Cartoon – Bad News! Is it Margins?
What should you take if you get Covid-19?
https://link.vox.com/view/608adc4e91954c3cef03e60dfi7ya.jor/68bd1086
Hey readers,
Last week, Florida Surgeon General Joseph Ladapo released a public service announcement talking about protecting your health from Covid-19. The PSA stood out for a couple of reasons:
1. While “vaccination” briefly appeared onscreen in a list of options, it didn’t merit a mention in the video.
2. The surgeon general listed guidance on “emerging” treatments that was … remarkably on point.
The absence of focus on vaccines in the video is unfortunate, if entirely in keeping with the GOP’s willingness to play to its anti-vax base. That’s bad, but not surprising.
What was surprising was No. 2. The information Ladapo shared about treatments was fairly accurate. In the video, he told Floridians to ask their doctor about monoclonal antibodies, fluvoxamine, and inhaled budesonide should they come down with Covid-19.
I’ve been reporting on the Covid-19 treatment beat for much of this year, and I’ve uncovered a massively confusing pile of contradictory information. But those are the top three treatments I’d recommend sick loved ones talk to doctors about, and while there’s much we still don’t know, solid science suggests they have real promise.
That said, the fact that such important (and accurate) information stood out in a government PSA indicates just how dismal the state of public communications on treatments is — and just how much misinformation and distrust are hampering the fight against Covid-19.
What should you take if you get Covid-19?
There’s been little public health communication about which treatments to pursue if you get Covid-19, perhaps because for much of the pandemic, it’s been unclear what options are better for mild Covid than just resting at home. While in 2021 the best treatment recommendations have gotten clearer, public health messaging over the last year has rightly been focused on vaccination.
The official CDC page on what to do if you get sick with Covid-19 advises you to wear a mask, wash your hands, and clean high-touch surfaces to avoid infecting those around you. If your breathing deteriorates or you show signs of severe illness like confusion or an inability to stay awake, the CDC advises you to go to the hospital.
All sound guidance — but what it doesn’t offer is advice on a question that patients who aren’t sick enough for hospitalization might desperately need to know: What medication should I take if I come down with Covid-19?
That’s not because there’s a lack of options. For instance, the FDA has approved monoclonal antibodies as a treatment for Covid-19 patients at risk of progressing to severe disease. They recently expanded this approval to include monoclonal antibodies for children as well. The treatment has to be administered in a clinic, as an IV infusion or as four shots, but it is highly effective, with some high-quality studies finding an 85 percent reduction in the risk of hospitalization or death.
Meanwhile, large, high-quality, peer-reviewed, and published randomized controlled trials (RCTs) have found promise for cheap therapies that are already FDA approved for other purposes and have an established safety profile.
One medication, fluvoxamine, is an antidepressant that appears to reduce hospitalizations from Covid-19 by about 30 percent. Another, budesonide asthma inhalers, was found in one large RCT to speed at-home recovery considerably and in another to reduce risk of hospitalization. In the US, there’s been no formal guidance on when to consider budesonide, but in the UK, health agencies have advised doctors they can consider prescribing it off-label to help older and at-risk patients recover at home, while in Canada doctors are encouraged to consider budesonide on a case-by-case basis.
Research underway will help provide a better understanding of both of these therapies, but there’s enough evidence that some doctors are already prescribing them to patients. If you have the opportunity to enroll in an ongoing clinical trial of these medications, you can get access to a potentially promising treatment and help contribute to our scientific understanding of whether these treatments really work.
Another exciting treatment in the pipeline is Paxlovid, an antiviral developed by Pfizer that showed impressive 90 percent efficacy in preventing hospitalization — so effective that in November, the clinical trial stopped enrolling new participants because investigators concluded it’d be unethical to put them in the control group. It has not yet been approved by the FDA, but it might be a game changer if, as is expected, it’s approved in January.
