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CVS, Walmart plan bigger in-store clinics: Will primary care practices suffer?
Jordan Grumet, MD, an internist in Northbrook, Ill., left his private practice about 2 years ago, partly because of competition from local retail clinics.
“We were always fighting the pharmacy clinics,” he said. “My generation of doctors was brought up to think we should have a one-stop shop. That was the idea behind being a primary care doctor. So it was very destructive to know your patients were going to another provider.”
Local retail clinics and urgent care centers were also co-opting many of the minor acute care visits that help primary care practices survive. “The number of visits for flu shots and simple medical problems drops,” said Dr. Grumet, who is now an end-of-life-care consultant and also works in hospices. “That can put downward economic pressure on primary care practices.”
Competition for primary care practices is ready to heat up even more, and the environment may soon become even more threatening for primary care doctors. Over the last year, the two largest pharmacy chains – CVS and Walgreens – announced their intentions to build larger retail clinics that will offer many aspects of traditional primary care. Walmart will also be doing the same.
How many geographical areas will be affected is unknown. However,
“There will be more competition, no question,” said George Abraham, MD, MPH, president of the American College of Physicians.
Andrew Bazemore, MD, MPH, senior vice president of research and policy for the American Board of Family Medicine, agreed. “Seeing retail clinics finally embrace the promise of coordination and comprehensiveness in primary care is a promising step. It’s good to see CVS, Walmart, and Walgreens embracing the notion that they have to do more than just urgent care. On the flip side, it’s a source of competition for longstanding primary care clinics.”
Jeff Kagan, MD, an internist in Newington, Conn., noted that during the pandemic the booming demand for primary care has reduced competition from alternative care settings.
“But if this was not pandemic times, it would be very different. There are more urgent care walk-in clinics that do some primary care, and they are pulling away patients.”
New alternative care settings
The number of retail health centers has leveled off at around 2,000 clinics, about the same as in 2016. But CVS, which has around half that total, is now adding HealthHUB facilities, which offer nonemergency care. CVS had 800 of these quasi-primary care clinics in the first quarter of 2021 and planned to have 1,000 by the end of 2021, according to Managed Healthcare Executive.
Walgreens closed 150 of its retail clinics while partnering with VillageMD to develop 600 VillageMD clinics that are larger than its current in-store offices. The chain plans to build these clinics adjacent to Walgreens stores in 30 markets over the next 4 years. Currently, Walgreens has more than 50 VillageMD clinics, mostly in Sunbelt states.
Walmart opened the first of its new expanded-service clinics in 2019. Now it has clinics in Georgia, Arkansas, Texas, and Florida. These Walmart Health locations offer urgent care, primary care, labs, x-ray, and mental health therapy, as well as dental, optical, and hearing services.
The number of urgent care centers (UCCs), meanwhile, has mushroomed during the last decade. With the addition of 400-500 centers every year since 2014, there were 9,279 UCCs in the United States as of June 2019, according to the Urgent Care Association.
These UCCs usually have on-staff physicians. In contrast, most retail clinics are staffed by nurse practitioners. Another big difference is that in retail clinics, two-thirds of the patients – many of them young and healthy – have no regular primary care clinician; only a third of UCC patients don’t have a personal physician.
Because of these rootless patients, competition from retail clinics “is no big deal” to some primary care practices, said Ateev Mehrotra, MD, a Harvard Medical School professor in Boston who has studied alternative care settings. On the other hand, he asked, why do so few UCC patients have a regular physician? That raises the question of how many of these patients would go to a primary care office if there were no retail clinics or UCCs.
Economic pressure on practices
Dr. Grumet’s point about retail clinics and UCCs depriving his practice of easy, lucrative visits is widely echoed among his peers. The fee-for-service payment system based on Medicare rates exacerbates the problem. As Dr. Abraham pointed out, when primary care doctors see a higher percentage of patients with complicated problems, the doctors don’t get compensated fairly for those visits.
