4/15/20 Primary Care and Public Health COVID Updates

It has been 25-28 days since local and State-wide Orders to Stay at Home was issued, and there are early signs that this (combined with related activities: many essential staff working from home, physical distancing, wearing facial coverings in public) have slowed the rate of new case identification, deaths, hospitalizations, and ICU bed utilization.  It is too soon to ease up on vigorous public health measures, but this trend, combined with analysis of current bed capacity suggests that the peak number of cases for this first wave of COVID-19 in our region may not stress our health care delivery system as severely as we were concerned about earlier.  The price of this apparent success is a large non-immune (and therefore susceptible to COVID) population which can lead to rapid focal outbreaks as public health measures are eased.  Yesterday Governor Newsom described the outline of how this delicate task might unfold.

A major task for outpatient providers will be to establish trust in the population that they can safely come in to the office for important medical, dental, vision, lab, radiology and physical therapy visits (that cannot adequately be done via video visits), even while many public health restrictions remain in place.  To be successful, practices will need to pair careful adherence to rigorous infection control procedures with a positive yet nuanced marketing campaign.

Here is a summary of major updates from PHC, the state and the medical word related to COVID-19, from the last 5 days.

1. Policy Updates:

A. Pending Changes to the 2020 PCP QIP: Due to the extenuating                        circumstances related to COVID-19, PHC’s internal and external                        committees have made recommendations for changes to the 2020 Primary      Care Provider Quality Improvement Program (PCP QIP).  The Core                  Measurement Set will be modified to a smaller group of measures, with            more attainable benchmark goals, as noted below.

Proposed Point Allocation and Threshold Changes:

  Family Practice Internal Medicine Pediatrics 50th Percentile
Clinical Measures Points per measure Full Points
Well-Child  Visit, First 15 months of Life (W15) 15.0 25.0 65.83%
Controlling High Blood Pressure (CBP) 15.0 20.0 61.04%
Colorectal Cancer Screening (COL)* 12.5 20.0 32.24%
Diabetes – HbA1C Good Control <9 (A1c) (CDC) 12.5 20.0 50.97%
Childhood Immunization Combo 10 (CIS-10) 15.0 25.0 34.79%
Asthma Medication Ratio (AMR) 15.0 20.0 25.0 63.58%
Non-Clinical Measures      
PCP Office Visits** 15.0 20.0 25.0 TBD
TOTAL POINTS AVAILABLE 100.0 100.0 100.0

* Colorectal Cancer Screening is the only measure in the PCP QIP that does not have an NCQA Threshold equivalent for PHC. The threshold here is the 25th percentile across the entire plan.

** The threshold for PCP Office Visits will be established after PHC has more data on the impact of the COVID-19 Pandemic and orders to shelter in place.

    The specifications for measures in the Core Measurement Set are not              changing, but some specification modifications are proposed for several            Unit of Service Measures.  Of note, we are lowering the thresholds for              submission of attestations for advance care planning conversations and            Advance Directives/POLST form updating.  This is an excellent time to              focus attention on this measure, as noted below.

    This collection of changes is a proposal that is pending final approval       and final specifications.  Final approval will be obtained from our               Physician Advisory Committee, in early May 2020.  The final details and       full specifications will be released by Mid-May 2020.  We are informing you       of the highlights of the Core Measure Set Changes so you can align your         activities to this more focused group of measures.

B. Difficult Conversations in the Time of COVID-19. Geriatricians are noting           greater receptivity to advance care planning conversations during the               COVID pandemic.  If your PCP practice has extra capacity, you may be             considering outreaching to more vulnerable patients to update their                   advance directives and POLST forms.  The Coalition for Compassionate           Care of California is hosting a free webinar today at noon by an expert in           palliative care communication, Robert Arnold.  A recording of this webinar         will be available afterwards on their website.  An excellent prior webinar             covering advance care planning in a virtual visit environment and other             COVID-specific issues is also available, on the same page.  The Coalition         also has put together an excellent COVID Conversations Toolbox with               other resources.

C. Presumptive Eligibility for Uninsured or Underinsured individuals with                COVID.  The Department of Health Care Services (DHCS) is creating a            new aid code that will allow individuals to seek the necessary diagnostic            testing, testing-related services, and treatment services, including all                medically necessary care, through the Medi-Cal fee-for-service (FFS)            program.  This new aid code will be available to California residents with          no insurance or who currently have private insurance that does not cover          diagnostic testing, testing-related services, and treatment service, including      all medically necessary care for COVID-19.  It will be available, regardless        of the person’s immigration status, income, or resources.

    The covered diagnostic test, testing-related services, and treatment                  services, including all medically necessary care such as the associated            office, clinic, or emergency room visit are paid up to the maximum FFS              Medi-Cal rate.  Individuals in this program will not be enrolled in a              Medi-Cal managed care plan, so services must be billed through FFS. 