The FDA is also in the process of considering molnupiravir, another repurposed drug that looks to be moderately effective, though there are some concerns it could spur new viral variants.
Why is it so hard to find good guidance about treatments?
The US government has communicated little about Covid-19 treatment options. NIH guidelines about treatments like fluvoxamine haven’t been updated since this past spring, meaning results from recent high-quality studies haven’t been incorporated into that guidance. Without it, physicians considering whether to prescribe these medications can’t turn to official public health resources for help.
From a certain perspective, that reticence is understandable. Learning which Covid-19 treatments work is very hard. While large-scale RCTs found promising evidence for fluvoxamine and inhaled budesonide, “promising” is still the most we can say — it could absolutely turn out that the real-world effects are much smaller than hoped for, or even fail to materialize altogether.
But it’s precisely because this area is so difficult to navigate for doctors and patients that the CDC, FDA, and NIH could play an important role in pointing out good treatments — yet it’s a role they have been puzzlingly reluctant to play.
Perhaps because of the dearth of formal federal government guidance on treatments — and because of politically driven crazes over drugs like hydroxychloroquine and ivermectin, which evidence thus far suggests do little to fight Covid-19 — Florida media has been critical of Ladapo’s PSA and its recommendations.
Politicians who pander to anti-vax sentiment are harming their constituents, and it’s very reasonable to be frustrated with their conduct. Ladapo is a DeSantis appointee who has forcefully opposed Covid-19 restrictions — and has refused to wear a mask in meetings with immunocompromised legislators — and lots of people are reasonably reading his PSA in that light.
But that justified irritation shouldn’t get in the way of a needed conversation about the possible benefits and drawbacks of monoclonal antibodies, fluvoxamine, and budesonide. As the US braces for an omicron surge that is likely to hit even vaccinated people, effective treatment is going to be essential for saving lives. Yes, promoting vaccines is a must, but tens of thousands of Americans are getting sick each day, which makes clear, accurate communication about which treatments to ask your doctor about extremely important.
The more society and public health get aligned on what works, the better off we’ll be in confronting omicron and other future variants.
Cartoon – Making Decisions vs Change
Cartoon – Backbone Deterioration
Michigan this week counted more people hospitalized with COVID-19 than at any other time during the pandemic
https://www.cnn.com/2021/12/09/us/hospital-covid-19-deaths-michigan/index.html
Nurse Katie Sefton never thought Covid-19 could get this bad — and certainly not this late in the pandemic. “I was really hoping that we’d (all) get vaccinated and things would be back to normal,” said Sefton, an assistant manager at Sparrow Hospital in Lansing, Michigan. But this week Michigan had more patients hospitalized for Covid-19 than ever before. Covid-19 hospitalizations jumped 88% in the past month, according to the Michigan Health & Hospital Association.
“We have more patients than we’ve ever had at any point, and we’re seeing more people die at a rate we’ve never seen die before,” said Jim Dover, president and CEO of Sparrow Health System.
“Since January, we’ve had about 289 deaths; 75% are unvaccinated people,” Dover said. “And the very few (vaccinated people) who passed away all were more than 6 months out from their shot. So we’ve not had a single person who has had a booster shot die from Covid.”
Among the new Covid-19 victims, Sefton said she’s noticed a disturbing trend.
“We’re seeing a lot of younger people. And I think that is a bit challenging,” said Sefton, a 20-year nursing veteran.She recalls helping the family of a young adult say goodbye to their loved one. “It was an awful night,” she said. “That was one of the days I went home and just cried.”
‘We haven’t peaked yet’
It’s not just Michigan that’s facing an arduous winter with Covid-19. Nationwide, Covid-19 hospitalizations have increased 40% compared to a month ago, according to data from the US Department of Health and Human Services. This is the first holiday season with the relentless spread of the Delta variant — a strain far more contagious than those Americans faced last winter.
