Categories
Intensive Care Unit Procedure Areas

Credentialling For Common Bedside Procedures

In the past, nearly all internal medicine residents were required to perform common bedside procedures during residency. However, currently, bedside procedure competency is no longer required during residency and the result is that hospitals are often challenged to have credentialed hospitalists available to perform them. These procedures include central venous catheter placement, arterial line placement, thoracentesis, paracentesis, lumbar puncture, endotracheal intubation, arthrocentesis, and bone marrow aspiration/biopsy. In order to ensure that the hospital has coverage for these different procedures requires innovative provider coverage models and careful wording of credentialing requirement documents.

Summary Points:

  • Fewer internal medicine residents learn to perform common bedside procedures during residency than in the past.
  • Hospitalists are less likely to be able to perform these procedures than in the past.
  • Hospitals require innovative tactics to ensure that credentialed healthcare providers are available 24-hours a day to competently perform common bedside procedures.

 

Residency & fellowship training program requirements

There are two organizations that dictate residency and fellowship training requirements, the Accreditation Council for Graduate Medical Education (ACGME) and the specialty board. In the case of internal medicine, the specialty board is the American Board of Internal Medicine (ABIM). The ACGME determines what the training programs have to teach and the ABIM determines what competencies trainees must have in order to become board certified. For internal medicine residents, the ACGME program requirements document states: “Residents are expected to demonstrate the ability to manage patients by demonstrating competence in the performance of procedures as appropriate to their career paths“. The ACGME document further states: “Experience must include opportunities to demonstrate competence in the performance of procedures listed by the ABIM as requiring only knowledge and interpretation“. In other words, the ACGME defers to the ABIM to dictate what procedures are required. The ABIM procedure for certification document states: “Not all residents need to perform all procedures. Program directors must attest to general competence in procedures at end of training. Residents must have the opportunity to develop competence in procedures which will further their development as fellows in their chosen subspecialty or as independent practitioners in their intended fields if entering practice after residency“. In other words, the ABIM leaves it up to the resident to decide what procedures he/she wants to do and leaves it up to the residency program director to determine if the resident is competent to perform the procedure.

The ABIM also dictates competency requirements for subspecialties. As relevant to bedside procedures, the ABIM requires the following:

Notably absent are the procedures of lumbar puncture and paracentesis that are not required by any ABIM subspecialty for board certification.

The ACGME has different requirements for what procedures subspecialty fellows need to be competent to perform during their fellowship training. In many cases, the ACGME subspecialty requirements differ from the ABIM subspecialty board requirements. Notably, paracentesis is required for gastroenterology, pulmonary, and critical care fellowship training. Also, lumbar puncture is required for pulmonary and critical care training. The ACGME has the following requirements for subspecialty fellows:

Although most hospitalists do internal medicine residencies, some hospitalists do family medicine residencies. Neither the ACGME nor the American Board of Family Medicine have specific procedure requirements.

In some hospitals, emergency medicine physicians perform many bedside procedures for hospital inpatients when there is no other provider available to perform those procedures. The ACGME training requirements for emergency medicine includes competency (with required numbers of procedures) in endotracheal intubation (35), central lines (20), lumbar puncture (15), sedation (15), and chest tubes (10).

The bottom line from the ACGME and ABIM is that hospitalists come out of residency training with variable procedural skills. Increasingly, many of them are not proficient to perform any bedside procedures. Over time, it can even become difficult for those residents who do want to be trained in bedside procedures to get that experience. Residents can only perform a procedure under the supervision of an attending physician who is credentialed for that procedure. As fewer of their internal medicine attendings perform these procedures, it can become difficult for the residents to get experience doing procedures during their training. This can result in a patchwork of consultation for procedures: anesthesia for endotracheal intubation, pulmonary for thoracentesis, rheumatology for arthrocentesis, interventional radiology for lumbar puncture & paracentesis, and surgery for central lines. In the middle of the night, it often falls to the emergency medicine physician on-duty to perform any bedside procedure.

Hospital credentialing

The ACGME and ABIM only determine what procedures are necessary to be taught during training or to become board-certified. Decisions about whether or not a physician is permitted to perform a procedure lies with the hospital’s credentials committee to set criteria for hospital privileges. There are two types of privileges: core privileges and optional privileges.

Core privileges are those that any physician credentialed in a given specialty can perform, without additional requirements. It can be easy to select a procedure to include in core privileges when either the ACGME dictates that competency in that procedure is required to complete residency/fellowship training or the ABIM dictates that competency is required to become board certified in that specialty. For example, the ACGME requires cardiology fellows read at least 3,500 EKGs during fellowship training and the ABIM requires pulmonologists be proficient in conscious sedation to become board certified. But credentials committees can also add additional procedures into core privileges that are not required by either the ABIM or the ACGME. These are typically procedures that are commonly performed by residents or fellows in their training even though they may not be specifically required by the ACGME or ABIM. In this case, the procedures are usually listed in the hospital privilege application with the option for the applicant to either request or opt out of each individual procedure privilege. It is then up to the department chair to attest whether or not the applicant is competent to perform that particular procedure. Including lumbar puncture in core privileges for hospitalists is an example.

Optional privileges are those for procedures that some physicians in a given specialty perform but others do not. These are generally not procedures that either the ACGME or ABIM specifies in their requirements and are procedures that require a relatively high level of skill or high level of risk. Often, the credentials committee will require documentation of successful completion of a certain number of these procedures under supervision. Including endotracheal intubation as an optional privilege for a hospitalist is an example.

When a physician get his/her initial appointment to a hospital’s medical staff, it is usually for a short probationary period – typically 6-months. At the end of the probationary period, if the new physician has not had any major quality issues, that physician then moves from a probationary appointment to a regular, full medical staff appointment. The probationary period is an opportune time for physicians who lack adequate training in a procedure to learn how to do that procedure and generate sufficient procedure numbers to qualify for hospital privileges for that procedure when they move from a probationary appointment to a regular appointment to the medical staff.

Hospital privileges usually last for 2 years at which time the physician must apply for re-credentialing. For core privileges, this usually just requires the physician to request those privileges without additional documentation (other than approval by the department chairman). Optional privileges will usually require documentation of on-going competency, such as a patient procedure log documenting the number of that particular procedure the physician has performed in the past 2 years. It is important that the credentials committee is careful and realistic in choosing which procedures require a specific number every 2 years to retain privileges for that procedure. For example, if the hospital has 18 hospitalists and there are a total of only 25 lumbar punctures performed in the hospital every 2 years, then if the credentials committee requires every hospitalist to perform 10 lumbar punctures every 2 years to retain lumbar puncture privileges, none of the hospitalists will realistically be able to do enough lumbar punctures to meet the privilege requirement. That hospital will soon find itself with no hospitalists credentialed to perform lumbar puncture.

Some practical solutions

It is the credentials committee’s obligation to ensure that anyone performing a procedure in the hospital is competent to do that procedure. It is the medical director’s obligation to ensure that when a patient needs a particular procedure, there is a person with hospital privileges available to do it. In order to meet both of these obligations, there are some specific tactics that the hospital can take.

  1. Include procedures that are already in ACGME or ABIM requirements in core privileges. In this case, there is no need to “recreate the wheel” by requiring procedure logs and it only results in applicants keeping unnecessary duplicate records. For example, since the ABIM requires that cardiology fellowship directors attest that a cardiology fellowship graduate is competent to perform cardioversion and since the ACGME requires cardiology fellows to document doing at least 10 cardioversions to graduate from fellowship, there is no need for a new cardiologist to have to provide procedure logs in order to become privileged to perform cardioversion as a member of the medical staff.
  2. Strategically include other low-risk procedures in core privileges. Since most hospitalists are general internists and neither the ACGME nor the ABIM have requirements for any procedures, this will apply to just about any procedure included in hospitalist core privileges. These should include those procedures that are commonly performed during residency and are relatively low risk. Examples are skin punch biopsies, arthrocentesis, and lumbar puncture. Giving the applicant the ability to opt-in or opt-out for individual procedures on the hospital privilege applications allows those hospitalists who have not been trained in these procedures to opt-out. The responsibility of confirming that the hospitalist is competent to perform these procedures thus lies with the division director or department chair who has to sign-off on the application before it goes to the credentials committee. This overcomes the problem of performing a specific number of a rarely performed procedure every two years, especially for procedures that pose relatively low risk of complications, such as a skin biopsy or lumbar puncture.
  3. Include optional privileges for any conceivable bedside procedure that a hospitalist might perform. This is particularly useful for procedures such as central venous catheters and endotracheal intubation. Some internal medicine residents perform many of these during residencies and become quite proficient with them. If a medical staff applicant can produce a procedure log documenting 20 successful proctored endotracheal intubations during internal medicine residency (which is the same number of intubations required by the ACGME for emergency medicine), then that internal medicine hospitalist should be eligible for intubation privileges.
  4. Develop training opportunities for optional procedures. If the hospitalists are the only physicians in the hospital at night, then hospitalists need to be credentialed to perform endotracheal intubation and central venous catheterization. If they were not adequately trained to do these procedures during residency, then the hospital needs to provide that training. At our hospital, we had new hospitalists without prior intubation training spend a couple of mornings in the operating room with our anesthesiologists to get a minimum number of proctored intubations. We additionally required then to perform a specific number of emergency intubations in the ICU and during code blues that were observed by one of the senior hospitalists. We also required them to attend an airway course in our simulation lab in order to get additional experience using different laryngoscopes, bougies, and end-tidal CO2 monitors.
  5. Don’t forget about ultrasound. Bedside ultrasound is routinely used during thoracentesis, paracentesis, arterial lines, and central venous catheters – it makes performing these procedures safer and reduces complications. In fact, many residents and fellows have never performed these procedures without using bedside ultrasound. Residents and fellows typically go through a formal ultrasound training course in a simulation lab. Completion of such a course is often required for bedside ultrasound privileges. We found that many of our older physicians learned how to use bedside ultrasound during their regular clinical practice and never attended an ultrasound course. When documentation of attending a course was required for hospital privileges, these physicians had to stop using ultrasound. The hospital has to be careful with ultrasound privileges – by being too strict, it can force physicians to do procedures such as central line placement without ultrasound guidance with the unintended result that patients are being made less safe. The reality is that today’s bedside ultrasounds are simple to use – it took me longer to learn how to use my fish finder sonar than the hospital ultrasound device. As ultrasound becomes increasingly ubiquitous during residency training, separate credentialing to use ultrasound for venous access guidance makes about as much sense as requiring separate credentialing to use a stethoscope.
  6. Utilize simulation labs. Particularly when credentialing or re-credentialing a physician for an infrequently performed procedure, a simulation lab can be invaluable. Performing a procedure is a skill and like every skill, the more you practice, the better you get. A simulation lab can allow a physician to do many practice procedures and can provide an opportunity for a more skilled proceduralist to give technique pointers and feedback. Although intubating a manikin is a lot different than intubating a live patient during CPR, practice in a simulation lab can at least allow a reduction in the number of live patient procedures required for re-credentialing every 2 years.
  7. Allow non-physician staff to work at the top of their license. Once again, endotracheal intubation is a great example. Respiratory therapists are trained in performing intubation during respiratory therapy school and most states allow respiratory therapists to perform intubations. When our hospital replaced our previous hospitalist group with a new hospitalist group, the new group did not perform intubations (and did not want to). We permitted our respiratory therapists to be credentialed to perform intubations at night (when hospitalists were the only physicians physically in the hospital). We used the same process of anesthesia proctored intubations in the OR, attendance at a simulation lab airway lab, and a specific number of emergency intubations observed by a previously credentialed provider.
  8. Utilize advance practice providers. Nurse practitioners and physician assistants do not have any specific procedure experience required during initial training. There are some advance practice provider fellowships (for example, our medical center has a 1-year critical care nurse practitioner fellowship) and these fellowships often include procedural training. Our critical care NPs and PAs can be credentialed to perform intubation, central venous line placement, and arterial line placement in the ICU.
  9. Consider procedure teams. These are particularly useful in large hospitals that have a reliably large number of regularly performed bedside procedures. These are sometimes lead by a physician credentialed in common procedures but are often staffed by advanced practice providers (NPs and PAs). Elective and semi-elective procedures that lend themselves for NP/PA procedure teams include central lines, lumbar puncture, thoracentesis, paracentesis, and bone marrow biopsy.
  10. Do not over-rely on surgeons and anesthesiologists. Some hospitals are large enough to have a designated in-house anesthesiologist (or CRNA) available to perform emergency intubations outside of the operating room. But small and medium-sized hospitals usually have all of their anesthesiologists assigned to operating rooms during the day and may not have an in-house anesthesiologist at night. Anesthesiologists and surgeons need to be in the operating room and usually cannot just pause a surgical procedure to run out to the ICU to place a central line or intubate a patient. Reserve using anesthesiologists for intubating only difficult airways and using surgeons for only difficult venous access situations.
  11. Have a back-up plan. Emergency medicine physicians are credentialed for most bedside procedures. However, ER doctors really need to remain physically in the ER whenever possible. They can be an important back-up at night in situations when the provider covering the ICU or covering code blue calls is unable to successfully intubate a patient or place a central venous catheter. Anesthesiologists often can play this same back-up role for intubations and surgeons can often play the same back-up role for central lines. But they should generally only be called as a last resort when the first line provider is unsuccessful.
  12. Promote a hospital culture of mutual assistance. As a pulmonary/critical care physician, I had hospital privileges for all common bedside procedures as well as deep sedation. As the hospital medical director, I was usually present in the hospital when not seeing outpatients in the clinic building. I frequently had the cardiologists (who were credentialed for moderate sedation but not deep sedation) schedule cardioversions between my hospital meetings and would pop in to push intravenous propofol and fentanyl for deep sedation. I also frequently performed lumbar punctures and endotracheal intubations when there was not a credentialed provider present. Not every medical director is credentialed for bedside procedures or has the time during the day to perform bedside procedures. But there is frequently other experienced physicians present in the hospital at any given time who can assist a hospitalist or other physician who is not experienced in performing a given procedure. The medical director can promote a culture of mutual assistance

It’s a new era

In bygone times, teaching hospitals were run by internal medicine and surgical residents. They were in the hospital 24-hours a day and did any and all bedside procedures by the time they were senior residents. The training process consisted of “see one, do one, teach one”. And the volume of procedures was so great that there were plenty of them for all residents to become proficient.

But things have changed. Antiseptic catheter coatings eliminated the need to place fresh central lines and arterial lines every 3 days. Ultrasonography reduced the need for pulmonary artery balloon catheters. PICC lines eliminated the need for many central lines. Better imaging reduced the need for lumbar punctures, thoracenteses, and paracenteses. In addition, quality initiatives increased the training requirements to demonstrate procedure competency. The ACGME and the ABIM reduced and in come cases eliminated the requirements for procedure proficiency for residency/fellowship completion or board certification.

As a consequence, internal medicine trainees now perform fewer procedures during residency/fellowship and hospitalists are frequently not prepared to perform those procedures when they join the medical staff. Hospitals must develop innovative new strategies so that all patients and get the procedures they need anytime of the day and night. The best solution for one hospital may not be the best solution for another hospital. But it is clear that hospitals can no long rely on the training and credentialing processes that were used 20 years ago.

