Feature

Q&A: Updates on COVID-19 protocols in primary care

Health care providers across the world are adjusting to the challenges of caring for patients during the global COVID-19 pandemic.

Healio previously spoke with Elisa Choi, MD, FACP, FIDSA, ACP Massachusetts Chapter Governor and member of the Infectious Diseases Society of America’s public health committee, about interim protocols for COVID-19 testing in primary care offices and how primary care physicians should manage suspected or confirmed cases of COVID-19.

In this update, Choi shares new information about testing and care, including the use of telemedicine, and offers practical advice for physicians on the frontlines.

Q: What is the protocol for COVID-19 testing in primary care?

A: This is a rapidly evolving area, more so perhaps than other areas because as time goes by and the infection spreads, we now face some difficult decisions in terms of how to navigate the demand for testing with the limited supply. Protocols are going to vary from hospital to hospital, health care organization to health care organization and possibly from state to state. I think a general trend that we are going to see is a shift toward prioritizing which individuals most need testing, rather than indiscriminately testing anybody who comes to care and expresses concern about potential exposure to COVID-19.

When I first discussed interim guidance, there was a focus on containment and really relying on exposure history or contact with known COVID-19-confirmed cases to determine who would be at higher risk. That has gone out the window at this point. The fact now is that we may not have a definitive contact or exposure history because there is community spread of COVID-19, more so in certain states than others. So, it is becoming increasingly difficult to determine who has “relevant” exposure and would warrant COVID-19 testing. Because COVID-19 can present with very nonspecific influenza-like symptoms and respiratory infection symptoms, it becomes more difficult to determine who may or may not have COVID-19.

In light of the community spread, the lack of any particular disease-specific or pathognomonic symptom presentations, as well as the difficulty in navigating the demand for testing with the currently available supply, testing approaches now involve identifying and prioritizing individuals whose results would have the greatest impact on secondary transmission. For a number of health care organizations, the focus now is testing health care workers and first responders, or individuals who work or live in congregate settings (like residential facilities, nursing homes, dormitories, homeless shelters, incarceration facilities and similar environments where COVID-19 can rapidly spread in a focal geographic area). Household contacts of health care workers and first responders, who are symptomatic, may also be higher testing priorities. At this time, testing of any of these high-priority individuals remains focused on symptomatic individuals and not on individuals who are asymptomatic.

The drive-through testing approach is becoming more common. Many of these drive-through test sites are sponsored by health care organizations, so there is an attempt to keep drive-through testing protocols consistent with testing in an office or hospital. However, there may be some drive-through testing sites that opt to test more widely. That can present challenges because there is such an increasing demand for COVID-19 testing and a limited supply of test kits. From my perspective, we really want to make sure that the people who have the highest risk for secondary transmission are prioritized. With the current situation we are facing, an infection that is really contagious and can spread pretty rapidly throughout communities, we need to deal with the fact that we don’t have unlimited supplies of testing kits, and focus most urgently on testing for whom the results will impact the risk of more widespread transmission. There are attempts to scale up the production of commercial test kits in addition to the test kits made available by state laboratories, but we still don’t have unlimited supplies.

Q: Is insurance complicating testing and care through telemedicine?

A: With the increasingly apparent reality that COVID-19 is spreading in the community, telemedicine can help minimize spread and “flatten the curve.” To be responsible stewards of public health, many health care organizations are trying to see if most medical conditions managed in the ambulatory setting can be addressed with an initial phone call visit or video visit, then make a determination of how clinically stable the individual is and whether they need a face-to-face visit. This is not to say that we are not providing adequate care, but certainly nonurgent visits, like routine physical exams or routine follow-up visits for chronic disease management, may be better served through telemedicine so patients are not being possibly exposed to COVID-19 by coming into clinics and health care facilities.

In recognition of widespread COVID-19 transmission, and the need to be judicious and prudent about face-to-face contact to minimize spread of infection, reimbursement for telehealth services is crucial. In order for the expansion of telemedicine to provide adequate care of patients in the current era of COVID-19 mitigation measures with social/physical distancing, previously noted barriers, such as lack of reimbursement for telehealth services, need to be removed. In the past, many insurance payors would not reimburse for telemedicine. But in the face of COVID-19, the promise of reimbursement for telehealth services has accelerated the efforts of health care organizations to expand telemedicine because there is a sense that they will be able to recoup their investment in the technology and in the care that they provide to patients.