Minor acute care, Dr. Abraham noted, is “easier work for the same pay. When I review 100 pages of records for someone who was hospitalized and figure out their 10 different problems and 20 medications, I get paid virtually the same as if I treated a diabetic with a common cold or a foot laceration. The complexity of thought is not factored completely into the reimbursement. And we use the easier visits to offset the more complex ones.”
What happened to continuity of care?
The fragmentation of care between primary care practices and alternative care settings also “diminishes the primary care function,” Dr. Bazemore said.
“Primary care is supposed to be first contact, covering most of what a patient needs – comprehensive, coordinated, and continuous,” he observed. “When you fragment and separate an urgent care function from the rest, so it’s not done in the context of that first contact, you weaken the primary care component without enhancing its function.”
Observers doubt the advent of larger retail clinics that provide more services is likely to solve this problem. In Dr. Mehrotra’s view, CVS’ HealthHUBs “are all about supporting primary care. But are they really? Who are the patients supposed to come back to? This is a critical point: When you ask patients who’s in charge of their care, what are they going to say?”
Retail clinics and urgent care centers have a similar issue, Dr. Grumet said. “If you see patients in the office, and they have problems late at night, they can call you. There’s a continuity of care you don’t get in alternative care settings. The real goal in those places is to get patients in, assess them, and get them out. Which is fine – for minor things. But for someone who needs more comprehensive care, it’s not so good.”
This is why the ACP advised against the provision of chronic care in alternative care settings, said Dr. Abraham. “The problem with retail clinics is they’ve expanded into chronic care management in one or more episodes that require care, but not true continuity of care. When you go to a primary care physician’s office, we discuss more than just acute problems or chronic health issues; we talk about wellness, lifestyle, preventive services, vaccines, and your family. Relationship-building occurs, which transcends more than care interaction. In a setting where you get your care and you leave, longitudinal, holistic care doesn’t build.”
Dr. Kagan put it more succinctly: “Sometimes urgent care walk-in clinics get in over their head [with chronic care]. They like the guy who has high blood pressure and comes in once or twice a year for a prescription refill. But they’re not involved with the guy who has much more trouble.”
None of the urgent care doctors he knows of are taking long-term responsibility for their patients, Dr. Kagan added. “They don’t schedule follow-ups. They’ll see a patient for something, then say: ‘If you’re not better, come back and see me in a couple of weeks.’ ”
Two flavors of urgent care
Dr. Kagan has seen another type of doctor-patient relationship since he sold his practice to Hartford HealthCare 2 years ago. Hartford HealthCare owns 50% of an urgent care group called GoHealth.
“If our Hartford HealthCare patients can’t get into the office, we encourage them to go to a GoHealth facility,” he noted. “It’s not competition; it’s like one of our colleagues. We use the same EMR, so I can see everything that happens. I can even send someone who needs an x-ray to a GoHealth Center just for that.”
Moreover, GoHealth provides only urgent care. “So if it’s one of my patients, they refer them back to me for follow-up. And if somebody wanders in there without a primary care physician, they’ll hook them up with a Hartford HealthCare clinician.”
Dr. Bazemore has had a similar experience. He practices 1 day a week in his residency clinic in Fairfax, Va., which is owned by the Inova Health System. Inova created an adjoining urgent care facility that is open 7 days a week and uses the same EMR as Dr. Bazemore’s clinic.
This is the kind of relationship that Dr. Abraham would like to see between alternative care settings and traditional primary care practices: complementary rather than competitive. However, he questions the motives of hospital systems that own urgent care centers.
“Health care systems are starting these urgent care centers because they want to cash in on the same market,” he said. “I’m not convinced that their goal is to feed their primary care doctors. That is a potential advantage, but they also feed their specialists and try to blend procedures and other lucrative aspects of care into their system.”
What pharmacy chains are up to
Pharmacy chains have their own ulterior motives, Dr. Abraham noted. They built retail clinics for the same reason they sell drugs: to increase sales of consumer goods in their stores. Dr. Bazemore added that retail clinics also aim “to achieve a certain patient volume and incentivize what’s purchased in the pharmacy.”