September 26, 2022

Categories
Outpatient Practice

Who Should Treat Hepatitis C?

An August 2022 study in the MMWR found that only 1 out of 3 people with hepatitis C are getting treated… and all of the patients in the study had health insurance. What are the barriers to treatment and how can we overcome them?

Summary Points:

  • Hepatitis C is common: 2 million Americans have chronic active infection.
  • Hepatitis C is under-treated: only 1 out of 3 insured Americans diagnosed with hepatitis get treated.
  • New therapy regimens have simplified the treatment of hepatitis C
  • It is time for primary care physicians and advance practice providers to treat most patients with hepatitis C

 

Hepatitis C is incredibly common. Worldwide, 100 million people have been infected and 71 million have chronic liver disease from the virus… that’s 1% of the world’s population! Here in the United States, hepatitis C has infected 1.5% of Americans and 2 million Americans have chronic active infection. More than 75% of infected people have no symptoms and do not realize that they are infected. Once initially infected, two-thirds of people go on to have chronic active infection. Of those, about one out of five will develop cirrhosis about 20 – 30 years after the initial infection.  It causes 19,000 deaths per year in the U.S. It is the most common cause of chronic liver disease and is the leading reason for liver transplantation.

Because it is so common and because most patients are initially asymptomatic, the Centers for Disease Control and the United States Preventive Services Task Force both recommend that all adults > 18 years of age be tested at least once for hepatitis C. The screening test is a simple and widely available blood antibody test. If the screening test is positive, then the next step is a blood hepatitis C RNA test to determine if the patient has chronic active infection. If the RNA test is negative, then the patient has resolved the infection and does not have chronic hepatitis C. But if the RNA test is positive, then the patient has a chronic infection and and should be considered for treatment.

Prior to 1991, hepatitis C was incurable. For the next 20 years, alpha interferon and ribavirin were the only available treatments. However, these drugs had significant toxicity, required a very long duration of treatment, and only resulted in cure of 6% of treated patients. Over the past 10 years, new anti-viral drugs have been developed that can cure the vast majority of patients and only require 8 to 12 weeks of treatment. So, why aren’t more people being treated and cured?

There are not enough hepatologists

Unlike most infections, the treatment of hepatitis C has been the realm of hepatologists, rather than infectious disease specialists or primary care physicians. However, hepatologists are relatively few in number. Most hepatologists do a 1-year hepatology fellowship following completion of a 3-year gastroenterology fellowship. Hepatology is a relatively new subspecialty. In 2006, the first board examination for hepatology was offered and there are only 59 hepatology fellowship training programs in the United States. Currently, there are 7,296 U.S. healthcare providers whose self-described practice is > 50% hepatology. However, the majority of these are gastroenterologists and advance practice providers with only a minority being board-certified hepatologists. There is little financial incentive for gastroenterology fellows to train for an extra year to become hepatologists. A study published in the January 2021 edition of Hepatology Communications found that the median total compensation for hepatologists in the U.S. is $320,728 which was less than the total compensation for gastroenterology assistant professors at $329,600. In other words, the reward for doing a hepatology fellowship is that you make less money than you would had you not done the extra year of training.

Most hepatologists practice at a relatively few large, referral hospitals. Consequently, most hospitals do not have a hepatologist on their medical staff, thus requiring patients with hepatitis C to travel long distances in order to be evaluated and treated by a hepatologist. This has resulted in a geographic barrier for most patients and is a contribution to the low rate of infected patients getting treated.

What is so complicated about treating hepatitis C?

Treating most infections is relatively simple: you get a culture, you give an inexpensive antibiotic for 5-7 days, and you’re done. But treating hepatitis C is a lot more complicated and requires specialized testing, counseling, expensive medications, and laboratory follow-up. The current recommendations for treatment are published jointly by the American Association for the Study of Liver Disease and the Infectious Disease Society of America. This is a lengthly document that is daunting for most non-hepatologists. A Simplified HCV Treatment Algorithm for Treatment-Naive Adults Without Cirrhosis is available that summarizes the recommendations in just 1 page:

Initial evaluation. Once a patients are diagnosed with hepatitis C, they need to undergo a series of laboratory tests including:

    • FIB-4 calculation. This is based on the patient’s age and three blood tests (AST, ALT, and platelet count). An on-line calculator is available to easily determine the FIB-4 score.
    •  Cirrhosis assessment. Cirrhosis can be identified by a FIB-4 score > 3.25, liver biopsy, transient elastography (“Fibroscan”), imaging (CT or ultrasound), clinical evidence of cirrhosis, or laboratory test (such as the “Fibrosure” blood test).
    • CBC
    • Liver function tests
    • Glomerular filtration rate
    • Hepatitis C viral load (HCV RNA)
    • HIV test
    • Hepatitis B surface antigen
    • Pregnancy test (for women of childbearing potential)

Treatment regimens. There are 12 drugs approved to treat hepatitis C and choosing among them can be formidable for non-hepatologists. Different drug regimens are used for different viral genotypes. In addition, several drugs that were approved in the past 10 years have been recently discontinued as more effective newer medications have been introduced. The result is that physicians who do not keep up with new developments in hepatitis C medications on a regular basis often feel uneasy prescribing treatments. Fortunately, there are two currently recommended medication treatments for hepatitis C in patients without cirrhosis, regardless of which genotype of hepatitis C patients are infected with:

    1. Mavyret – glecaprevir (300 mg) + pibrentasvir (120 mg) for 8 weeks
    2. Epclusa – sofosbuvir (400 mg) + velpatasvir (100 mg) for 12 weeks.

Laboratory monitoring. The newer hepatitis C medications do not require routine lab monitoring. This is a significant improvement over previous drugs that required regular blood tests during treatment. Because of the possibility of drug interactions, patients with diabetes taking hypoglycemic drugs should have their glucose levels checked periodically and patients taking warfarin should have their INR levels checked periodically.

Post-treatment testing. 12 weeks after completing treatment, patients should have liver enzymes checked. They should also have a hepatitis C RNA level checked at that time to confirm that they are cured. Those patients who continue to have detectable HCV RNA may require referral to a specialist.

The two drugs used to treat hepatitis C are expensive. Mavyret costs $34,000 for an 8-week course if purchased out of pocket ($13,000 to $16,000 if purchased using GoodRx). Eclusa costs $31,000 for a 12-week course ($11,000 to $19,000 if purchased using GoodRx). Because of their expense, most commercial insurance companies require prior authorization when these medications are prescribed and this poses another barrier for non-hepatologists who are less familiar with the drugs.

The simplified recommended treatment regimen for patients with compensated cirrhosis is very similar to that used for patients without cirrhosis with the main difference being that Mavyret can be used for any genotype of hepatitis C but Eclusa can only be used for genotypes 1, 2, 4, 5, & 6. To make things utterly simple, if prescribing Mavyret, the same management protocol can be used whether or not a patient has compensated cirrhosis.

The simplified treatment regimens are applicable to most patients with chronic hepatitis C infection. Patients not eligible for one of the two simplified regimens will likely require referral to a specialist. This includes patients with:

  • Prior hepatitis C treatment
  • End-stage renal disease
  • Decompensated cirrhosis 
  • HIV or HBsAg positive
  • Current pregnancy
  • Known or suspected hepatocellular carcinoma
  • Prior liver transplantation

So, who should treat hepatitis C?

It is clear that the shear number of Americans infected with hepatitis C is too great for all patients to be treated by the country’s relatively few hepatologists. But fortunately, the newer regimens are very protocolized, making their use much simpler that previous regimens. Because of this, two groups of providers are now in position to treat most patients with hepatitis C.

  1. Primary care physicians. In the past, primary care physicians referred patients with hepatitis C to hepatologists or gastroenterologists for treatment. The drugs were toxic, expensive, and required complex regular monitoring. Furthermore, busy primary care physicians did not want to deal with insurance prior authorization for drugs that they were not very familiar with. The simplicity of the new treatment regimens now makes it easier for primary care physicians. All that is required is creation of a hepatitis C order set in the electronic medical record and a fairly straight forward prior authorization that the office nurses can usually do on their own.
  2. Advance practice providers. Treatment regimens that are based on protocols are ideal for nurse practitioners and physician assistants. This can be a great option for larger primary care groups or for hospitals that designate an advance practice provider to specialize as the go-to hepatitis C treatment provider.

A time for change…

In summary, the number one cause of chronic liver disease and number one indication for liver transplantation can now be cured relatively easily. In communities that lack easy access to a trained hepatologist, the newer hepatitis C treatment regimens lend themselves to implementation by either primary care physicians or advance practice providers. In order to improve the numbers of Americans who are cured of hepatitis C before it results in cirrhosis, we must overcome historical barriers to treatment. Our hospitals can help by sponsoring CME programs to train primary care physicians in hepatitis C management and by financially supporting advance practice providers to specialize in hepatitis C management.

September 22, 2022

Categories
Uncategorized

Do Doctors Get Paid More To Diagnose Patients With COVID?

Recently, a relative mentioned that she had heard that doctors were over-diagnosing COVID deaths because doctors get paid $3,000 for every COVID diagnosis listed on a death certificate. Fortunately, she did not believe what she was being told. I personally cared for hundreds of COVID patients in our COVID monoclonal antibody infusion center and in our ICU… and I can promise you that I did not get paid an extra $3,000 for a single one of them. But misinformation abounds when it comes to falsification of COVID diagnoses. The problem is that behind every misinformation lie, there is often a kernel of truth.

 

Summary Points:

  • There are three coding systems used in healthcare billing:
    • ICD-10 codes – these are unique codes for every disease. There are 72,748 different ICD-10 codes
    • DRG codes – these are groups of similar ICD-10 codes. Each DRG has a specific dollar amount that the hospitals get paid for caring for a patient with one of the ICD-10 codes in that DRG. There are 740 different DRG codes
    • CPT codes – these are level of service codes and are not tied to any specific diagnosis. Each CPT code has a specific dollar amount that the doctors get paid each day for caring for a patient.
  • Medicare pays hospitals 20% more per DRG when patients have COVID
  • Doctors get paid the same whether or not patients have COVID
  • The CDC’s COVID statistics underestimate the true number of Americans who have had COVID

Do hospitals get paid extra for COVID patients?

It costs a lot to take care of COVID inpatients. They have to be in a private hospital room rather than a less expensive semi-private room. They require nurses and staff to used expensive disposable personal protective equipment. They require expensive medications. And when they end up on a ventilator, they stay in the ICU for a long, long time. Because these costs are considerably higher than for inpatients with other types of respiratory infections, Congress passed the CARES Act (Coronavirus Aid, Relief, and Economic Security Act) that was signed into effect on March 27, 2020 by then-president Trump. The CARES Act created a new ICD-10 diagnosis code for COVID infection (U07.1). The Act also authorized CMS to pay 20% more per DRG for inpatients with COVID infection who are on Medicare.

As a result, hospitals do get paid more for for patients with COVID. However, Medicare specifically requires that patients must have a positive COVID test in order to diagnose COVID – hospitals cannot use diagnosis code U07.1 unless there is a documented positive COVID test within 14 days of admission to the hospital. Using code U07.1 in the absence of a positive COVID test would be considered in violation of Federal fraud laws. In other words, hospitals do not get paid more for COVID unless patients have confirmed COVID infection.

So where did the misinformation come from? In April 2020, Minnesota Republican Senator Scott Jensen stated on Fox News that hospitals get paid more if they list COVID as a diagnosis. Later that month, he wrote:

“Hospital administrators might well want to see COVID-19 attached to a discharge summary or a death certificate. Why? Because if it’s a straightforward, garden-variety pneumonia that a person is admitted to the hospital for – if they’re Medicare – typically, the diagnosis-related group lump sum payment would be $5,000. But if it’s COVID-19 pneumonia, then it’s $13,000, and if that COVID-19 pneumonia patient ends up on a ventilator, it goes up to $39,000.”

Senator Jensen’s and other people’s comments served as the kernel of truth that then morphed into the misinformation that doctors were putting COVID infection on people’s death certificates to get paid more. Additionally, the misinformation was that COVID death numbers were being blown out of proportion because doctors were putting COVID on the death certificates of people who did not really have COVID. So, what is the truth?

Every disease is coded by a unique ICD-10 diagnosis code. However, hospitals get paid by the DRG code (diagnosis related group) and not by the ICD-10 code. A DRG is the code for a number of similar diseases (each disease having its own different ICD-10 code) that are grouped together for hospital billing purposes. Medicare assigns each DRG a payment amount based on the U.S. average length of stay for those diseases and the U.S. average cost to treat those patients (including hospital personnel, supplies, equipment, medications, etc.). No matter how many days an individual patient is actually in the hospital or how much the hospital actually spends to treat that patient, Medicare pays the hospital the same amount – whatever that particular DRG is worth. As an example, DRG #177 (respiratory infection with major co-morbidity) has an average hospital length of stay of 6.9 days and the typical U.S. hospital gets paid $14,263. If a patient has a respiratory infection due to COVID, the hospital gets paid an additional 20%, or $17,116 (nearly $3,000 more). Similarly, DRG #207 (respiratory system diagnoses with ventilator support > 96 hours) has an average hospital length of stay of 14.1 days and the typical U.S. hospital gets paid $45,987. If that patient has COVID, then the hospital gets an additional 20%, or $55,184 (more than $9,000 more).

So, it is true that hospitals do get paid more if a patient is diagnosed with COVID. However, since that payment requires that the patient have a documented positive COVID test within 14 days of hospital admission, it is not possible for hospitals to falsely label non-COVID patients as having COVID for the purposes of getting paid more. Given how much sicker patients with a COVID infection are compared to other viral infections, hospitals needed that extra 20% Medicare payment just to cover their costs.

Do doctors get paid extra for COVID patients?

Unlike hospitals, physicians do not get paid based on a patient’s diagnosis. Instead, doctors are paid by the CPT code. There are 3 CPT codes for the first hospital day, 3 codes for subsequent hospital days, and 2 codes for the discharge day. Each of these CPT codes are based on the patient’s complexity and the amount of time the doctor spent taking care of the patient on that day. A level 1 CPT code is used for patients with the simplest medical problems that require the least amount of a physician’s time. A level 3 CPT code is used for patients with the most complex medical problems that require the greatest amount of a physician’s time. Most inpatients are coded as a level 2 or level 3 CPT code. In addition, there is a separate code for care of critically ill patients (those in intensive care units). It does not matter what the patient’s diagnosis is – doctors get paid exactly the same for a level 3 hospital visit whether the patient has COVID, has a bleeding ulcer, or has a drug overdose.

So, physicians have no incentive to falsely list COVID as a patient’s diagnosis in a hospital chart, on a Medicare bill, or on a death certificate.

That being said, it is true that many critical care physicians did make a lot of money during the COVID pandemic. If you have more patients on ventilators in your intensive care unit, you generate more patient bills. If you generate more patient bills, you get paid more. At the peak of the pandemic, many hospitals had to double or triple the size of their intensive care units due to the massive surge in COVID patients with respiratory failure. All of a sudden, critical care physicians had more business than they could handle and many made a lot of money (but at a cost of becoming overworked and burned out). I personally made a lot of extra income by working at our medical center’s COVID vaccination clinics on the weekends.