D. DHCS requested flexibility on timing of Initial Health Assessments (IHA) for       new Medi-Cal beneficiaries.  CMS requires DHCS to require the health             plans to ensure that all new Medi-Cal beneficiaries have an initial health           assessment (a first visit, including a health screening with the DHCS’s               Staying Healthy Assessment questionnaire.  Normally this assessment             includes an examination and must occur within 120 days of enrollment into       Medi-Cal Managed care.  Since a new Medi-Cal member has 1 month to           select a PCP, the assigned PCP has about 90 days to complete this                   assessment.

     Four days ago, DHCS requested the flexibility to have up to 180 days to           complete this initial assessment.  We will monitor this and inform you when       CMS responds.  In the meantime, as mentioned in the last email (related to       state prisoner release), we hope you will develop a process for conducting       new patient intake appointments through virtual visits.

2. Coronavirus PCR Testing

A. Quest issued an updated specimen collection guide (attached). This                   includes the methodology for collecting nasal swab specimens (which can         be self-collected), as well as a number of permitted substitutions for scarce       collection gathering supplies.

B. Scarce testing materials being spread out.  Quest informed us that due to         regulatory reasons related to responding to a shortage of supplies, testing         materials that are sent out must be mostly used up before replacement             testing materials are replenished.  This means that most large volume               testers will be frequently feeling like they are on the verge of running out of       supplies.  Close communication as any particular component of testing             runs low is important.

C. Adapting testing recommendations in office setting as tests become more        available.  The CDC recommends that individuals with mild illness consult        their medical provider to decide if they should be tested or not.  Office-              based testing criteria may be looser than County Health Department                  criteria for testing.  If patient is staying at home anyway, there is little                  urgency in identifying milder cases of COVID.

    As testing becomes more available, and as Stay at Home Orders are lifted,      we must think differently about testing milder illness to identify clusters of          infection earlier.  County Health Departments will be involved in making            recommendations to their local PCPs about testing criteria.  If a PCP has          plenty of testing capacity, be sure to let your local health department know,        so they can guide you on what criteria to use to expand testing.

     Examples of expanded testing strategies:  The county health department           may ask PCPs to assist with testing known contacts of confirmed COVID         cases or doing follow up testing on patients with suspicious symptoms with       a negative initial test, for example.  They may ask a subset of providers to         test all patients with mild respiratory symptoms as part of community                 surveillance or recommend testing anyone with any level of suspicious             symptoms (something being done in Michigan).  With sufficient capacity,           some testing of asymptomatic essential workers (e.g. grocery store clerks,       bus drivers, EMTs, hardware store workers) who are regularly exposed to         the public may be helpful to prevent asymptomatic transmission.  A                   hospital in New York tested all pregnant women arriving in labor, and found       14% of asymptomatic women tested positive, prompting precautions to             prevent spread in the hospital.

     These are but a few options.  Developing a local strategy for scaling up             testing as it becomes more available is worth a joint discussion between           local clinicians and public health leaders.

D. PCR tests vs. Imaging for confirming COVID.  The sensitivity of COVID             PCR tests is fair (around 70%), and the results take a while to come back.         An emergency room in New York found that half of all patients with COVID       had an abnormal chest X-ray (usually bilateral, peripheral or basilar                   pattern,  sometimes described as ground glass interstitial pneumonitis).  A         study in China, among patients admitted with COVID, found that 95% had         an abnormal CT scan of a particular pattern.  Some radiologists in the US         have been hesitant to recommend using CT for diagnosis, citing concerns         about the need to sterilize the CT scanner after scanning a patient with             suspicious symptoms.  As their primary justification, they state that there           are methodological problems with the studies published so for on CT’s               specificity for COVID.

     Decisions to test a patient should not be dominated by concern over                 cleaning the equipment.  If patient with hypoxia and a normal Chest X-ray         is admitted to the hospital, given the differential diagnosis, a CT scan                 would often be helpful in ruling out non-COVID pathology, as well as                 helping with in-hospital disposition if the patient does have a pattern                 consistent with COVID, while awaiting PCR test results which have only a         70% sensitivity.

3. Coronavirus Antibody Tests  (Thanks to Dr. Marshall Kubota for gathering these studies) 

A. Pattern of Development of Neutralizing Antibodies.  A Chinese study of 175       patients with COVID found that SARS-CoV2 specific neutralizing                       antibodies developed starting 10-15 days after “onset of disease.”  Patients       with milder disease had lower plasma titers of these antibodies than those         with more severe disease.  Ten patients with confirmed COVID had                   undetectable antibodies, suggesting either a poor response or perhaps that       the PCR test/clinical diagnosis had a specificity of 94% to match its                   sensitivity of 70%.