Q: What are the next steps after a patient tests positive?

A: If a patient tests positive, the severity of their symptoms needs to be assessed. The first branching point is determining if a patient is clinically stable and can be managed with supportive care at home in self-isolation. If they are too sick to be managed at home, then they need to be taken care of in the hospital.

There was a brief report circulating that perhaps ibuprofen use could lead to more severe COVID-19 disease. There was even more confusion when a WHO spokesperson made a conservative statement and suggested that WHO for the time being recommends avoiding ibuprofen, just in case there could be some worsening disease. However, there are no clear data to support the claim that ibuprofen makes COVID-19 disease worse. So, at this time, neither WHO nor the FDA are making the recommendation that ibuprofen and nonsteroidal inflammatory drugs need to be avoided as over-the-counter remedies for COVID-19 symptom management. They can be part of the therapeutic toolkit, along with acetaminophen and other over-the-counter medications.

Q: What other advice do you have for physicians?

A: I have had the privilege to be on the front lines as the COVID-19 pandemic starts to gain steam and accelerate. It needs to be acknowledged that this is a very challenging and stressful time for everybody. But for physicians, particularly those on the front line, there is so much uncertainty. We are in the middle of an evolving pandemic with a novel emerging pathogen — a virus that has never been seen before in the human population. What we think we know about COVID-19 on 1 day may be very different the next day — even the next hour. The ibuprofen controversy is a great example of that.

For my fellow physicians who are bravely managing and taking care of patients on the front lines during this situation, my practical advice is to make sure that we take care of ourselves, which is easier said than done sometimes when we are also trying to stay up to date with the latest information from credible sources. We need to ensure that we take care of our own health. There is a common urban myth that has some validity and truth to it, that doctors make the worst patients. I think that notion stems from the fact that many of us will sometimes work long hours to make sure that we are getting everything done to take care of our patients, but then we may neglect our own self-care. We need to not do that during this unprecedented pandemic because we need each other to be present for our patients, and we can do that by staying healthy. This includes physical health as well as psychological well-being. We need to make sure that we rely on each other if need be and to know our limits and partner with each other. I have been really grateful to see a lot of teamwork happening. Not that I wasn’t expecting that to happen, but I think everyone is recognizing, especially physicians on the front line, just how uncertain things are and how hard it is to keep up with the everchanging body of knowledge that seems to be cropping up. We need to help and be kind to each other so that we can continue to take care of ourselves as much as possible so that we can ultimately take care of our patients. I’ve seen how important that is just in the last 2 weeks since the COVID-19 situation has really escalated.

As the number of COVID-19 cases is taking off, unfortunately I keep hearing cases of outright racism, harassment, bigotry and even violent assaults targeting individuals of Asian descent. Such unacceptable acts stem from stigmatizing or scapegoating Asians, by blaming Asians for “causing” the COVID-19 pandemic or for being “carriers” of SARS-CoV2. It cannot be overstated that we, as physicians and medical care practitioners who ground our care for our patients in facts and science, also have to make sure that we combat the misinformation that the general public or even some of our own patients might mention to us. We need to do it in a diplomatic way and maintain professionalism. There is already too much misinformation out there. We want to take care of our patients and be empathetic to what they are going through, but we also need to gently but firmly make sure that if we are hearing any of our own patients propagating anti-Asian racism, or any racism for that matter, to make sure that we repudiate that at every opportunity. I’m grateful because in speaking out about this particular issue, I have been so heartened to hear fellow physician colleagues who have shared with me how they have done exactly that.

These are very unprecedented times, but I think that as we are learning more, we can really provide outstanding empathetic care to our patients based on science and medical facts but also make sure that we do not stand for intolerance of any kind.

For more information:

Choi E, et al. Ann Intern Med. http://freshlook.annals.org/2020/03/respiratory-disease-and-racism-covid19.html. Accessed March 22, 2020.

Disclosure: Choi reports no relevant financial disclosures.

Editor’s note: This interview reflects the views and opinions of Choi and not her affiliations or institutions.