“We keep talking about how we haven’t peaked yet,” Sefton said.Health experts say the best protection against Delta is to get vaccinated and boosted. But as of Thursday, only about 64.3% of eligible Americans had been fully vaccinated, and less than a third of those eligible for boosters have gotten one.
Sparrow Hospital nurse Danielle Williams said the vast majority of her Covid-19 patients are not vaccinated — and had no idea they could get pummeled so hard by Covid-19.“Before they walked in the door, they had a normal life. They were healthy people. They were out celebrating Thanksgiving,” Williams said. “And now they’re here, with a mask on their face, teary eyed, staring at me, asking me if they’re going to live or not.”
‘The next few weeks look hard’
Dover said he’s saddened but not surprised that his state is getting walloped with Covid-19.“Michigan is not one of the highest vaccination states in the nation. So it continues to have variant after variant grow and expand across the state,” he said.
“The next few weeks look hard. We’re over 100% capacity right now,” Dover said.”Most hospitals and health systems in the state of Michigan have gone to code-red triage, which means they won’t accept transfers. And as we go into the holidays, if the current growth rate that we’re at today, we would expect to see 200 in-patient Covid patients by the end of the month — on a daily basis.”And that would mean “absolutely stretching us to the breaking point,” Dover said.”We’ve already discontinued in-patient elective surgeries,” he said. “In order to create capacity, we took our post-anesthesia recovery care unit and converted it into another critical care unit.”
‘There’s a lot of frustration’
Nurse Leah Rasch is exhausted. She’s worked with Covid-19 patients since the beginning of the pandemic and was stunned to see so many people still unvaccinated enter the Covid unit.
“I did not think we’d be here. I truly thought that people would be vaccinated,” the Sparrow Hospital nurse said.”I don’t remember the last time we did not have a full Covid floor.”The relentless onslaught of Covid-19 patients has impacted Rasch’s own health. “There’s a lot of frustration,” she said. “The other day, I had my first panic attack … I drove to work and I couldn’t get out of the car.”
‘We need everybody to get vaccinated’
Dover said many people have asked how they can support health care workers.”If you really want to support your staff, and you really want to support health care heroes, get vaccinated,” he said. “It’s not political. We need everybody to get vaccinated.”
He’s also urging those who previously had Covid-19 to get vaccinated, as some people can get reinfected.”My daughter’s a good example. She had Covid twice before she was eligible for a vaccine,” Dover said. “She still got a vaccine because we know that if you don’t get the vaccine, just merely having contracted Covid is not enough to protect you from getting it again. And I know that from personal experience. “And those who are unvaccinated shouldn’t underestimate the pandemic right now, Dover said.
“The problem is, it’s not over yet. I don’t know if people realize just how critical it still is,” he said.”But they do realize it when they come into the ER, and they have to wait three days for a bed. And at that point, they realize it.”
Americans Are Already Over Omicron
Americans seem to be greeting the Omicron variant with a collective “eh,” according to new polling data from Axios/Ipsos.
Compared to other COVID-19 strains, Omicron seems to be extra transmissible and possibly more likely to cause breakthrough infections, at least based on preliminary data. As of Dec. 8, 22 U.S. states had reported at least one case related to the variant. But despite the early panic about the variant, most people surveyed by Axios/Ipsos in early December said they weren’t going to make big changes to their behavior. Specifically, the poll found that just:
- 33% of surveyed U.S. adults are likely to stop dining inside restaurants
- 28% are likely to stop gathering with people outside their households
- 23% are likely to cancel holiday travel plans
- 13% are likely to stop going to work in person
It’s hard to blame people. At this point in the pandemic, it’s safe to say everyone is tired and ready to be done with COVID-19. Plus, 60% of the U.S. population is now fully vaccinated, and thus, based on what we’ve seen so far, largely protected from the worst the virus can do. People who have received a booster dose are in an even better position, given early reports that boosters hold up well against Omicron.