So, are the COVID numbers accurate?

Actually, the answer is a resounding no, the COVID numbers are not accurate. They are an underestimate of the true number of COVID infections and COVID deaths. Many patients with COVID infection had mild (or no) symptoms and so they did not get tested; without a test, there was no diagnosis reported to the CDC. Once home testing became available, many patients opted to test themselves; the results of those home tests are not reported to the CDC. Many patients with COVID infection died suddenly at home and if they had not been previously tested, then they were often labeled as having “death from natural causes” and the doctors could not list COVID on their death certificates since there was no way to know (or even suspect) that they had COVID.

One way of determining how many people die from a pandemic is the number of excess deaths. We can fairly reliably predict how many Americans will die each year based on how many died in previous years. When there are more deaths than expected, these are called “excess deaths”. The CDC reported that between March 7, 2020 and March 5, 2022, there were 1,105,736 excess deaths in the United States compared to the normal predicted number of deaths. However, there were only 958,864 documented COVID deaths. This means that the excess deaths for that time period were 15% higher than the number of deaths that could be attributed to COVID. It is likely that many (if not most) of these 15% excess deaths were due to undiagnosed COVID infection.

Worldwide, many counties lack the testing and access to healthcare that we have in the U.S. A report from the World Health Organization determined that in 2020 and 2021, there were 14.9 million excess deaths but there were only 5.42 million deaths documented to be due to COVID. The implication is that as many as 9.5 million people worldwide died from undiagnosed COVID.

I experienced the COVID pandemic first hand and saw it through the eyes of a critical care physician and of a hospital medical director. The conspiracy theorists who say that the infection isn’t real or that the case & death numbers have been overstated are just plain wrong. For as long as humans have studied science, there have always been science doubters and science deniers. And history has repeatedly shown that those doubters and deniers were either misinformed or were fools. The COVID era has been no different. It’s like showing a person an ocean but not being able to convince him that it is wet.

September 19, 2022

Categories
Medical Economics

Understanding Hospital Ratings (and how hospitals can game those ratings)

Consumers use ratings in everything that they buy. Amazon rates merchandise, Consumer Reports rates cars and appliances, Trip Advisor rates hotels, Yelp rates restaurants, and Google rates about everything. There are also rating systems for hospitals. But are these rating systems a reflection of the actual quality of care in the hospital or a reflection of the patient population served by the hospital? And if the latter, do hospitals attempt to choose their patients in order to improve their ratings?

The main four hospital rating systems are published by U.S. News & World Report, CMS’s Hospital Compare, Healthgrades, and Leapfrog. In an 2019 article in NEJM Catalyst, the authors rated the rating systems and found that all of the rating systems had flaws. In the article, each rating system was given a letter grade and none received an “A”.

  • U.S. News & World Report: B
  • CMS Hospital Quality Star Ratings: C
  • Leapfrog Safety Score: C-
  • Healthgrades: D+

Each of these rating systems uses different measures to determine hospital ratings. In order to understand what the rating really means, you need to first understand how the ratings were made.

U.S. News & World Report

The highest rated system was U.S. News & World Report’s annual hospital ranking. Each year, U.S. News & World Report updates their methodology in order to continually improve on its accuracy and relevancy. This process of annual methodology revision has resulted in the U.S. News & World Report ratings becoming more accurate each year. This year, the rankings are determined by four elements that are each weighted differently in determining the overall hospital rank:

  1. Patient outcomes (37.5%) – measured by the number of Medicare patients who died within 30 days of being admitted to the hospital in 2018, 2019, & 2020. The measure was adjusted to factor in each patient’s age & gender, the type of care received, co-morbidities, and whether patients were on Medicaid as well as Medicare. The Medicaid adjustment is important because it is a marker of low-income Medicare patients. A criticism of this measure is that the survival data is 3-5 years old and may not reflect the hospital’s current survival data.
  2. Patient experience (5%) – measured by the HCAHPS patient satisfaction surveys
  3. Other care-related indicators (30%) – measured by nurse staffing, patient volume, certain clinically proven technologies and professional & specialty-specific recognition
  4. Expert opinion (27.5%) – measured by an annual survey to board-certified physicians about which 5 hospitals they consider to be the best for their particular specialty.

CMS Hospital Quality Star Ratings

The current (2022) year CMS Hospital Quality Star Rating is based on five elements:

  1. Mortality (22%) – measured by the number of Medicare patients with specific diseases who died within 30 days of admission in 2017, 2018, and 2019. The diseases include: myocardial infarction, coronary artery bypass & graft surgery, COPD, heart failure, pneumonia, stroke, and surgical patients.
  2. Patient safety (22%) – measured by eight different safety measures obtained from 2017 to 2020. Some of the measures include central line infections, C. difficile infections, and surgical site infections.
  3. Readmission (22%) – measured by the number of patients with 11 specific diagnoses who required readmission within 30 days of discharge from the hospital. Data are from 2017, 2018, and 2019.
  4. Patient experience (22%) – measured by the HCAHPS patient satisfaction surveys from 2019.
  5. Timely and effective care (12%) – measured by 13 different elements from 2019 and 2020. Some of the measurements include percent of staff vaccinated for influenza, ER length of stay times, percent of ER patients who left without being seen, appropriate follow-up interval for routine screening colonoscopy, and number of patients with low back pain who got an MRI without first getting physical therapy.

Leapfrog Safety Score

The Leapfrog Group was founded in 2001 by a group of large employers who wanted to have objective quality metrics in order to change the way that these companies purchased healthcare for their employees. They give hospitals a grade of A through F based exclusively on patient safety. Leapfrog uses data from CMS and from their own survey. A criticism of Leapfrog is that only about half of U.S. hospitals return the Leapfrog survey. In addition, there is no audit process in place to validate the self-reported survey responses, creating opportunities for falsifying survey responses in order to appear more favorable. The Leapfrog grade is based on two elements:

  1. Process measures (50%) – these are 12 different measures of how healthcare is delivered by the hospital such as whether there is computer order entry, how the ICU is staffed by physicians, and how frequently staff practice hand hygiene. The measures are assessed on data from 2020 to 2021.
  2. Outcome measures (50%) – these are 10 different measures such as: frequency of MRSA infection, frequency of patient falls, and frequency of air embolism. The measures are assessed on data from 2018 to 2021.

Half of the Leapfrog Safety Score is based on process measures that only indicate whether the hospital has those specific processes in place and does not indicate whether those processes actually improve patient care in that particular hospital. Another criticism of the Leapfrog Safety Score is that it does not incorporate mortality, which can be argued is one of the more important measures of the effectiveness of hospital care.

Healthgrades

Healthgrades bases its rating on outcomes for 33 medical conditions and procedures. The data for hospitals in 34 states is derived only from Medicare reported data. In the other 16 states, data is derived from both Medicare reports and all-payer reports. Outcomes are adjusted for a large number of co-morbidities. However, there are a large number of exclusions, for example, any Medicare patient under age 65. The elements of the rating are:

  1. Mortality cohorts – these measures are based on the number of patients with 17 different diagnoses who die within 30 days of admission. The diagnoses include conditions such as bowel obstruction, cranial neurosurgery, and pancreatitis.
  2. In-hospital complication cohorts – these measures are based on whether complications occurred in patients undergoing 15 different surgical procedures such as appendectomy, prostatectomy, and hip replacement. In addition, complications occurring during one medical condition (diabetic emergencies) is included.

The problems with the rating systems

All four of the hospital rating systems have flaws. One of the most important flaws is that they rely heavily on Medicare data. This data is quite robust for assessing the outcomes of Medicare patients. However, the only patients in the Medicare database are those who either are over age 65, are receiving dialysis for kidney failure, or are disabled. Currently, only 18.4% of the U.S. population is on Medicare so there is no hospital outcome data for the majority of Americans. Because hospital ratings drive hospital quality improvement processes, American hospitals have been more strongly motivated to improve care to patients older than age 65 with less attention given to improving care to younger patients.

A second flaw is that most of the outcome data is based on information that is several years old. In the case of U.S. News & World Report, the data is up to 4 years old and in the case of CMS, the data is up to 5 years old. Hospitals are constantly improving their patient care practices and most hospitals have made changes in those practices over the past 5 years. As a result, the data from which the ratings are derived can be significantly out of date and not reflective of current hospital practices.

A third flaw is that the rating systems rely on surveys. The HCAHPS survey data is used by the U.S. News & World Report rating and by the CMS Hospital Quality Star rating. Nationwide, on average only 26.7% of patients respond to the HCAHPS survey and there is wide variation with many hospitals having significantly lower response rates. A 2019 study in the Patient Experience Journal found that the higher a hospital’s HCAHPS survey response rate, the higher that hospital’s average HCAHPS score was from those surveys. The implication is that patients are more likely to fill out a survey if they were unhappy with their care so that the sample of patients responding to the survey is not representative of the total hospital patient population. Those hospitals that can convince more patients to fill out surveys will thus have higher HCAHPS scores.

Leapfrog sends surveys to hospitals to fill out but only about half of U.S. hospitals respond to their survey. Those Leapfrog surveys are typically filled out the the hospital’s quality staff who can have a conflict of interest in their survey responses since those staff generally also have their job performance evaluations based on the reported quality outcomes. As a result, the Leapfrog surveys can portray the hospital as performing better than it actually is. For hospitals that do not respond to their survey, Leapfrog obtains surrogate data from other sources. It is not clear if data from those other sources is equivalent to the survey data so it is uncertain if valid comparisons can be made between those hospitals that do fill out Leapfrog surveys and those hospitals that do not return surveys.

A fourth flaw in the ratings is that only a limited number of medical conditions are evaluated. U.S. News & World Report’s rating is based on overall mortality with the result that not much is known about the quality of care for patients who do not die. The CMS Hospital Quality Star rating also uses mortality but only for 7 specific conditions. CMS readmission data is limited to patients with 11 specific diagnoses and its patient safety data is based on only 8 complication diagnoses. The Leapfrog rating does not incorporate mortality data and only incorporates a very limited number of complication diagnoses. The Healthgrades rating is disproportionately based on surgical outcomes and incorporates very little outcome data on non-surgical patients.

The problem of healthcare gerrymandering

In politics, gerrymandering is when politicians set district boundaries in order to choose their voters to win elections. In medicine, the equivalent of elections are annual hospital ratings. Medical gerrymandering is when hospitals choose their patients in order to improve their ratings. After years of having to explain low hospital ratings to hospital CEOs, Deans, and hospital board members, I’ve come to realize that it easy for hospitals to game the rating systems. Here are some of the specific ways that hospitals can improve how they look on the various surveys. Some are legitimate but others are quite nefarious.

Diagnosis selection. It might seem like a patient’s diagnosis is pretty straightforward but this is not always the case. For example, pneumonia is typically defined as a respiratory infection accompanied by an infiltrate on a chest x-ray. But what if the x-ray is normal and the infiltrate is only seen on a chest CT scan? Or what if the x-ray is normal but the doctor believes that the patient has pneumonia based on physical exam? These pneumonia patients tend to be less sick and therefore less likely to either die or be readmitted. Consequently, by being liberal with diagnosis definitions in less ill patients, the hospital can reduce the death rate and readmission rate by including more patients who have mild illness. Often, the diagnosis that is submitted to CMS or other rating organizations is based on the DRG diagnosis that is selected for a given patient’s admission. The DRG diagnosis is usually chosen by the hospital’s coding department staff and if there are 2 possible diagnoses that they can chose from, they will usually chose the DRG diagnosis that pays more. For over a year, I reviewed the charts of all patients who died in our hospital and found that in some, the DRG diagnosis did not really match the patient’s actually clinical diagnosis. By changing the DRG diagnosis, the patients were sometimes re-classified with a diagnosis that was not included in the rating data.

Co-morbidity selection. As a general rule, the more co-morbidities that a patient has, the more likely they are to die or be readmitted to the hospital. Once again, these co-morbidities are generally selected by the coding staff. When I reviewed the inpatient charts of those patients who died in the hospital, I was often able to find co=morbidities that the coding staff overlooked. Because the U.S. News & World Report rating system takes into account these co-morbidities, the more you can list, the better your overall rating will be.

Classify dying patients as being in observation status. Hospitals usually lose money on those patients who are kept in observation status. Observation patients are considered to be outpatients so they have more co-pays and the hospital cannot charge the insurance company for a lucrative inpatient DRG. As a general rule, patients who are anticipated at the time of admission to require a hospital stay of “less than 2 midnights” are considered to be in observation and are not considered to be inpatient admissions. This turns out to be very important in hospital rankings because the mortality rates are only based on those patients who have an inpatient admission. In other words, patients in observation status who die are not included in the mortality calculations for hospital rankings. It is very common to have patients admitted to the intensive care unit after an out-of-hospital cardiac arrest or some other catastrophic medical event and those patients die in the ICU a few hours later. The hospital finance department will want those patients to be classified as inpatients (since they have a medical condition that would have required a stay of greater than 2 midnights if they had lived). However, I trained our admitting physicians to put those patients (who were anticipated to die within 24 hours) in observation status when first admitted to the ICU. If they died within the first day of their ICU stay, they would die in observation status and not be included in our inpatient mortality data. If they survived for more than a day in the ICU, the physician would change their admission level of care order from observation to inpatient admission so that the hospital got paid for the admission. Because inpatient mortality is based on Medicare patients, some hospitals further game the system by only classifying Medicare patients with impending death as being in observation status and leaving commercially-insured patient who are not on Medicare as being inpatient status.

Keep “frequent flyers” in observation status. Similar to mortality rates, only patients with an inpatient admission are included in readmission rate calculations. There are some patients who you know are likely to return to the hospital within 30 days. If you keep them in observation status rather than admit them as inpatients, they won’t count against the hospital’s 30-day readmission rate.

Enroll dying patients in hospice. Medicare does not include patients who are enrolled in hospice in mortality data. However, patients must either already be enrolled in hospice prior to an inpatient admission or become enrolled in hospice during their first hospital day. Identifying those patients who have ultimately terminal diseases and getting them enrolled in hospice early not only helps serve the patients’ palliative care needs but also eliminates those patients from counting toward the hospital’s mortality rate if they die within 30 days of an inpatient admission.

HCAHPS survey response rates. As described in the last section, the patients who do not fill out HCAHPS surveys tend to be those who were more happy with their care. Hospitals that have tactics in place to get more patients to fill out their HCAHPS surveys will get a higher average score on their surveys. Therefore, hospitals that put resources into getting as many patients as possible to respond to the HCAHPS survey will have higher ratings than hospitals with a low survey response rate.

Flood U.S. News and World Report with expert opinion surveys from your own physicians. Americans in 2022 have survey fatigue. We are constantly receiving phone surveys, mail surveys, and email surveys. There are just too many surveys so we don’t bother to fill most of them out. Physicians are no different and many (or most) physicians who receive a U.S. News & World Report expert opinion survey just toss it in the trash. But if a hospital can convince all of its doctors to respond to the expert opinion survey (and rank the hospital in their top 5), then it can move up in the overall ratings. With expert opinion accounting for 27.5% of the overall U.S. News & World Report rating, this strategy is low-hanging fruit for hospitals, especially for hospitals with a large medical staff.