Health care providers across the world are adjusting to the challenges of caring for patients during the global COVID-19 pandemic.

Healio previously spoke with Elisa Choi, MD, FACP, FIDSA, ACP Massachusetts Chapter Governor and member of the Infectious Diseases Society of America’s public health committee, about interim protocols for COVID-19 testing in primary care offices and how primary care physicians should manage suspected or confirmed cases of COVID-19.

In this update, Choi shares new information about testing and care, including the use of telemedicine, and offers practical advice for physicians on the frontlines.

Q: What is the protocol for COVID-19 testing in primary care?

A: This is a rapidly evolving area, more so perhaps than other areas because as time goes by and the infection spreads, we now face some difficult decisions in terms of how to navigate the demand for testing with the limited supply. Protocols are going to vary from hospital to hospital, health care organization to health care organization and possibly from state to state. I think a general trend that we are going to see is a shift toward prioritizing which individuals most need testing, rather than indiscriminately testing anybody who comes to care and expresses concern about potential exposure to COVID-19.

When I first discussed interim guidance, there was a focus on containment and really relying on exposure history or contact with known COVID-19-confirmed cases to determine who would be at higher risk. That has gone out the window at this point. The fact now is that we may not have a definitive contact or exposure history because there is community spread of COVID-19, more so in certain states than others. So, it is becoming increasingly difficult to determine who has “relevant” exposure and would warrant COVID-19 testing. Because COVID-19 can present with very nonspecific influenza-like symptoms and respiratory infection symptoms, it becomes more difficult to determine who may or may not have COVID-19.

In light of the community spread, the lack of any particular disease-specific or pathognomonic symptom presentations, as well as the difficulty in navigating the demand for testing with the currently available supply, testing approaches now involve identifying and prioritizing individuals whose results would have the greatest impact on secondary transmission. For a number of health care organizations, the focus now is testing health care workers and first responders, or individuals who work or live in congregate settings (like residential facilities, nursing homes, dormitories, homeless shelters, incarceration facilities and similar environments where COVID-19 can rapidly spread in a focal geographic area). Household contacts of health care workers and first responders, who are symptomatic, may also be higher testing priorities. At this time, testing of any of these high-priority individuals remains focused on symptomatic individuals and not on individuals who are asymptomatic.

PAGE BREAK

The drive-through testing approach is becoming more common. Many of these drive-through test sites are sponsored by health care organizations, so there is an attempt to keep drive-through testing protocols consistent with testing in an office or hospital. However, there may be some drive-through testing sites that opt to test more widely. That can present challenges because there is such an increasing demand for COVID-19 testing and a limited supply of test kits. From my perspective, we really want to make sure that the people who have the highest risk for secondary transmission are prioritized. With the current situation we are facing, an infection that is really contagious and can spread pretty rapidly throughout communities, we need to deal with the fact that we don’t have unlimited supplies of testing kits, and focus most urgently on testing for whom the results will impact the risk of more widespread transmission. There are attempts to scale up the production of commercial test kits in addition to the test kits made available by state laboratories, but we still don’t have unlimited supplies.

Q: Is insurance complicating testing and care through telemedicine?

A: With the increasingly apparent reality that COVID-19 is spreading in the community, telemedicine can help minimize spread and “flatten the curve.” To be responsible stewards of public health, many health care organizations are trying to see if most medical conditions managed in the ambulatory setting can be addressed with an initial phone call visit or video visit, then make a determination of how clinically stable the individual is and whether they need a face-to-face visit. This is not to say that we are not providing adequate care, but certainly nonurgent visits, like routine physical exams or routine follow-up visits for chronic disease management, may be better served through telemedicine so patients are not being possibly exposed to COVID-19 by coming into clinics and health care facilities.

In recognition of widespread COVID-19 transmission, and the need to be judicious and prudent about face-to-face contact to minimize spread of infection, reimbursement for telehealth services is crucial. In order for the expansion of telemedicine to provide adequate care of patients in the current era of COVID-19 mitigation measures with social/physical distancing, previously noted barriers, such as lack of reimbursement for telehealth services, need to be removed. In the past, many insurance payors would not reimburse for telemedicine. But in the face of COVID-19, the promise of reimbursement for telehealth services has accelerated the efforts of health care organizations to expand telemedicine because there is a sense that they will be able to recoup their investment in the technology and in the care that they provide to patients.

