase again in some of the original COVID hot spots—New York, New England, the Pacific Northwest—healthcare leaders there will need to learn from the experiences of their colleagues in the newly-hit Midwest, about how to take an already virus-weary clinical workforce back onto the battlefield.
Virtual visits have declined, but the emails haven’t
https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8
While telemedicine visits have decreased sharply since their early pandemic peak, we’re hearing from providers across the country that patient demand for email communication has persisted.
Many patients have missed meaningful in-person interactions with their doctors. But once they sign up for the portal and realize they can email, they don’t want to go back to spending time on hold or scheduling a visit to get a prescription refill or the answer to a simple question.
Email and messaging saves patients a lot of time, but the sheer amount has quickly become unmanageable for many doctors. “Last year I got half a dozen emails per week from patients,” one primary care physician told us. “Now I’m spending two hours a day answering MyChart messages, and I’m still not keeping up.”
And as many are quick to point out, there is little to no compensation for time spent emailing. Health systems and physician practices can’t “roll back” this service—removing this satisfier would expose them to losing patients altogether.
In the near term, systems must invest in the staff and infrastructure to create a centralized process to triage messages. And longer-term, they must align physician compensation and payment models away from visit-based economics and toward comprehensive patient communication and management.
Atrium, Wake Forest Baptist merge to create 42-hospital system
Charlotte, N.C.-based Atrium Health and Winston-Salem, N.C.-based Wake Forest Baptist Health have completed their merger, creating a 42-hospital system with more than 70,000 employees.
With the transaction complete, Wake Forest Baptist Health and Wake Forest School of Medicine will become the “academic core” of Atrium Health. The health system said it plans to build a second campus of the school of medicine in Charlotte.
“As the healthcare field goes through the most transformative period in our lifetime, in addition to a new medical school, our vision is to build a ‘Silicon Valley’ for healthcare innovation spanning from Winston-Salem to Charlotte,” Atrium President and CEO Eugene A. Woods said in a news release. “We are creating a nationally-leading environment for clinicians, scientists, investors and visionaries to collaborate on breakthrough technologies and cures. Everything we do will be focused on life changing care, for all, in urban and rural communities alike. And we will create jobs that provide inclusive opportunities to enhance the economic vitality of our entire region.”
Atrium cited an independent economic analysis that showed the direct and indirect annual employment impact of the combined system exceeds 180,000 jobs.
“The impact of the strategic combination will be far-reaching, elevating North Carolina as a clear destination of choice to receive medical care for people all across the nation,” said Julie Ann Freischlag, MD, CEO of Wake Forest Baptist Health and dean of Wake Forest School of Medicine. “Through our combined, nationally recognized clinical centers of excellence in multiple specialties, we will be able to expand our research in signature areas, such as cancer, cardiovascular, regenerative medicine and aging, and target bringing research breakthroughs to the community in less than half the time of the national average.”
Mr. Woods will serve as president and CEO of the combined system, and Dr. Freischlag was appointed chief academic officer for Atrium Health in addition to her current positions.
A 16-member board of directors appointed by the Charlotte Mecklenburg Hospital Authority and Wake Forest University Baptist Medical Center will govern the new nonprofit enterprise.
Trinity Health’s annual revenue dips to $18.8B
Trinity Health saw revenue decline in fiscal year 2020, and the Livonia, Mich.-based health system ended the period with a loss, according to recently released financial documents.
Trinity Health saw revenue decline 2.4 percent year over year to $18.8 billion in the 12 months ended June 30. The health system attributed the drop in revenue to the COVID-19 pandemic and the divestiture of Camden, N.J.-based Lourdes Health System in June 2019.
The 92-hospital system’s expenses were down 1.4 percent year over year in fiscal 2020. Trinity Health took several steps to reduce operating and capital spending in response to the pandemic, including implementing furloughs and reducing salaries for executives.
Trinity Health reported an operating loss of $344.7 million for fiscal 2020, compared to operating income of $106.8 million a year earlier.
After factoring in investments and other nonoperating items, Trinity Health posted a net loss of $75.5 million in fiscal 2020, down from net income of $786 million in fiscal 2019. Lower nonoperating gains in the most recent fiscal year were primarily driven by the pandemic’s effect on global investment market conditions, the health system said.
HENRY KOTULA 