Choosing your patients. The best way to improve the hospital’s rating (and most immoral) is for the hospital to select the patients that it admits. Whether a patient dies within 30 days of being admitted and whether a patient is readmitted within 30 days of discharge is only partially dependent on the medical care delivered while that patient was admitted to the hospital. Socioeconomic factors that the hospital cannot control are at least as important. Age, income level, employment status, housing status, health insurance status, access to transportation, level of education, smoking status, primary language spoken, marital status, alcohol use, drug use, psychiatric co-morbidity, and race can also have a profound impact on disease outcomes, particularly after discharge. Hospitals that care for a larger percentage of older, low-income, unemployed, homeless, uninsured, smoking, low education level, foreign born, or racial minority patients will inevitably have worse mortality and readmission rates than hospitals that mainly care for patients coming from a high socioeconomic group. There are several ways that a hospital can alter their inpatient population in order to improve their overall outcomes and thus their ratings.

    • Location, location location. By building a hospital (or a satellite hospital facility) in an affluent suburban area, that hospital will naturally attract a more affluent patient population. For hospitals that own primary care practices, by locating those physician offices in affluent suburban areas, it can ensure more affluent patients being admitted to the hospital.
    • Nurture referring physician relations. One of the most important reasons that patients choose to go to a particular hospital is whether their physician recommends that particular hospital. If the hospital fosters relations with private practice primary care physicians who are located in affluent neighborhoods, it can improve the average socioeconomic status of that hospital’s inpatients and by doing so, improve the hospital’s rating.
    • Nurture referral hospital relations. For those hospitals that receive a relatively large number of hospital transfers, by fostering referrals from smaller hospitals that are located in affluent communities, the hospital can skew its inpatient population to a patient group that is more likely to have better readmission and mortality rates.
    • Discourage unfavorable patients. In large cities, patients usually have a choice of emergency departments and hospitals to utilize. When patients have a bad experience at one hospital, they will tend to go to another hospital in the future. Cab vouchers and free meals in the emergency department can encourage low income patients to come to the hospital. On the other hand, liberal use of collection agencies for unpaid bills can discourage those patients. Hospitals have ways to tacitly discourage low income patients, minorities, smokers, and foreign-born patients from coming back. If the outpatient physicians affiliated with the hospital do not accept Medicaid or require up-front full payment from uninsured patients, then those patients will migrate to other health systems. This is the ugly side of American healthcare but unfortunately, ugly exists in every state and every large city.
    • Encourage favorable patients. Hospitals cannot get away with giving something tangible to one group of patients and withholding that something from another group. At the worst, it may be against the law and at best, it results in bad publicity. However, there are subtle ways to attract patients who are more likely to have better mortality and readmission outcomes. Since these outcomes are based on Medicare data, the trick is to attract “favorable” patients over age 65. Adding extra free wellness programs as part of commercial insurance contracts makes the hospital attractive to those seniors who can afford to purchase secondary health insurance. Similarly, free hospital-sponsored wellness programs in affluent neighborhoods can attract more affluent seniors. Hospital advertising campaigns that feature physically fit seniors hiking, swimming, and going on vacations to foreign countries will appeal to healthy, affluent Medicare enrollees.

I spent most of my career practicing in an urban hospital that served a patient population that would be considered “unfavorable” from a socioeconomic standpoint… and if I had to do it all over again, I would not change a thing. Idealism was one of the reasons I went into medicine in the first place. But for every hospital that is motivated by idealism, there is at least one hospital that is motivated by profit and fame. Unfortunately, our hospital rating systems reward the latter and not the former.

September 16, 2022

Categories
Life In The Hospital

Donut Resuscitation

It’s 3:00 AM and you’ve been at the hospital taking care of patients and being on-call for 20 hours straight. You’re tired, you’re grumpy, and you’re hungry. So you go to the physician’s lounge searching for something to eat. The only food you can find is a stale donut from the morning before. During 6 years of residency and fellowship followed by 30 years practicing critical care medicine, I spent hundreds of nights in the hospital, almost always after working a regular workday earlier that day. And from those nights on-call, I learned how to resuscitate a stale donut.

People who work night shifts have to develop unique survival food skills. After 6 o’clock PM, the cafeterias close, the coffee shops close, and the gift shops (purveyors of chips and snacks) close. You’re on your own to forage what you can find from the previous day’s leftovers. The good news is that there are tricks that can make those leftovers palatable, although they will never be epicurean delights.

Donuts

Donuts are the quintessential physician lounge food. The hospital realizes that it has to do something to show that it is a physician-friendly workplace and donuts are the perfect offering. They’re cheap, readily available almost everywhere, and come in convenient boxes of 12. They are cost effective, too. For less than $1 a piece, they will give hospitalists that sugar rush that helps them get done with morning rounds faster. Faster morning rounds means patients get discharged earlier in the day. Earlier discharges means greater hospital profits. By spending $3,500 a year on donuts, the hospital can probably save $50,000 in operational expenses. But donuts are morning rounds fuel and are not designed for night call. By 3 o’clock AM, that last donut in the physician lounge is about 24 hours old and has been sitting out desiccating all day and all night.

Fortunately, there is a solution. Physician lounges are not gourmet kitchens but most will have a  microwave. Five seconds on high for a small donut and 15 seconds for a large donut works wonders. They won’t be like Krispy Kremes fresh out of the donut oil but they’ll be the next best thing.

Bagels

After the donut, the second most common physician lounge food is the bagel. The problem with the donut is that the sugar buzz you get from it wears off in 2-3 hours. The resulting crash at about 10 o’clock AM requires a break for either another hit of sugar or a cup of coffee. Being mostly carbohydrates, bagels do not result in the mid-morning sugar crash that donuts do so bagels are best suited for surgeons and anesthesiologists who can’t take a sugar/caffeine break in the middle of an operation but need sustained energy to get them through until lunch. The wise hospital administrator will stock the physician lounge with both donuts and bagels every morning. But by 3 o’clock AM, the previous morning’s bagel is now as hard as a hockey puck.

Once again, food science comes to the rescue. Wet a paper towel with water and squeeze it mostly dry. Microwave the paper towel on high for about 10 seconds then wrap the bagel in the warm, damp paper towel and microwave it an additional 15-20 seconds. However, it must be eaten warm – if you wait until it cools, it will be even harder than it was in the first place.

There is a second option for bagels that are so stale that they cannot be fully resuscitated in the microwave. Take a lightly damp paper towel and wipe it over the top of the bagel. Sprinkle it with coarse salt. Let it dry for 5 minutes. Now, it’s no longer a bagel, it’s a pretzel.

Cookies

Columbus is the home of Cheryl’s Cookies, the maker of individually wrapped iced sugar cookies. Our hospital would buy them by the box for special occasions like doctor’s day or holidays. By being individually wrapped, they will stay fresh for weeks but their popularity means that they have a very short half-life in the physician lounge and are generally gone by noon.

Making cookies a viable on-call sustenance requires strategy and planning. Cookies are generally dropped off in the physician lounge in the morning, just when the night call physicians are checking their patients out to the day shift physicians. The secret is that iced sugar cookies freeze incredibly well. So, keep an empty frozen dinner box in the physician lounge freezer, preferably something that no one would steal, like Lean Cuisine Goat Liver and Kohlrabi Puree dinner. Squirrel away a couple of cookies in the box in the morning and no one will find them until the next time you have an overnight call again.

Popcorn

Half-eaten bags of microwave popcorn are ubiquitous in physician lounges. Maybe the doctor who made it couldn’t eat the whole bag or maybe got called away for a patient emergency. Sometimes at 3 o’clock AM, that partially eaten bag of popcorn is the only food left in the lounge.

The best way to resuscitate stale popcorn is by heating it up on a baking sheet in a regular oven. But physician lounges do not have regular ovens so we again have to turn to the microwave. Put the stale popcorn in a bowel and cover it with a damp paper towel. Microwave on high for 30 seconds. If it still seems stale, give it another 10-15 seconds.

Pizza

Admit it. You’ve reheated left-over pizza in the microwave at some time in your life. It is a measure of true desperation. Many pizza aficionados will tell you that if all you have to heat up pizza is a microwave, you’re better off just eating it cold. If you have a toaster oven in the lounge or if your microwave has a convection oven mode, then you’re in luck – 10 minutes at 350 degrees will make it almost as good as new. If you must use a microwave, then put a mug of water on the plate with a slice of pizza and cook it for 30 – 45 seconds. It won’t be great but it will be marginally better than if you just microwaved the pizza by itself.

Coffee

At 3 o’clock AM, coffee has one purpose and one purpose only… it is a drug. This is not the time for a foo-foo coffee drink and there is no place for a no-fat butterscotch and pumpkin spice double mocha latté with extra whipped cream. Coffee should taste terrible when you are on-call so that you only drink it as a last resort when you are falling asleep typing your last admission’s history and physical into the hospital computer system. Ideally, coffee should be at least 12 hours old, heated up in the microwave, and drunk black with no sugar or creamer. It should not be soothing and instead should harsh enough that the taste alone serves as a sleep-deterrent.

Unfortunately, many hospitals have gone to providing instant brew K-cups in the physician lounge. The result is that any doctor can get reasonably good-tasting coffee, anytime of the day. The solution is instant coffee. These are now available in individual packets designed for use with 6 ounces of hot water. Instead, add 1 packet of regular instant coffee and 2 packets of decaf instant coffee to 6 ounces of water. This will give you the right amount of caffeine but taste sufficiently awful, particularly if you buy the cheapest generic instant coffee you can find. If it doesn’t taste bad enough, there are always left-over condiment packets laying around the physician lounge – try adding a half-packet of mustard or mayonnaise to the coffee.

Refrigerator scavenging 

As tempting as it is to rummage through the physician lounge refrigerator for uneaten food at 3 o’clock AM, this can be particularly hazardous. No one ever cleans out these refrigerators and forgotten food can stay forgotten for years. The hard boiled egg may be from 1997 and the half of a left-over tuna sandwich could have been made when you were still in high school. Moreover, it is poor etiquette to eat some other on-call doctor’s dinner. If you have multiple call nights in a row, take a picture of the opened refrigerator with your phone’s camera on the first night. Anything that hasn’t moved after 3 days is fair game. But stick to visibly non-rotten fruit and unopened yogurt that is not past its “use by” date.

Special circumstances:

  1. Emergency surgeries. When an on-call resident has to assist with an emergency surgery at night, it can be tempting to drink a cup of coffee or a can of caffeinated soda just before the procedure. Don’t do it. You’ll have to pee before you finish dissecting out the gall bladder. A 1-ounce espresso has three times as much caffeine as a 12-ounce cola and a 2-ounce energy shot has more caffeine that 16 ounces of coffee.
  2. Pregnancy. Night call food foraging during pregnancy poses unique challenges. Caffeinated coffee is generally off the menu and you’re trying to only eat healthy foods in order to have a healthy baby. The solution? The waiting room candy machine. A 2-ounce Snickers bar has 5 mg of caffeine, just enough that you won’t feel guilty about it. In the middle of the night, the chocolate is more soothing than zen. And the peanuts have a lot of fiber so that you can convince yourself that a Snickers bar is really just as healthy as a serving of vegetables.
  3. Potato salad & chicken salad. Don’t eat it. Ever. After these foods have sat out at room temperature for a few hours hours, there is an increasing risk of Staphylococcal food poisoning resulting in nausea, vomiting, and diarrhea within 6 hours. You see mayonnaise, I see bacterial culture media.
  4. Easy Cheese. Is there a can of Easy Cheese in the lounge refrigerator? The stuff is designed to help armageddon survivors out-live zombies and lasts for about forever. Go to the waiting area vending machine and buy a bag of Doritos. Put them on a paper plate and spray liberally with Easy Cheese. Microwave for 20 seconds. Now you have nachos. NOTE: don’t put the Doritos bag into the microwave – it has a foil lining and will spark and burn in the microwave.

Cooking shows and celebrity chefs never talk about night-call cuisine. But for physicians and other healthcare workers who roam the hospital halls at night, lounge foraging is a major component of the daily diet. Although not as complicated as resuscitating a patient in cardiac arrest, resuscitating a donut is nevertheless a critical survival skill at 3 0’clock AM.

September 8, 2022

Categories
Epidemiology Inpatient Practice Outpatient Practice

2022-23 Influenza Season Predictions

You would think that August would bring a lull in the work of U.S. influenza epidemiologists. But August is when we get some of the most important information that predicts what our winter flu season will look like. And the projections are a little scary this year.

The best predictors of North American influenza in our winter is Australian influenza during our summer. Normally, influenza season in Australia starts in April and runs through October, corresponding with winter in the Southern Hemisphere. What happens with influenza in Australia usually fairly closely matches what happens later in the year in the United States. Thus, by examining the epidemiological data from the Australian Department of Health’s Influenza Surveillance, we can predict when influenza cases will start to be seen, what age groups will be affected, what serotypes will be predominant, and what severity will occur here in the United States and Canada.

Recent U.S. influenza seasons

Over the past 3 influenza seasons, we have seen an inverse relationship between COVID cases and influenza. One of the primary reasons for fewer influenza cases when COVID cases increase is social distancing and mask-wearing to prevent COVID. It turns out that these measures help prevent COVID but they are even more effective to help prevent influenza. We can see that effect in the 2019-20, 2020-21, and 2021-22 influenza seasons.

The graph above shows seven previous influenza seasons in the United States. The 2019-20 influenza season (green line) started off quite severe with sustained high numbers of cases from December through March. The onset of the COVID pandemic in the United States in March 2020 marked the closure of schools, work from home initiatives, and public masking. This coincided with a precipitous fall in influenza-like infections at the end of March.

The 2020-21 influenza season (pink line) was the mildest in recent history with only a small peak in cases of influenza-like infections in November and December. At this time, social distancing and masking were more ubiquitous and the COVID vaccines were not yet widely available. It was not until the summer of 2021 that influenza-like infections began to rise – this was a time when COVID vaccines were widely available and it was generally believed that the end of the COVID pandemic was in sight. Consequently, mask mandates were discontinued, children returned to schools, and workers returned to their workplaces. This created conditions that allowed influenza to have a summer rebound.

The 2021-22 season is in red with red triangles. It peaked in December, much earlier than usual. This coincides with the rise in case numbers of the Omicron variant of COVID that caused people to resume masking and social distancing in December. Once these measures to prevent the spread of COVID went back into effect in December 2021, the frequency of influenza-like infections fell.

The exceptional influenza season was the H1N1 outbreak in 2009-10 when cases began to increase in August and peaked in September and October. This represented an unusually early influenza season that caught physicians off-guard. Making matters worse, this particular H1N1 strain had not circulated for decades and was not predicted to appear that season with the result that it was not covered by that season’s flu shots. These factors together resulted in an unusually large number of cases and large numbers of deaths, particularly among younger people who had no natural immunity to H1N1.

What we are learning from Australia

When will influenza season start?

In the last several years, the influenza season in the U.S. has mirrored the influenza season in Australia that occurs earlier in the year. So, what is Australia telling us this year? First, we are likely to see influenza cases start to increase earlier than normal this season. The graph below shows the last several seasons of positive influenza testing in Australia.