B. Similar pattern of antibodies was found in a Norwegian Study of H1N1,            which found that 2/46 patients diagnosed with mild H1N1 had no                        detectable antibodies to H1N1.  Again, this may reflect either a poor                  generation of an immune response or a specificity of 96% in the initial                diagnostic test for H1N1.

C. Other Coronaviruses Exhibit waning Immunity over Time.  Interviews of             experts by NPR noted that the more benign coronaviruses that cause the         common cold can cause repeat sickness, even if a person has a                       documented prior antibody response.  Speculations on potential reasons           include genetic variation of the virus over time or some other factor that             impacts the effectiveness of antibodies from prior infection.  Since classic         SARS was found to have a more robust and long-term immune response,         and they were all symptomatic with serious infection, this supports the               hypothesis that surviving more serious illness generates a longer-lasting           and stronger response.

4. Bio-aerosols and masks

A. The study that prompted CDC to recommend wearing face coverings in             public showed that surgical masks reduced coronavirus detection and viral       copies in large respiratory droplets and aerosols from exhaled breathing           (versus coughing, in which some spread occurs with any facial covering).

B. Another study pointing toward potential aerosol spread was done at the US      biohazard containment center in Nebraska.  Presented at a National                  Academy of Science Webinar, Dr. John-Martin Lowe showed that viral RNA      was detected at distances greater than 6 feet from 82% of COVID positive        outpatients in a quarantine facility and was also detectable in air samples in      the hallways outside the patient rooms.  It is not known yet if this viral DNA        was part of infectious viral particles.  In the Q&A, Dr. Lowe quoted a                  Singaporean study that showed that viral RNA was found on particles 1-4          microns in size (bio-aerosol size).  He said it was better to think of Droplet        and Aerosol as being part of a continuum of infectiousness and infectivity in      COVID.  This means that perhaps the aerosol infectivity is less than                  measles, it can still be transmitted via aerosols, particularly in closed                spaces where the infectious aerosols can build up in concentration to a            dose sufficient to infect those who spend time in that space.

C. Dry heat better than autoclave for sterilizing N95 masks for re-use.                    (Thanks  to Dr. Mills Matheson for finding this reference.)  In an earlier              email a couple of weeks ago, I reviewed an article showing that autoclaving      preserved filtration better than alcohol, ultraviolet light and gas sterilization.      A better study looking at various conditions shows that heating masks to           170-200 degrees Farenheit for 30 minutes resulted in a trivial loss of                  filtration, even when repeated 20-50 times.  Filtration started to drop off            steeply at temperatures over 212 degrees.  Steam resulted in greater loss        of filtration integrity (about 2% per steam cycle), explaining why                          autoclaved N95 masks should probably be discarded after just a few                autoclaved cycles, and why the rice cooker sterilization method mentioned        in a prior email is done without adding water to the rice cooker.  A CDC              summary of methods of re-using N95 is not very helpful, listing many                options but not distinguishing between them very well.

5. Other Scientific Updates 

A. Case report of Guillain Barre syndrome associated with onset of COVID            (“parainfectious profile”) instead of “postinfectious profile” seen with Zika          and other viruses.

B. Studies of Compassionate Use of Convalescent Plasma.  The same NAS        webinar as noted above described the state of knowledge of studies of              using plasma from patients who have recovered from COVID to treat                critically ill patients with COVID.  Earlier studies in classic SARS found a          tripled survival rate associated with this treatment.  Starting March 24, the        FDA has allowed compassionate use of convalescent plasma to treat                COVID.  A clinical trial was started on April 3 at Johns Hopkins.  On April 8,      the FDA published recommendations on its use.  Blood banks can collect          plasma from patients recovered from COVID.  See the American Red Cross      website for screening criteria.  For a moving account of one New York City        Oncologist’s effort to find matching plasma for her critically ill brother-in-            law’s father, see this article in the Atlantic.  One recovered patient’s plasma      can be used to treat 3 critically ill patients.

C. Compassionate Use Experience of Remdesivir.  This summary of                       experience with the use of Remdesivir based on compassionate use in             hospitalized patients suggested better outcomes compared to historical             experience.  Controlled trials are in progress.

6. On a lighter note: Personalizing care while wearing full PPE:  put your                       portrait onto your gown.

PPE Portraits

PPE Portraits

See this document for details, credits and a how-to guide.  “PPE Portraits are simply disposable portrait picture stickers (4×5) put on PPE – personal protective equipment.  Anecdotal pilot data captured during treatment of Ebola showed the PPE Portrait Project helped patients feel connected to their caregivers, and helped healthcare workers feel more like a team and less dehumanized, though this has yet to be formally studied.  From a placebo standpoint, we know that provider warmth and competence are positively associated with physiological health biomarkers.  From our standpoint, PPE signals competence; portraits could be one of the only signals of warmth for COVID19 and potentially-COVID19 patients.”

Thanks for your hard work and innovative spirit in this challenging time!

Robert Moore, MD MPH MBA,
Chief Medical Officer

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