Americans are also, to some degree, doing what public figures told them to do. President Joe Biden called Omicron “a cause for concern—but not a cause for panic.” And many health officials have jumped to assure the public that we are not going back to square one, thanks to the protection offered by vaccines.
The caveat, however, is that we’re still learning about Omicron. Early indications suggest the variant does not cause more severe disease than other variants, but it’s too soon to say that definitively. If it does turn out to be highly contagious, good at outsmarting vaccines and capable of causing serious disease, we may have to return to some precautions, for the sake of individuals and our overburdened health care system. The variant is already taking root in Europe, which may be a harbinger of what’s to come here.
The good news? The Axios/Ipsos poll did find that most Americans are still willing to step up and take protective measures when necessary. More than 60% said they were likely to go back to (or continue) always masking in public, and almost 70% said they’d support businesses requiring customers to wear masks.
Facing a “new normal” of higher labor costs
https://mailchi.mp/161df0ae5149/the-weekly-gist-december-10-2021?e=d1e747d2d8
Attending a recent executive retreat with one of our member health systems, we heard the CEO make a statement that really resonated with us. Referring to the current workforce crisis—pervasive shortages, pressure to increase compensation, outsized reliance on contract labor to fill critical gaps—the CEO made the assertion that this situation isn’t temporary. Rather, it’s the “new normal”, at least for the next several years.
The Great Resignation that’s swept across the American economy in the wake of COVID has not spared healthcare; every system we talk to is facing alarmingly high vacancy rates as nurses, technicians, and other staff head for the exits. The CEO made a compelling case that the labor cost structure of the system has reset at a level between 20 and 30 percent more expensive than before the pandemic, and executives should begin to turn attention away from stop-gap measures (retention bonuses and the like) to more permanent solutions (rethinking care models, adjusting staffing ratios upward, implementing process automation).
That seemed like an important insight to us. It’s increasingly clear as we approach a third year of the pandemic: there is no “post-COVID world” in which things will go back to normal. Rather, we’ll have to learn to live in the “new normal,” revisiting basic assumptions about how, where, and by whom care is delivered.
If hospital labor costs have indeed permanently reset at a higher level, that implies the need for a radical restructuring of the fundamental economic model of the health system—razor-thin margins won’t allow for business to continue as usual. Long overdue, perhaps, and a painful evolution for sure—but one that could bring the industry closer to the vision of “right care, right place, right time” promised by population health advocates for over a decade.
Affiliation improves rural hospital sustainability
https://mailchi.mp/161df0ae5149/the-weekly-gist-december-10-2021?e=d1e747d2d8
In 2020, a record-breaking 19 rural hospitals closed their doors due to a combination of worsening economic conditions, changing payer mix, and declining patient volumes. But many more are looking to affiliate with larger health systems to remain open and maintain access to care in their communities. The graphic above illustrates how rural hospital affiliations (including acquisitions and other contractual partnerships) have increased over time, and the resulting effects of partnerships.
Affiliation rose nearly 20 percent from 2007 to 2016; today nearly half of rural hospitals are affiliated with a larger health system.
Economic stability is a primary benefit: the average rural hospital becomes profitable post-affiliation, boosting its operating margin roughly three percent in five years. But despite improved margins, many affiliated rural hospitals cut some services, often low-volume obstetrics programs, in the years following affiliation.
Overall, the relationship likely improves quality: a recent JAMA study found that rural hospital mergers are linked to better patient mortality outcomes for certain conditions, like acute myocardial infarction. Still, the ongoing tide of rural hospital closures is concerning, leaving many rural consumers without adequate access to care. Late last month, the Department of Health and Human Services announced it would distribute another $7.5B in American Rescue Plan Act funds to rural providers.
While this cash infusion may forestall some closures, longer-term economic pressures, combined with changing consumer demands, will likely push a growing number of rural hospitals to seek closer ties with larger health systems.
Cartoon – Building Up Speed
Importance of Leadership Courage
HENRY KOTULA 