The current influenza season is in red. It began much earlier than in past years and also peaked much earlier. Cases began to rise in late April which corresponds to late October in the Northern Hemisphere. Cases peaked in late May in Australia which corresponds to late November in the U.S. By late July, the Australian influenza season was pretty much over – this would correspond to late January in the United States and Canada. So based on these data, we should expect to see influenza cases start to increase in October 2022 with peak numbers in November and December 2022.

How severe will influenza be this year?

Hospitalization data from Australia predicts that this will be an average year with respect to influenza severity. The graph below shows the number of influenza hospitalizations in Australia over the past several seasons. The current season is in red with hospitalizations mimicking the case number graph above. Hospitalizations began to increase in April and were back to baseline by late July. 

Based on this data, in the United States, we should expect influenza-related emergency department visits and hospitalizations to peak in November and December 2022.

What ages will be most affected?

A unique finding during the current Australian influenza season has been the propensity to affect children. The graph below shows the number of laboratory-confirmed influenza cases by age.

The largest case rates have been in people under age 20. This would predict that U.S. pediatricians will be seeing more influenza than U.S. internists this season.

Will the influenza vaccine cover it?

The vast majority of cases of influenza in Australia were influenza A with unusually few cases of influenza B as shown in the graph below.

The seasonal influenza vaccines in Australia this year included the following serotypes:

Egg-based quadrivalent influenza vaccines:

  1. A/Victoria/2570/2019 (H1N1)pdm09-like virus;
  2. A/Darwin/9/2021 (H3N2)-like virus;
  3. B/Austria/1359417/2021-like (B/Victoria lineage) virus; and
  4. B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

Cell-based quadrivalent influenza vaccines:

  1. A/Wisconsin/588/2019 (H1N1)pdm09-like virus;
  2. A/Darwin/6/2021 (H3N2)-like virus;
  3. B/Austria/1359417/2021 (B/Victoria lineage)-like virus; and
  4. B/Phuket/3073/2013 (B/Yamagata lineage)-like virus.

Although it is still too early to be confident of Australian vaccine effectiveness, we can look at whether the strains seen during the flu season corresponded to the strains covered by the influenza vaccines. In all, 97.4% of influenza A (H1N1) isolates were antigenically similar to the vaccine components. 93.2% of influenza A (H3N2) isolates were antigenically similar to the corresponding vaccine components. And all of the influenza B isolates were similar to the corresponding vaccine components. The U.S. quadrivalent influenza vaccine for the 2022-23 season has identical components to the egg-based quadrivalent influenza vaccine used in Australia. Therefore, it is likely that this season’s flu shots will cover the strains of influenza that we are likely to see in North America.

What we should do in the U.S.

Based on the Australian experience, there are several steps that we should take to prepare ourselves for the 2022-23 influenza season:

  1. Start vaccinating early. It takes about 2 weeks for immunity to develop after a flu shot. Therefore, we should insure that most Americans get vaccinated in September this year if case numbers begin to rise in October as anticipated. If cases peak in late November, as expected, then people who wait until December or January to get vaccinated will have waited too long.
  2. Target kids for vaccination. With children being disproportionately affected by influenza in Australia, it is likely that we will see the same trend in the U.S., particularly as schools return to in-person classes.
  3. Prepare for a surge of hospitalizations in November and December. Normally, this is a low-census period for medical admissions in American hospitals. It is also a time when many people get elective surgeries over the winter holidays and before the end of the calendar year to take advantage of annual insurance deductibles. If the early influenza peak occurs as expected, we may need to institute routine pre-op influenza testing for elective surgeries much as was done with COVID testing during the worst of the COVID pandemic.
  4. Anticipate the effect of Thanksgiving travel. Thanksgiving and Christmas holidays are times when many Americans travel to be with family. The Australian influenza season predicts that U.S. influenza cases may be peaking around Thanksgiving. This could result in holiday travel accelerating influenza spread this year.

No one can predict the influenza season with 100% accuracy. But if historical trends follow, then the U.S. will likely experience a similar season as Australia. Given that most Americans are starting to relax as the COVID-19 case numbers fall, we could be especially vulnerable to influenza this year, particularly if it comes early and preferentially affects children as expected.

August 10, 2022

Categories
Epidemiology

Public Health Hall Of Shame Nominees

The NFL has a hall of fame in Canton. Cooperstown has the baseball hall of fame. There is even a polka hall of fame in Euclid, Ohio. It is time to create a memorial to prominent figures in public health but instead of a hall of fame, I propose we create a hall of shame to recognize people whose actions have promoted disease, injuries, and death. Here are 10 people worthy of induction into the Public Health Hall of Shame, listed in chronological order.

1. Christopher Columbus

Unlike many of of the Hall of Shame nominees, Christopher Columbus did not knowingly promote the spread of disease but his inadvertent actions make him worthy of inclusion. He was the first worldwide disease importer/exporter. On October 12, 1492, Columbus arrived in the Bahamas bringing to the newly discovered lands European diseases. When he returned to Spain on March 15, 1493, he brought gifts from the New World. One of those gifts carried by crew members was syphilis that then spread to Spanish soldiers. Two years later, in 1495, Pope Innocent VIII invited King Charles of France to wage war against the King of Naples in Italy. Spanish mercenaries employed by the French army brought syphilis with them to Naples and within a few years, syphilis had spread throughout Europe. Because of the association with the French army, syphilis became known as the “French disease” but it was really the Spanish sailors who brought it back with them from the Americas. Recently, historians have proposed that syphilis occurred sporadically in Europe before Columbus sailed but given the correlation with the Naples war, it seems likely that his crew carried the infection on their return to Spain thus fostering its European spread in the 16th century. For his contribution to the spread of syphilis to Europe (even though inadvertently), Christopher Columbus is nominated to the Hall of Shame.

2. Hernán Cortés

Another Spaniard who warrants inclusion in our Hall of Shame was the conquistador, Hernán Cortés. He was from a lesser nobility family in Spain but chose to come to the New World to seek gold and silver rather than live the life of a nobleman in Europe. In February 1519, he sailed from Cuba to Mexico in order to conquer the Aztecs and loot their empire. His force of 1,000 men was no match for the 200,000 residents in the Aztec capital of Tenochtitlan in Central Mexico. But Cortés had a secret weapon… smallpox. One of Cortés’ soldiers had become infected with smallpox before leaving Cuba. The Aztecs and other Native Americans had no immunity to smallpox because it had not existed in the Americas until it was brought by the early European explorers. 70 days after Cortés first arrived in Mexico, 40% of the population of Tenochtitlan was dead from smallpox. Within a few years, between 5-7 million Aztecs and other indigenous Mexicans died from smallpox. Cortés proved that infectious diseases are more powerful in battle than swords and cannon. In all, it is suspected that infectious diseases brought by European explorers resulted in the death of up to 95% of the native population of the Americas. For his actions resulting in the deaths of millions of Native Mexicans due to smallpox, Hernán Cortés is nominated to the Hall of Shame.

Honorable mention: Colonel Henry Bouquet. In June 1763, Bouquet was the commanding officer at Fort Pitt during Potomac’s War. When the fort was under siege by members of the Delaware Tribe, Bouquet needed help to defeat the Native Americans. So, he ordered his men to distribute smallpox-infested blankets to the besieging warriors in an attempt to infect them and reduce their forces. More than 100 Native Americans died from the resultant smallpox outbreak. Bouquet can be considered the father of germ warfare.

3. Anthony Comstock

In 1873, U.S. postal inspector Anthony Comstock formed the New York Society for the Suppression of Vice. Later that year, he lobbied the U.S. Congress to pass what became known as the Comstock Act that prohibited the postal service from delivering obscene material. As a result, more than 15 tons of books that Comstock determined were obscene were destroyed. These included anatomy books used by medical schools because those books included drawings of reproductive organs. Another provision of the Comstock Act was to prohibit the production of or publication of information about methods of contraception or prevention of venereal disease. Comstock was convinced that by making condoms illegal that Americans would stop having sex outside of marriage. He was oblivious to the fact that the drive to have sex is the most powerful drive in all species of living organisms on planet Earth. He zealously prosecuted and imprisoned anyone who defied his definition of morality, including Julius Schmidt, the inventor of the rubber condom. After release from prison, Schmidt resumed condom manufacturing in a clandestine production facility in New York City. During World War I, being unable to legally sell his condoms to the U.S. Army because of the Comstock Act, Schmidt turned to other allied governments that enthusiastically purchased and distributed condoms to their servicemen. As a result, unlike other Allied armies, at any given time, approximately 15% of the U.S. military force in Europe was actively infected with a venereal disease. Eventually, the U.S. government relented and the production and distribution of condoms became legal but not before Comstock’s efforts had resulted in tens of thousands of cases of syphilis and gonorrhea that could otherwise have been prevented. For his efforts to promote the spread of sexually transmitted disease, Anthony Comstock is deserving of induction into the Hall of Shame.

4. Mary Mallon

From 1900 to 1907, Mary Mallon worked for eight wealthy New York families as a cook. At each household where she worked, household members developed typhoid fever. When a public health investigator determined that Ms. Mallon was the common link in the series of typhoid outbreaks, he went to interview her. But when he asked her to provide samples to test, she attacked him with a fork. She was sentenced by the Health Department to quarantine at North Brother Island from 1907 – 1910. She was released from quarantine under the condition that she never resume work as a cook again. However, she went back to cooking for families, restaurants, and hospitals under a false name. Everywhere she went, she left a trail of typhoid cases. In 1915, when 25 inpatients developed typhoid at a hospital where she worked as a cook, she was again sentenced to quarantine at North Brother island where she lived for 23 years. For her efforts to spread typhoid fever as an asymptomatic carrier, she earned the name “Typhoid Mary” and warrants induction into the Hall of Shame.

5. Emma Marie Harrington

Also known as E.C. Harrington, she was an attorney and the first woman registered to vote in San Francisco. She was a champion of progressive issues in California in the early 1900’s. However, she became famous for her actions that today would make her the darling of political conservatives. In March 1918, an army cook at Camp Funston in Kansas became sick with a respiratory infection. Within days, 522 soldiers became ill. Because the U.S. had entered World War I, troops from Camp Funston were sent to Europe to fight. By April, the H1N1 strain of influenza had spread throughout the world. Within 2 years, one-third of the world’s population had become infected. The number of deaths were estimated to be as high as 100 million making it the second most deadly pandemic after the 14th century bubonic plague. Because there were no vaccines or anti-viral medications at that time, the only defense against influenza was to avoid getting it in the first place. The two public health measures that were found to reduce the spread of the infection were face masks and banning mass gatherings. But some Americans considered face mask mandates to be an affront to personal liberty. Many of them organized to oppose face masks which they called “muzzles”. One of these organizations was the San Francisco Anti-Mask League and E. C. Harrington was its president. During the fall of 1918 and early winter of 1919, more than 3,000 San Francisco residents had died from influenza and the death rate per 100,000 was one of the highest in the world. Despite magnitude of deaths, the Anti-Mask League put enormous political pressure on the city government to lift its mask ban. On January 27, 1919, Mrs. Harrington submitted a petition to the city’s Board of Supervisors to repeal the mask ordinance and 5 days later, on February 1, 1919, San Francisco lifted its mask requirement. For helping to promote influenza deaths in 1919 and for later inspiring thousands of anti-maskers during the COVID-19 pandemic, E. C. Harrington deserves nomination into the Hall of Shame.

6. John W. Hill

America’s economic fortunes were built on tobacco. When anticipated riches from early settlements such as Jamestown failed to materialize, the settlers turned to growing tobacco for export to Europe. Demand for tobacco was enormous and soon farms and plantations across the colonies were making their fortunes by growing tobacco. The invention of a machine for large scale manufacturing of cigarettes in 1880 revolutionized the U.S. tobacco industry. After the turn of the century, per capita cigarette consumption increased exponentially. But by 1950, there were increasing reports that tobacco smoke could be harmful to people’s health. The CEOs of the largest cigarette makers – American Tobacco Co., R. J. Reynolds, Philip Morris, Benson & Hedges, U.S. Tobacco Co. and Brown & Williamson, were worried that sales would suffer so they turned to John W. Hill, the founder of Hill & Knowlton, one of the top public relations firms in the country. In 1953, Hill devised a PR campaign to discredit the mounting scientific data and named it “Operation White Coats”. The plan was to employ physicians and scientists (who wore white coats) to downplay the health hazards of cigarette smoke. Operation White Coats was the genesis of the Tobacco Research Council that provided easy-to-obtain grants to prominent medical researchers for studies that showed health benefits of nicotine and other tobacco components. Hill’s cigarette marketing strategy was successful and by 1965, 45% of U.S. adults were daily smokers. In reality many people have contributed to the the misinformation campaigns of American tobacco companies but John W. Hill stands out as of the most effective in denying that smoking cigarettes causes lung cancer, COPD, and other diseases. His has been a legacy of death and even today, smoking accounts for 480,000 deaths per year in the U.S., or about 1 out of every 5 deaths. For his contribution to to the death of millions of Americans since his 1953 advertising campaign, John W. Hill is our 6th nominee to the Hall of Shame.

Honorable Mention: Carrie Nation. She was the public face of the Women’s Christian Temperance Union which was the primary driver of the prohibition movement that led to passing the 18th Amendment to the U.S. Constitution outlawing the sale of alcohol on January 16, 1919. She claimed to have a divine vision from God commanding her to destroy bars and saloons. She traveled across the United States with a hatchet that she would use to smash saloon fixtures and liquor bottles. She described herself as “a bulldog running along at the feet of Jesus, barking at what He doesn’t like”. Overall, prohibition did reduce U.S. alcohol consumption by about 30% but instead of drinking low-alcohol percentage beer, people just started drinking bootlegged liquors. These were produced in unregulated stills and were frequently contaminated with methanol. Sellars of illegal spirits would often water them down and then add various poisonous chemicals to mimic the taste and color of liquors. During prohibition, over 1,000 people per year died from consuming tainted liquor. Within 15 years, it became apparent that prohibition did not stop people from drinking, it only created a market for poisonous moonshine. In 1933, the 21st Amendment repealed prohibition.