PAGE BREAK

Q: What are the next steps after a patient tests positive?

A: If a patient tests positive, the severity of their symptoms needs to be assessed. The first branching point is determining if a patient is clinically stable and can be managed with supportive care at home in self-isolation. If they are too sick to be managed at home, then they need to be taken care of in the hospital.

There was a brief report circulating that perhaps ibuprofen use could lead to more severe COVID-19 disease. There was even more confusion when a WHO spokesperson made a conservative statement and suggested that WHO for the time being recommends avoiding ibuprofen, just in case there could be some worsening disease. However, there are no clear data to support the claim that ibuprofen makes COVID-19 disease worse. So, at this time, neither WHO nor the FDA are making the recommendation that ibuprofen and nonsteroidal inflammatory drugs need to be avoided as over-the-counter remedies for COVID-19 symptom management. They can be part of the therapeutic toolkit, along with acetaminophen and other over-the-counter medications.

Q: What other advice do you have for physicians?

A: I have had the privilege to be on the front lines as the COVID-19 pandemic starts to gain steam and accelerate. It needs to be acknowledged that this is a very challenging and stressful time for everybody. But for physicians, particularly those on the front line, there is so much uncertainty. We are in the middle of an evolving pandemic with a novel emerging pathogen — a virus that has never been seen before in the human population. What we think we know about COVID-19 on 1 day may be very different the next day — even the next hour. The ibuprofen controversy is a great example of that.

For my fellow physicians who are bravely managing and taking care of patients on the front lines during this situation, my practical advice is to make sure that we take care of ourselves, which is easier said than done sometimes when we are also trying to stay up to date with the latest information from credible sources. We need to ensure that we take care of our own health. There is a common urban myth that has some validity and truth to it, that doctors make the worst patients. I think that notion stems from the fact that many of us will sometimes work long hours to make sure that we are getting everything done to take care of our patients, but then we may neglect our own self-care. We need to not do that during this unprecedented pandemic because we need each other to be present for our patients, and we can do that by staying healthy. This includes physical health as well as psychological well-being. We need to make sure that we rely on each other if need be and to know our limits and partner with each other. I have been really grateful to see a lot of teamwork happening. Not that I wasn’t expecting that to happen, but I think everyone is recognizing, especially physicians on the front line, just how uncertain things are and how hard it is to keep up with the everchanging body of knowledge that seems to be cropping up. We need to help and be kind to each other so that we can continue to take care of ourselves as much as possible so that we can ultimately take care of our patients. I’ve seen how important that is just in the last 2 weeks since the COVID-19 situation has really escalated.

PAGE BREAK

As the number of COVID-19 cases is taking off, unfortunately I keep hearing cases of outright racism, harassment, bigotry and even violent assaults targeting individuals of Asian descent. Such unacceptable acts stem from stigmatizing or scapegoating Asians, by blaming Asians for “causing” the COVID-19 pandemic or for being “carriers” of SARS-CoV2. It cannot be overstated that we, as physicians and medical care practitioners who ground our care for our patients in facts and science, also have to make sure that we combat the misinformation that the general public or even some of our own patients might mention to us. We need to do it in a diplomatic way and maintain professionalism. There is already too much misinformation out there. We want to take care of our patients and be empathetic to what they are going through, but we also need to gently but firmly make sure that if we are hearing any of our own patients propagating anti-Asian racism, or any racism for that matter, to make sure that we repudiate that at every opportunity. I’m grateful because in speaking out about this particular issue, I have been so heartened to hear fellow physician colleagues who have shared with me how they have done exactly that.

These are very unprecedented times, but I think that as we are learning more, we can really provide outstanding empathetic care to our patients based on science and medical facts but also make sure that we do not stand for intolerance of any kind.

For more information:

Choi E, et al. Ann Intern Med. http://freshlook.annals.org/2020/03/respiratory-disease-and-racism-covid19.html. Accessed March 22, 2020.

Disclosure: Choi reports no relevant financial disclosures.

Editor’s note: This interview reflects the views and opinions of Choi and not her affiliations or institutions.

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