7. Peter Duesberg, PhD

Athel cb CC BY-SA 4.0 via Wikimedia Commons

In the early 1980’s, gay men were dying from an immunodeficiency syndrome and no one knew why. In 1983, the cause was identified simultaneously by French virologist Luc Montagnier and American virologist Robert Gallo. It was a virus that became known as HIV, or human immunodeficiency virus. Soon after, a lab test was created to diagnose the infection followed by development of AZT, a life-saving anti-viral drug that could treat AIDS. These milestones should have been celebrated by the medical and scientific community as breakthroughs in conquering AIDS. But history has proven that for every disease, there is a disease denialist and for AIDS, the most prominent denialist was Peter Duesberg. He is a Professor of Molecular Biology at the University of California, Berkley who built a successful academic career on his discovery of genes that could cause cancer. He argued that HIV was a harmless virus and that the cause of AIDS was long-term consumption of recreational drugs and anti-viral drugs. Because of his academic credentials, he developed a following of AIDS denialists in the 1990’s. Around the globe, people continued to die of AIDS and by 2000, about 25% of all deaths in South Africa were due to AIDS. Thabo Mbeki, the president of South Africa, convened an AIDS advisory committee to help direct public policy. The committee included Peter Duesberg. Mbeki bought into Duesberg’s AIDS denialism and withheld the use of anti-retroviral drugs in his country. As a result, it is estimated that there were 330,000 preventable deaths from AIDS in South Africa. Duesberg has kept up his claims that HIV does not cause AIDS and as recently as 2012 said on the Joe Rogan podcast that HIV is “one of the most harmless type of viruses we know”. For his actions that contributed to one-third of a million AIDS deaths in South Africa and his inspiration for AIDS denialists everywhere, Peter Duesberg should be nominated for the Public Health Hall of Shame

Honorable Mention: Christine Maggiore. She was diagnosed with HIV in 1992 and became involved in AIDS activism. In 1994, she met Peter Duesberg who convinced her that HIV does not cause AIDS. She came to believe that her own positive HIV test was actually due to an influenza vaccination. She authored a book entitled What If Everything You Thought You Knew about AIDS Was Wrong? and became prominent in the AIDS denialist community. She founded an organization that urged HIV-positive pregnant women to avoid anti-HIV medication. Ironically, she went on to become pregnant herself and refused to take HIV medications. She give birth to a daughter, Eliza Jane, and refused to allow her infant daughter to be tested for HIV. Eliza Jane died of AIDS at age 3 and Christine Maggiore died of AIDS three years later.

8. Jay Dickey

Most of our Hall of Shame nominees are proposed because of their actions that resulted in the proliferation of disease. Although bullets are not a disease, guns have proliferated in the United States just like contagious pathogens. Each year, more than 45,000 Americans die from gunshots and twice that number suffer non-fatal gun injuries. One of the barriers to reducing firearm deaths over the past 25 years has been a law prohibiting research into firearm-related deaths and injuries. The architect of that law was U.S. Representative James Dickey of Arkansas who at the behest of the National Rifle Association, added a clause to the 1996 Omnibus bill that became known as the Dickey Amendment. The amendment stated that “…none of the funds made available for injury prevention and control at the Centers for Disease Control may be used to advocate or promote gun control.” It effectively stopped all research by the CDC into gun-related deaths and injuries. It was not until 2018 that Congress passed a law allowing the CDC to report data on firearm injuries and not until 2020 that Congress allowed funding for firearm injury research by the CDC. By prohibiting the CDC to study gun injuries for 22 years, there was no good data on which to base public policy to reduce firearm injuries and hundreds of thousands of Americans died from guns. Later in his life, Dickey reversed his opinion about gun violence research but he nevertheless deserves inclusion in the Hall of Shame.

Gage Skidmore, CC BY-SA 2.0 via Wikimedia Commons

Honorable mention: Wayne LaPierre. Mr. LaPierre has been the executive vice president and chief executive of the National Rifle Association since 1991. It was he who was the principal lobbyist who influenced Dickey to add the NRAs amendment to the Omnibus bill in 1996. LaPierre has continued to lobby for the proliferation of guns in the United States. Because of his efforts, the U.S. is now the only country in the world with more guns than people.

9. Andrew Wakefield, MD

Bladość, CC BY-SA 4.0, via Wikimedia Commons

As the son of two physicians, it was no surprise that Andrew Wakefield went to medical school at St. Mary’s Medical School in London. He went on to do research in liver and small intestine transplantation and became a member of the Royal College of Surgeons. He developed a hypothesis that the measles virus might be the cause of Crohn’s disease. This evolved into a hypothesis that the measles vaccine might cause Crohn’s disease. Both of these hypotheses were disproven. But Wakefield was undeterred in his quest to link the measles vaccine to some disease. So, he turned to autism and in 1998, he published a paper in The Lancet in which he concluded that 12 children with autism developed “autistic enterocolitis” from the MMR vaccine (measles, mumps, rubella vaccine). He then called for a suspension of childhood vaccination with MMR in a press conference at his hospital. In 2000, he repeated his claims on the CBS news show, 60 Minutes, introducing his theory to American vaccine conspiracy theorists. In 2004, the British public service network Channel 4 reported that before he published his 1998 article about the MMR vaccine, Wakefield submitted a patent for a rival measles vaccine that he said would not cause autism. Presumably, if his vaccine replaced the MMR vaccine worldwide, he would stand to profit enormously. He also started a company to make diagnostic test kits for “autistic enterocolitis” that he predicted would make him $43 million per year. In 2009, his original research was found to be fraudulent and in 2010, The Lancet retracted his 1998 article. Three months later, his medical license was revoked. Dr. Andrew Wakefield’s false claims about the MMR vaccine were the inspiration for other anti-vaxxers. This not only led to thousands of children not receiving appropriate vaccinations but also laid the groundwork for false claims about the COVID-19 vaccines. For his efforts to increase childhood infections, Andrew Wakefield should be included in the Hall of Shame.

Maxlovestoswim, CC BY-SA 4.0 via Wikimedia Commons

Honorable Mention: Robert F. Kennedy, Jr. The son of the late Senator Robert F. (Bobby) Kennedy is an environmental lawyer who makes a living as an anti-vaxxer. Since 2005, he has promoted Andrew Wakefield’s discredited idea that vaccines cause autism. When 2 Samoan infants died in 2018, he opined that the cause of their death was the MMR vaccine. It was later determined that the infants had been errantly injected with a muscle relaxant along with the vaccine and the muscle relaxant was the cause of death. Nevertheless, his views caused many Samoans to forgo the MMR vaccine in their children. As a consequence, in 2019, a measles outbreak resulted in 5,700 infections or 3% of the Samoan population; 83 Samoans died from measles infections. Kennedy became convinced that the preservative thimerosal in vaccines could cause neurological disorders such as autism in children and spread anti-vaccine misinformation. As a result, thousands of pregnant women refused influenza vaccination and thousands of parents refused to allow their children to get flu shots resulting in countless influenza infections and deaths. Many studies have shown that thimerosal in vaccines is safe. He has been a tireless conspiracy theorist and suggested that Anthony Fauci and Bill Gates conspired to prolong the COVID pandemic for financial gain. He promoted the use of ivermectin to treat COVID, despite studies showing that the anti-parasite drug had no effect on COVID infection. Other members of the Kennedy family issued a joint statement about his efforts and said: “…on vaccines he is wrong. And his and others’ work against vaccines is having heartbreaking consequences.”

10. Joseph Mercola, DO

The last of our nominations is for efforts to promote the spread of COVID-19. Dr. Joseph Mercola is an American alternative medicine proponent with a lucrative internet business selling dietary supplements. He stopped seeing patients in 2009 to devote his attention to his internet business and has stated that his net worth is in excess of $100 million. Following in Andrew Wakefield’s shoes, he has been a staunch vaccine critic. It was during the COVID-19 pandemic that Dr. Mercola really hit his stride by promoting unproven supplements (that he sold) as treatments for COVID. He also advocated using inhaled hydrogen peroxide to prevent or cure COVID. An article in the New York Times identified him as the single most influential spreader of COVID misinformation. Becker’s Hospital Review reported that a “Disinformation Dozen” individuals were responsible for 65% of all of the misinformation about COVID and number 1 on that list was Joseph Mercola. His actions have contributed to unfounded fears of effective COVID vaccines and even as of today, one-third of the U.S. population is not fully vaccinated. For his contribution to the perpetuation of the COVID pandemic that has so far killed more than 1 million Americans, Dr. Joseph Mercola is our 10th nominee for induction into the Hall of Shame.

Honorable Mention: Sherri Tenpenny, DO. Occupying the 4th rank in the COVID “Disinformation Dozen” is Ohio’s own Dr. Sherri Tenpenny. She is an anti-vaccine activist who supports the claim that vaccines cause autism. She has written 4 books claiming dangers of vaccines and has stated that COVID vaccines cause death, autoimmune disease, and infertility. She sells these books along with videos and dietary supplements on her website. She stated that COVID-19 vaccines will turn people into “transhumanist cyborgs” and that “by the end of 2022, every fully vaccinated person over the age of 30 may have the equivalent of full-blown vaccine-induced immune suppressed AIDS”. She claims that wearing face masks makes people unhealthy by suppressing their immune systems. In June 2021, she was called by Ohio Republican legislators to testify at the Ohio Statehouse against vaccine mandates. She testified that the COVID vaccines cause people to become magnetized and meanwhile her minions posted on-line videos of spoons stuck to their noses to try to prove her point. Dr. Tenpenny’s claims about magnetism proved to be too far-fetched even for Ohio’s conservative State Representatives and the bill to ban childhood vaccine requirements died in committee.

History is replete with people who have helped to spread disease. Some, like Columbus, did it unknowingly. Some, like Bouquet, did it purposefully. Some, like Comstock, did it in defiance of human nature. Some, like Hill, did it by spreading misinformation. Others, like Mercola, did it in order to make a profit. But whether their actions were intended or unintended, each of our nominees for induction in the  Public Health Hall of Shame helped to promote disease, death, or injury by their actions. The bitter news for the medical profession is that as long as we have people like these 10 inductees, doctors and morticians will never go out of business.

August 9, 2022

Categories
Epidemiology Inpatient Practice Outpatient Practice

Preparing For Monkeypox

Monkeypox is spreading rapidly across the United States. There are steps that every hospital and every medical practice need to take now to protect patients and healthcare workers. As of yesterday, there were 6,326 known cases and undoubtedly considerably more that have gone undiagnosed. Infected patients will be presenting to your hospital, office practice, and emergency department in the next few weeks.

Where did monkeypox come from?

Monkeypox is a type of orthopoxvirus that is related to smallpox. It was first found in monkeys in a Danish research lab in 1958. The virus is not unique to monkeys, however, and has since been found in various mammalian species in Western Africa. Humans have sporadically become infected after contact with infected animals. Although most human cases have been reported in Africa, there have been occasional clusters of cases in other countries over the past 20 years.

One of the most notable clusters occurred in the United States in 2003 when 47 Americans became infected with monkeypox that originated from an infected giant Gambian rat that had been imported from West Africa for sale as an exotic pet. The rat then infected a group of captive prairie dogs that were also sold. Of the 47 cases, all but one person acquired monkeypox directly from an infected animal. In only one case was there human-to-human transmission (from a child to mother).

In July 2021, a traveler from Nigeria was diagnosed with monkeypox in Texas. In November 2021, a second travel-related case was diagnosed in Maryland. The current outbreak began on May 7 2022 when a travel-related case was diagnosed in the United Kingdom. Later that month, cases were diagnosed in Massachusetts and New York. Since that time, the number of cases has been growing exponentially. Because of lack of familiarity with the disease and difficulty in obtaining diagnostic tests, it is likely that most cases initially went undiagnosed and that the true number of U.S. cases is much higher.

How is it spread?

Because the initial cases were reported in gay men, there is a misconception that monkeypox is a sexually-transmitted disease, like syphilis or HIV. It is not. Monkeypox is primarily spread by skin-to-skin contact, similar to MRSA. Thus, the initial cases occurred in gay men not because they had sex with other men but because they had close skin contact with infected men. Although the virus can also be spread by respiratory secretions, it is not as contagious as other respiratory viruses, such as COVID. Therefore, it requires closer and/or more prolonged exposure for airborne transmission. However, because it can be spread by both contact and airborne routes, both contact and airborne isolation is recommended for inpatients. Other points to know about monkeypox transmissibility:

  • It can be transmitted to and from pets
  • Bed linens, clothing, eating utensils, and drinking glasses can be infectious
  • Infected persons remain contagious until scabs have all crusted over and a layer of new skin has developed
  • Usual hospital disinfectants can eliminate the virus
  • The average incubation period is 7 days and persons can be contagious during the incubation period

Signs, symptoms, and diagnosis

As of today, most cases have been in men who have sex with men. However, since monkeypox virus is spread by skin contact (rather than sexual contact), the demographic of infected people is expected to rapidly change in the next few weeks. A person does not have to be gay or to even have sex with another person to become infected. Common signs and symptoms reported in a recent article in the New England Journal of Medicine include:

  • Rash – 95% (with 64% having <10 lesions)
    • Anogenital – 73%
    • Trunk or limbs – 55%
    • Face – 25%
    • Palms or soles – 10%
  • Fever – 62%
  • Lethargy – 41%
  • Myalgia – 31%
  • Headache – 27%
  • Pharyngitis – 21%
  • Lymphadenopathy – 56%

Because 98% of the 528 patients reported in this article were either gay or bisexual men, the incidence of anogenital lesions may be higher than in other patients. The rash is most frequently described as vesiculpustular (53%) but can present as a macular rash (4%), multiple ulcers (19%), or single ulcer (11%). Additional photos of the rash can be found on the CDC website.

Image: UK PHS

The diagnosis is made using swabs of skin lesions – preferably 2 swabs, each from a different lesion. Testing is done by orthopoxviral PCR and results can be available in 2-3 days. Specimen handling procedures can vary from lab to lab so be sure to follow specific instructions from the lab that the sample will be sent to. Until recently, testing was only available through the CDC and results could take 1-2 weeks. Now, testing is available through local health departments as well as several commercial labs making it possible to submit specimens as a regular send-out test from U.S. hospitals. Serology testing is also available through the CDC but the turn around time is 14 days.

Treatment

In cases reported during this outbreak, the mortality rate is low and in most people, the disease is self-limited and of mild-moderate severity. Consequently, to date, only a minority of patients receive anti-viral treatment (5% in the New England Journal of Medicine study). Certain patients are at higher risk of severe disease and these patients should be targeted for treatment:

  1. Those with severe disease (hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization)
  2. Immunocompromised persons
  3. Children (particularly those < 8 years old)
  4. Persons with exfoliative skin disorders (atopic dermatitis, psoriasis, etc.)
  5. Pregnant or breast-feeding women
  6. People with monkeypox complications (secondary bacterial skin infection; severe gastroenteritis; bronchopneumonia; etc.)
  7. Involvement of anatomic areas at risk of permanent injury (eyes, mouth, anus, genitalia, etc.)

The treatment of choice is tecovirimat (TPOXX). This drug is currently only available through the Strategic National Stockpile. Physicians have to contact either their state health department or the CDC (770-488-7100 or email at Poxvirus@cdc.gov). The dose is 600 mg PO BID x 14 days given within 30 minutes after a full meal of moderate/high fat. Drug side effects can include headache and nausea. TPOXX may reduce blood levels of midazolam and may increase levels of repaglinide.

Other treatments that may be effective but have less scientific data to support their use include intravenous Vaccinia immune globulin, cidofovir, and brincidofovir.

Vaccination

There are two vaccines available that are effective against monkeypox.Both of these are live virus vaccines (unlike most routine vaccines such as COVID vaccines or flu shots). The JYNNEOS vaccine contains a live non-replicating virus. The ACAM200 vaccine contains a live replicating virus.

JYNNEOS is given as 2 injections with the second dose given 4 weeks after the first dose. Full immune response develops 2 weeks after the second dose. The most common side effects are fatigue, headache, and myalgias. Unlike ACAM200, the JYNNEOS vaccine is not contraindicated in immunocompromised persons, pregnancy, or HIV infection.

The ACAM200 vaccine contains a live replicating Vaccinia virus that is given as a single dose. Because ACAM200 contains a replicating virus, it is contraindicated in immunocompromised persons, HIV infection (regardless of immune status), pregnancy, persons with heart disease, children < 1 year old, persons with eye conditions requiring topical steroids, and persons with a history of exfoliative skin disorders (eczema, atopic dermatitis, etc.). Although most side effects of ACAM200 are mild, 1 out of every 175 persons receiving it develop myocarditis or pericarditis. It takes 4 weeks for maximal immune development after vaccination.

Both vaccines are available from the Strategic National Stockpile. Because of limited supply (particularly of the JYNNEOS vaccine), widespread vaccination of the public and of most healthcare workers is not currently advised. Currently, the CDC only recommends pre-exposure prophylaxis vaccination for people at very high-risk of exposure (primarily laboratory workers performing diagnostic testing for monkeypox). The CDC anticipates expanding the indications for pre-exposure prophylaxis vaccination to broader populations as supplies of the vaccine increase in the future.

Most monkeypox vaccines are currently being given for post-exposure prophylaxis. When given within 4 days of exposure, vaccination can prevent the disease and when given between 4-14 days after exposure, vaccination can reduce the severity of monkeypox infection. Persons who should be prioritized for vaccination include:

  • Known contacts who are identified by public health via case investigation, contact tracing, and risk exposure assessments
  • Persons with a sexual partner in the past 14 days who was diagnosed with monkeypox
  • Persons who have had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox
  • Healthcare workers with a high risk exposure such as:
    • Unprotected contact with skin, lesions, or bodily fluids of a patient with monkeypox
    • Aerosol-generating procedures without N-95 mask and eye protection

Healthcare workers with an intermediate risk exposure should be offered post-exposure vaccination on a case-by-case basis and after discussion of the risks and benefits with the exposed healthcare worker. Intermediate risk exposures include: (1) being within 6 ft of an infected unmasked patient for more than 3 hours when the healthcare worker was not wearing a mask and (2) contact with patient’s clothing, skin lesions, or soiled linens while wearing gloves but not wearing a gown.

Healthcare workers with a low risk exposure generally do not require post-exposure vaccination. Low risk exposures include: (1) entering an infected patient’s room without wearing eye protection, (2) being in a room with an infected patient while wearing gown, gloves, eye protection and at least a surgical mask or (3) being within 6 feet of an unmasked patient for less than 3 hours without wearing at minimum, a surgical mask. Additional information about managing exposed healthcare workers can be found on the CDC website.

Isolation recommendations for infected outpatients

The vast majority of people infected with monkeypox can be treated as an outpatient. In order to control the spread of monkeypox in the community, it is essential that infected persons adhere to proper isolation procedures at home for the duration of infectivity. Infected persons remain contagious for 2-4 weeks. Isolation can be discontinued when until all symptoms have resolved, including full healing of the rash with formation of a fresh layer of skin in areas of vesicles and ulcers. Isolation practices include:

  • Remain in the home with no contact with other people
  • Avoid close physical contact, including sexual and/or close intimate contact, with other people.
  • Avoid sharing utensils or cups. Items should be cleaned and disinfected before use by others.
  • Do not share items that will be worn or handled with other people or animals.
  • Wash hands often with soap and water or use an alcohol-based hand sanitizer, especially after direct contact with the rash.
  • Avoid contact with pets
  • Launder and disinfect items that have been worn or handled and that have been touched by a lesion
  • Do not dry dust or sweep as this may spread the virus
  • Do not wear contact lenses (because of risk of spreading the virus to the eyes)
  • Clean and disinfect surfaces with an Environmental Protection Agency-registered disinfectant. If other household members are responsible for cleaning, they should wear a medical mask and disposable gloves, at a minimum
  • If the infected person must leave home for medical care or for an emergency, cover the lesions, wear a well-fitting mask, and avoid public transportation

Infection control in the outpatient office

Although not as contagious as COVID, there is still a risk of an outpatient with monkeypox infecting other patients or healthcare workers. All employees of outpatient medical practices need to be familiar with monkeypox infection control practices to minimize the risk of spreading the infection. Specific measures include:

  • Utilize telemedicine for patients known or suspected to have monkeypox
  • If using pre-registration procedures in advance of patients arrival to the office, include questions about monkeypox signs and symptoms
  • Place patients with known or suspected infection in a private exam room with the door closed. These patients should be escorted from the building entrance directly to the exam room and should not wait in a waiting area
  • Have patients with known or suspected infection wear a surgical face mask with areas of skin rash covered
  • Healthcare workers entering an exam room of a patient with known or suspected infection should wear a disposable gown, gloves, eye protection, and an N-95 mask
  • Use disposable paper exam table drapes and patient gowns. Dispose of these materials using medical waste trash bags and do not shake out gowns or drapes
  • When the patient leaves, sanitize the room surfaces. Most standard hospital disinfectants will suffice. A list of cleaning products can be found on the Environmental Protection Agency website.

Infection control in the hospital

Only a small minority of patients will require admission to the hospital. Some of the indications for admission include pain management (such as severe anorectal pain), soft-tissue superinfection, pharyngitis limiting oral intake, eye lesions, acute kidney injury, myocarditis, and public health infection-control purposes. Infection control measures for hospitalized patients include:

  • Place patients with known or suspected infection in a private room with private bathroom and with the hallway door closed (negative airflow is not required)
  • Transport and movement of the patient outside of the room should be limited to medically essential purposes
  • When patients must be transported outside of their room, they should wear a medical mask and have any exposed skin lesions covered with a sheet or gown
  • Healthcare workers should wear a disposable gown, gloves, eye protection, and an N-95 mask
  • If aerosol-generating procedures are to be performed (e.g., intubation or bronchoscopy), use an airborne isolation room
  • Environmental services such as dry dusting, sweeping, or vacuuming should be avoided in rooms housing infected patients
  • Disposables such as paper towels should be disposed of using medical waste trash bags
  • Use surface cleaning products that are believed to be effective for emerging viral pathogens  (listed on the Environmental Protection Agency website)
  • Do not shake soiled linen, towels, and gowns. Soiled items should be enclosed in a proper laundry bag for transport to the laundry and staff handling laundry from infected patients should wear proper personal protective equipment as recommended by the CDC
  • Visitors should be limited to those essential for the patient’s care and wellbeing

Don’t think of monkeypox as a sexually-transmitted disease

Because the current outbreak has so far primarily affected men who have sex with men, monkeypox has developed a mistaken stigmata of being a sexually transmitted disease. It is important that we educate our patients and our co-workers that it is not necessary to have sex with someone to become infected with monkeypox. Measures that prevent spread of HIV and syphilis will not work with monkeypox. Abstinence will not stop it. Condoms will not stop it.

One of our best weapons against monkeypox is education.

August 3, 2022

Categories
Epidemiology

Do Republicans Live Longer Than Democrats?

Who lives longer, Republicans or Democrats? The answer may surprise you. Many people hold the stereotype of Republicans being wealthy, being better educated, and having better access to healthcare. Democrats often hold the stereotype of being working class, poor, and wanting government healthcare handouts. Intuitively, this would translate to Republicans being healthier and living longer than Democrats.

Summary Points:

  • Health metrics correlate with the partisan index
  • People living in Republican-leaning states have a significantly shorter life expectancy than people living in Democrat-leaning states
  • Republican states have a higher COVID death rate, higher prevalence of obesity, and higher prevalence of smoking than Democrat-leaning states
  • Residents of Democrat-leaning states have a higher annual household income than residents of Republican-leaning states

 

Historically, Republicans were found to be healthier than Democrats. In a 2009 article from the International Journal of Epidemiology, investigators analyzed data from the 1972 – 2006 General Social Surveys and found that survey respondents who identified as Republican had better self-reported health and were less likely than Democrats to be smokers. Similarly, a 2015 article from the journal Political Research Quarterly found that people who identified as having good health were more likely to vote Republican in the preceding presidential election.

A more recent study in the May 2022 edition of the British Medical Journal found that the association of political party with health may be reversing. This study compared the voting patterns of individual U.S. counties in the 5 presidential elections between 2000 to 2019 with the changes in the mortality rates in each of those counties during the same time period. The results indicated that counties voting Democratic had greater improvements in mortality rates than counties voting Republican. Moreover, the separation between improved mortality rates and political party voting only became apparent after 2008. This suggests that there has been a change over the past 15 years with Democrats now becoming the healthier of the two political parties.

It turns out that determining how political party affiliation affects life expectancy and other health metrics is quite difficult. Nowhere on a death certificate is there an entry for the doctor to  record political party. Because our voting choices are confidential, there is no way to do a public record search for how dead Americans voted in the past Therefore, the only way to study political party affiliation and health outcomes is by correlation studies that look at voting patterns and health metrics of different geographic locations.

The Cook Partisan Voting Index

In 1997, a new method of determining political affiliation was developed called the Cook Partisan Voting Index. For the past 25 years, the index has been used to determine how strongly a congressional district or a state leans toward the Republican party or the Democratic Party. The index is based on voting patterns in the previous two presidential elections. The most recent data is based on voting in the 2016 and 2020 elections. The higher the number, the more strongly a state leans towards one political party.

In this table, Democratic-leaning states are in blue and are denoted with negative numbers; the more negative the number, the more the state leans Democratic. Republican-leaning states are in red and denoted with positive numbers; the higher the number, the more the state leans Republican. The most strongly Republican state is Wyoming and the most strongly Democratic states are Vermont and Hawaii. Two states (Nevada and New Hampshire) are equally split between Republican and Democratic parties and they are denoted in purple. The use of negative numbers for Democratic states and positive numbers for Republican states in this table is purely to facilitate statistical comparisons.

The Cook Partisan Index also reports the political leaning by individual congressional district. The most Democratic district is California’s 12th (Oakland area) and the most Republican district is Alabama’s 4th (rural northern Alabama).

Party affiliation and life expectancy

If we use the Cook Partisan Voting Index as a marker for party affiliation, then we can compare states with a high Republican index to states with a high Democratic index and see how those voting patterns correlate with health metrics. Life expectancy is one of the simplest of these metrics. Life expectancy can be measured in several ways. The most common measurements are (1) life expectancy from birth, (2) life expectancy from age 18, and (3) life expectancy from age 65. Each of these measurements has advantages and disadvantages.

Life expectancy from birth will be lower if there is a high infant and childhood mortality rate. Life expectancy from age 18 eliminates infant mortality but will be affected by gun-related deaths, drug overdoses, and motor vehicle deaths that are more common in young adults. Life expectancy from age 65 eliminates those young adulthood causes of death and is more affected by life-long unhealthy habits such as smoking, obesity, and alcohol abuse. For this analysis, let’s use life expectancy from birth since it incorporates all of the variables that can affect mortality from infancy through early adulthood and into older age.

In comparing the Cook Partisan Voting Index to life expectancy from birth, many people would suspect that Republicans would have a longer life expectancy than Democrats. However, just the opposite is true. People living in Democratic party states live longer than those in Republican party states. States that most strongly leaned Democrat had the longest life expectancy.

Overall, life expectancy in states found to be Democratic by the Cook Partisan Voting Index had a mean life expectancy of 79.6 years whereas the mean life expectancy in Republican states was 77.4 years (p < 0.001). This represents an average 2.2 year longer life expectancy in Democrat-leaning states.

Party affiliation and smoking

The finding of longer life expectancy in states that lean Democratic indicates that there has been a change in political party affiliation and health measures compared to older studies that showed Republicans were generally healthier than Democrats. One of the strongest predictors of life expectancy is smoking. In the past, Republicans were less likely to be smokers than Democrats. Could a change in the prevalence of smoking among people voting Republican versus Democrat be partially responsible for the change in life expectancy?

To answer this question, let’s examine the association between the Cook Partisan Voting Index and smoking rates by state. Each year, the Centers for Disease Control reports the percentage of adults in each state who smoke. Overall, the percentage of all Americans who smoke has been steadily falling since the mid-1960’s.

However, there are wide differences in smoking patterns between different states, ranging from a low of 7.9% of adults smoking in Utah to a high of 23.8% of adults smoking in West Virginia. Overall, states that lean Republican have a higher prevalence of smoking than states that lean Democratic (r = 0.64). The average adult smoking rate was 13.7% in Democrat states and 17.8% in Republican states (p < 0.001).

Party affiliation and obesity

A second health demographic that has changed over the past several decades is obesity. Overall, Americans have been becoming more obese each year. The CDC reports that the rate of obesity (BMI > 30) has increased from 30.5% in 2000 to 42.4% in 2018. Similarly, the rate of severe obesity (BMI > 40) has increased from 4.7% to 9.2%. These statistics are from the National Health and Nutrition Survey (NHANES) which is based face-to-face surveys performed in participating American’s homes by a physician and other health professionals.

As with smoking, there are substantial differences in the rate of obesity among different states. The Behavioral Risk Factor Surveillance System (BRFSS) reports obesity rates by state based on adult self-reported information from phone surveys. These self-reported obesity data differ from the NHANES data with a lower overall incidence of obesity than NHANES. This difference has been attributed to differences in how the data are obtained (in-person interview versus phone survey). The state with the highest rate of obesity is West Virginia and the state with the lowest rate of obesity is Colorado. Based on the BRFSS data, states that lean Democratic have an adult obesity prevalence of 29.1% and states that lean Republican have an adult obesity prevalence of 34.3% (p < 0.001)

Party affiliation and COVID mortality

One of the major causes of death in the United States in the past two years has been COVID-19. So far, 1,024,611 Americans are known to have died from COVID and many more have likely died from COVID or COVID complications that were not listed on death certificates. A study published last month in JAMA Internal Medicine found that in 2021, COVID was the 4th leading cause of death in Americans age 25-34 (after accidents, suicide, and assault), the number 1 cause of death in Americans age 45-54, and the 3rd leading cause of death in Americans over age 65 (after cancer and heart disease).

As noted in a previous post, there are significant differences in how Republicans and Democrats fared during the COVID-19 pandemic with residents in Democratic states more likely to be vaccinated against COVID, less likely to become infected with COVID, and less likely to die from COVID than residents in Republican states. By comparing the Cook Partisan Voting Index to the death rate of COVID for each state, we again find that the  there is an association between party affiliation and death from COVID. Overall, 260 people per 100,000 population have died from COVID in Democrat-leaning states whereas 331 per 100,000 died from COVID in Republican-leaning states (p = 0.005).

Party affiliation and personal income

As noted earlier, historically Republicans had a higher self-reported annual income than Democrats. The stereotypical Republican was a capitalism-supporting business owner and the stereotypical Democrat was a blue collar worker who belonged to a union. Personal income has been shown to affect health outcomes with wealthier persons having better health and poorer persons having worse health. Could a change in income demographics between Republicans and Democrats be partially responsible of the shorter life expectancy of residents of Republican states?

By comparing household income to the Cook Partisan Voting Index, we find that residents of states leaning Democratic have a higher annual income than residents of states leaning Republican. The average income in Democratic-leaning sates was $71,264 and the average come in Republican-leaning states was $59,108 (p < 0.001).

Money is only worth what you can buy with it. The highest income states are also the states with the highest cost of living so the above analysis man not necessarily equate to the purchasing power of each household. Nevertheless, it appears that voters favoring Republicans in the last two presidential elections have a different relative annual income than voters favoring Republicans in previous presidential elections. Residents of states who have recently favored Republicans have a lower income than those favoring Democrats.

Today’s Republicans are not your parent’s Republicans

A generation ago, compared to Democrats, Republicans were wealthier, healthier, and less likely to smoke. Today’s Republicans have a lower income, are more obese, are more likely to smoke, and are more likely to die young than Democrats. This generational reversal in the relationship between party affiliation and health metrics has implications for future healthcare utilization.

For example, given a 2.2 year longer life expectancy, residents of Democrat-leaning states would be expected to utilize 18% more Medicare and Social Security benefits than residents of Republican-leaning states (assuming Medicare and Social Security benefits starting at age 65). The longer a person lives, the more elections that person can vote in. The results imply that people voting Democrat will vote in an average of 2 more annual elections over the course of their lifetimes than those who vote Republican.

Obesity is associated with other health conditions such as diabetes, hypertension, sleep apnea, and arthritis. This could indicate that people voting Republican are more likely to have these conditions in addition to being more likely to be smokers. The result could be a higher incidence of disability among people voting Republican than among people voting Democrat.

It seems paradoxical that people living in states that lean toward the Democratic party have higher incomes and thus are in higher income tax brackets and pay more in income tax than people living in states that lean toward the Republican party. Democrats are often characterized as favoring higher taxes whereas Republicans are generally characterized as favoring tax cuts.

We will not fully know all of the healthcare implications for the apparent change in voter demographics for several years. However, it is likely that the evolving differences in health metrics between states that vote Republican and states that vote Democrat will result in very different approaches to healthcare policy.

August 1, 2022

Categories
Academic Medicine Physician Retirement Planning

Is Your Public Pension Safe? Check The Pension’s Vital Signs!

Physicians at academic medical centers often have an option to contribute to a state teacher’s pension plan. Although a pension can be an important component of a diversified retirement portfolio, some public pensions are currently in danger. How safe is your state’s public pension and should you contribute to it? The answer is in the pension’s vital signs.

Summary Points:

  • Most physicians employed by public universities can participate in their state’s public pension
  • Each state’s public pension is managed separately
  • Some public pensions are healthier than others
  • The funded ratio and the funding period are two important vital signs that indicate the health of a public pension

 

In Ohio, the State Teachers Retirement System (STRS) is our state’s public pension for academic physicians at state-funded universities (such as the Ohio State University). STRS is similar to Social Security or an annuity in that it gives university-employed physicians an option to participate in a defined benefit plan that will pay you a fixed amount of money every month that you are alive after you retire. There is also an option for survivor benefits so that your spouse can continue to receive a monthly payment after you die. The advantage of defined benefit plans, such as STRS, is that you never run out of money in retirement. The disadvantage is that as an investment, you may be able to come out ahead by investing the money yourself rather than contributing to the pension during your working years.

In the past, most American workers had access to employer-sponsored pensions but many private employers have abandoned pensions and replaced them with 401(k) plans. However, pensions are still quite common for employees of state and local governments. Everyone’s retirement portfolio should be diversified and contain several different types of investments, such as stocks, bonds, and real estate. A pension can be an important component of those investments, less risky than bonds but also having a low rate of return.

However, all types of investments have risk and a pension is no different. Social Security is generally considered to be very low-risk, as investments go. But even Social Security is in danger of running out of money in 2035, unless action is taken by the U.S. Congress in the future. Private company pensions occasionally run out of money, leaving retirees with reduced or no monthly pension payments. State public pensions are somewhere in-between Social Security and private company pensions with respect to investment risk.

In some states (such as Ohio), academic physicians have an option of either participating in the public pension (STRS) or self-directing payroll deduction retirement savings into investments of their own choice. In other states, participation in the public pension is mandatory and there is not an option to self-direct. When deciding whether or not to participate in a public pension or deciding whether or not to take a university job in a mandatory public pension state, you should look carefully at the state’s public pension. Some states’ public pensions are considerably safer than others. When researching a state’s public pension, there are two pension vital signs that are important: (1) the funded ratio and (2) the funding period. Understanding these two numbers is critical to understanding the health of a public pension.

The Funded Ratio

The funded ratio is the ratio of a pension’s assets to its current and future liabilities. In simple terms, the assets are all of the money that the pension currently has in cash and in investments. The liabilities are the total amount of money that the pension plan will pay out to retirees now and in the future plus the administrative cost of the pension. In an ideal world, the funded ratio should be 100% or higher. In other words, the pension plan should have enough money to pay for the pensions of all of its current participating members. A funded ratio below 100% can be cause for concern and a funded ratio below 80% can be a sign that the pension plan is in jeopardy. The Equitable Institute recently released its annual State of Pensions report for 2022 and there are some concerning findings. From the map below, it is apparent that some states’ public pensions have very strong funded ratios and others have very poor funded ratios.

Washington, Utah, South Dakota, Wisconsin, Tennessee, New York, the District of Columbia, and Delaware all have funded ratios greater than 90% (dark green). On the other hand, Illinois, Kentucky, South Carolina, New Jersey, Connecticut, Hawaii, and Rhode Island all have severely low funded ratios that are below 60% (dark red). In between these extremes are thirteen states that mildly low funded ratios between 80-90% (light green). Fourteen states have moderately low funded ratios between 70-80% (yellow). And nine states have moderate-severely low funded ratios between 60-70% (light red).

One of the main reasons that many states’ funded ratios have recently fallen is the downturn in the stock market in the past 7 months. Public pensions do not just keep all of their money in a checking account, they invest the money in order to keep up with inflation and to ensure that they have sufficient money to pay their retirees in the future. Most public pensions estimate that their investments will have an average 6.9% annual return. Last year, in 2021, the average pension plan’s rate of return was 25.3% – an extraordinarily high rate of return, primarily because stock markets had an exceptional year. So far in 2022, the average pension plan has had a -10.4% rate of return. In other words, instead of gaining 6.9% this year, the average pension has already lost 10.4%.

There are several reasons why a state might have a low funded ratio:

  1. Inadequate funding. Public pensions are funded by a combination of employee contributions (payroll deductions) plus employer contributions (usually as a fixed percentage of gross salary). If the contribution rates are set too low, then the public pension fund will not have sufficient funds to pay monthly retirement benefits. Currently, the average employee contribution is 8.07% of total salary, an increase from 7.06% in 2001. In addition to employee contributions to the public pension, there are also employer contributions to the pension and these currently average 29.8% of total payroll, an increase from 9.13% in 2001.
  2. Excessively high retirement benefits. Similarly, if the amount of money that retirees receive in their monthly pension payments is set too high, then the funded ratio will fall as the pension gradually runs out of money. The amount of the pension fund contributions and the amount of the pension fund distributions requires a very careful actuarial analysis and this in turn requires well-trained and highly skilled actuaries. Not every state has equally high-quality actuaries working for their public pensions. Public pensions should have periodic external audits to validate the conclusions and recommendations of the pensions internal actuaries. These audit reports should be available to pension participants and can be a valuable source of information about the pension’s health.
  3. Poor investment choices. Each state’s pension is managed differently – some by internal fund managers and some by external investment companies that employ their own fund managers. Inevitably, some fund managers will be better than others at selecting winning investments. However, as has been shown with managed mutual funds compared to index funds, most fund managers will not beat the overall stock market. This year, one of the particularly bad investment choices was in Russian investments. Prior to the Russian invasion of Ukraine, U.S. public pensions held approximately $5.8 billion in Russian market assets, securities, and real estate. These investments have lost enormous value since 2021. Over the past 15 years, there has been a growing trend to outsource investment decisions – currently 15% of public pension funds are managed by either a hedge fund or a private investment company.
  4. Unrealistic projected rates of return. The average annual rate of return on public pension fund investments is 6.9%. If a fund projects a higher rate of return, say 8.5%, then there is a high likelihood that their investments will not meet their projected rate of return, leading to lower than anticipated asset value. A pension fund’s rate of return on its investments will be largely determined by the ratio of stocks:bond:real estate in the fund’s investment portfolio. This ratio is in turn determined by the decisions made by the pension fund managers.
  5. The value of stocks and bonds fall. Some years, the stock and bond markets go up and some years they go down. Because public pension funds are mainly investing for the long-term, it is expected that the funded ratio will fall during short-term market downturns but then go up when the market recovers. 2021 and 2022 exemplify this perfectly with large losses in stock and bond values in 2022 but even larger gains in 2021. This resulted in a higher average funded ratio in 2021 that then fell in 2022 (graph below). It is more important to look at public pension fund investments over a several year period to determine how well the fund is doing.
  6. Inflation. If the public pension fund retiree distributions are tied to inflation, then there can be large cost of living increases in monthly pension payments during years that there is a high inflation rate. In these pensions, when inflation rises unexpectedly high (as in the previous 12 months), then the funded ratio can fall due to higher than expected monthly pension payments. Of 372 public pensions, 204 of them have automatic cost of living increase provisions with the majority of these linked to the inflation rate or the fund’s overall performance. Because of the danger of inflation eroding the funded ratio, other public pensions limit or do not give any regular cost of living increases in pension distributions.
  7. Increased life expectancy. This is often cited as a cause of a low funded ratio because if retirees live longer than expected, then the overall amount that the pension fund pays those retirees will be higher than expected. However, it turns out that annual increases in life expectancy have only a very small effect on funded ratios. It remains to be seen whether the opposite effect (shorter life expectancy) will improve funded ratios in the next few years since the majority of the more than 1 million U.S. COVID-19 deaths in 2020 and 2021 were in retirees.

The Funding Period

When a public pension’s funded ratio falls, or when actuarial analysis projects that it will fall in the future, there are a number of tactics that the pension can take to rectify the low funded ratio. For example, the pension managers can suspend cost of living increases in pension distributions. Or they can increase the contributions by increasing the percentage of employed pension members’ salaries going into the pension fund. Or they can increase the number of years a member must work before being eligible for full retirement benefits. When a public pension makes these corrective actions, it can take many years for the funded ratio to increase to 100%. The projected number of years that it will take to reach 100% is called the funding period.

Simply having a low funded ratio may not necessarily be bad as long as the public pension managers have taken corrective actions to improve the funded ratio. How effective these corrective actions are projected to be is measured by the length of the funding period. In general, the shorter the funding period, the better. In Ohio, the State Teachers Retirement System is required by state statute to have a funding period of less than 30 years. Funding periods in excess of 30 years are generally too long and can be a sign of an unhealthy public pension.

Many of the same variables that affect the funded ratio also affect the funding period. For example, the Ohio State Teachers Retirement System funding period dropped from 30 years to 8 years in 2021 due to the unusually large rate of investment return in 2021.

Public pensions with both a low funded ratio and a long funding period are in trouble. These pensions are in danger of being unable to meet future obligations. From a retirement portfolio standpoint, they are poor investments.

A Story Of 3 States

To illustrate the variability in public pension health, let’s examine three states: one that is in trouble, one that is in great shape, and one that was in trouble but has taken effective measures to improve.

Illinois. Illinois has 5 different state government public pension programs and all of them have a long history of being underfunded. At the end of 2021, these public pensions had an average funded ratio of only 46.5%, the highest ratio for the Illinois public pensions since 2008, before the great recession. Although improved, this is still among the lowest of all states’ public pension funded ratios. The state legislature has created a plan to increase the funded ratio to 90% by the year 2045. However, the state’s actuary and outside actuarial consultant have advised that a 90% funded ratio target in 23 years is insufficient and instead have advised a funding period to a 100% funded ratio of no more than 25 years. So far, no legislative action has been taken to improve the funding period. As a consequence, participation in the Illinois public pension is very risky compared to other states’ public pensions.

Wisconsin. The primary state public pension is the Wisconsin Retirement Benefit. It has a track record of being well-managed and as a consequence, it has a funded ratio that exceeds 100%. In fact, the funded ratio at the end of 2021 was 120.6%. That puts its funded ratio as the eighth highest out of 167 statewide public pensions in the country. Academic physicians can feel secure that their contributions to the Wisconsin public pension will be safe and that they can count on their monthly pension benefits in retirement.

Ohio. There are 5 statewide public pensions in Ohio. Academic physicians have the option of participating in one of them, the State Teachers Retirement System of Ohio.  In 2001, STRS was in good shape with a funded ratio of 91%. The great recession severely impacted STRS and by 2012, the funded ratio had fallen to 56%. By 2017, the funding period to reach a funded ratio of 100% had risen to 60 years, putting the entire pension in jeopardy. STRS enacted three corrective measures to stabilize the pension fund: (1) suspension of annual cost of living increases in retiree pension distributions, (2) a 2.91% increase in the employer contributions to the pension fund, and (3) an increase in the number of years of service to full retirement benefits from 30 years to 35 years. By the end of 2021, the pension’s funded ratio was 80.1% and the funding period was 8 years. STRS’s willingness and ability to make hard decisions to increase contributions and limit distributions has resulted in it once again becoming a safer retirement investment for participants.

Even healthy public pensions are vulnerable to forces that can destabilize them. For example, the next pension fund manager could make poor investment choices. The state legislature could enact statues that acquiesce to lobby pressure to increase retiree benefits or decrease employee/employer contributions. The next actuaries may make faulty life expectancy projections. For these reasons, it behooves all participants to periodically check the status of their public pension. At a minimum this should entail reviewing the current funded ratio and funding period of the pension. In this sense, a pension is an investment and should be monitored similarly to how one monitors their 401(k) or 403(b) fund.

“If you’ve seen one public pension, you’ve seen one public pension”

A strong and secure retirement investment portfolio is one that is diversified. Ideally, one’s portfolio should consist of a mixture of stocks, real estate, bonds, fixed income, and cash. For each of these types of investments, the potential long-term return is directly related to the short-term risk of the investment.

For most Americans, the fixed income component is Social Security. But academic physicians and other employees of state-funded universities usually do not participate in Social Security. The public pension substitutes for for Social Security and is thus the main component of the fixed income portion of academic physicians’ retirement portfolio.

Some financial pundits have argued that it is better to not participate in a public pension and instead take the money that would have gone into the pension fund from payroll deduction and invest that money into stocks. The argument is that in the long-term, the rate of return from stock investments will be greater than the return from pension distributions in retirement. However, a more accurate view of a public pension is that it forms a crucial low-risk/low-return component of a balanced retirement portfolio. By having a public pension in the portfolio, the academic physician can devote a larger percentage of other retirement investments (403b, 457, IRA, etc.) into higher risk stocks and real estate.

In addition to functioning as a fixed income retirement investment, public pensions have other features that can increase their value to the participant. Survivor benefits for one’s spouse and dependents can replace the need to purchase separate life insurance. Disability benefits can replace the need to purchase separate disability insurance. Access to group rates for health, dental, and vision insurance can result in insurance premiums that can be thousands of dollars less per year than equivalent insurance policies purchased individually. And access to financial counselors at the public pension can provide some elements of free financial planning advice.

But each state’s public pension has different degrees of risk as evidenced by their varying funded ratios and funding periods. Before committing to participating in a public pension, it is important to carefully examine the health of that particular state’s public pension. Do a routine vital sign check of the pension by following its funded ratio and funding period.

July 22, 2022