Exacerbating the situation, CVS now owns Aetna, one of the biggest health insurers. Dr. Kagan believed that CVS’ new emphasis on HealthHUBs may be related to that. “CVS seems to be closing drugstores and opening up more primary care places, and now that they own Aetna, they’re trying to make Aetna patients go to CVS when they have a problem,” he said. Aetna patients are now required to fill their prescriptions at CVS.
Walmart has said it plans to open expanded-service clinics in locales that don’t have sufficient primary care, especially rural areas. The experts we consulted agree that Walmart won’t stop there if its new model is successful. In fact, Dr. Bazemore noted, competition from the new generation of in-store clinics is likely to be in areas where there are plenty of primary care doctors.
“For economic reasons, you’re going to see more of these clinics fill spaces where there’s already a sufficiency [of primary care] – starting with wealthy suburban areas,” Dr. Bazemore said. “Where you have a Walmart, Walgreens, or CVS, you tend to find more purchasers. I don’t know that it’s necessarily the answer to our access problems.”
What should primary care doctors do?
The obvious response of primary care practices to competition from retail clinics and urgent care centers that are open 7 days a week, 12 hours a day, is to expand their hours. In addition, they can introduce same-day scheduling or reserve a block of time every day for walk-in patients.
That’s the approach that Dr. Grumet took in his private practice. “When my patients called me, I tried to deal with it right away. So it was baffling that some of them went to retail clinics.”
Actually, it’s not so baffling, Dr. Abraham said, when you consider that retail clinics are part of a one-stop-shopping experience that will become even more all-encompassing in stores that add quasi-primary care clinics. “You can pick up the consumables you need, you can pick up prescriptions, and you can see your physician without having to make multiple stops. It’s a great idea for pharmacies.”
How about telemedicine? A lot of acute care similar to that provided in alternative care settings can be offered during virtual visits, noted Dr. Bazemore. However, the pharmacy chains have been providing telemedicine for years, using third-party services. And while the convenience of virtual visits appeals to some patients, that’s no guarantee they won’t go to retail clinics.
Reaching out to patients with reminders about the need for checkups and preventive visits, either by phone or through a patient portal, is another technique that practices can use to retain patients. A recent Press Ganey poll showed that people value this kind of communication. But it hardly seems sufficient to hold off the competitive assault of pharmacy chains.
A flaw in the pharmacies’ strategy, however, could eventually come back to bite them: Because the new, larger clinics don’t provide comprehensive care, people will eventually have to turn to traditional primary care – if it’s still around.
“Here’s the problem,” Dr. Grumet explained. “If you’re going to do [in-store primary care], you have to take ownership of the patient and manage everything. You have to be a full-fledged primary care practice with on-call hours and ER coverage. Otherwise, you’re taking bits and pieces – probably low-hanging fruit – to make money, and taking those away from the primary care practice. Which means you’re taking them from the people who should be doing the job.”
A version of this article first appeared on Medscape.com.
Jordan Grumet, MD, an internist in Northbrook, Ill., left his private practice about 2 years ago, partly because of competition from local retail clinics.
“We were always fighting the pharmacy clinics,” he said. “My generation of doctors was brought up to think we should have a one-stop shop. That was the idea behind being a primary care doctor. So it was very destructive to know your patients were going to another provider.”
Local retail clinics and urgent care centers were also co-opting many of the minor acute care visits that help primary care practices survive. “The number of visits for flu shots and simple medical problems drops,” said Dr. Grumet, who is now an end-of-life-care consultant and also works in hospices. “That can put downward economic pressure on primary care practices.”
Competition for primary care practices is ready to heat up even more, and the environment may soon become even more threatening for primary care doctors. Over the last year, the two largest pharmacy chains – CVS and Walgreens – announced their intentions to build larger retail clinics that will offer many aspects of traditional primary care. Walmart will also be doing the same.
How many geographical areas will be affected is unknown. However,
“There will be more competition, no question,” said George Abraham, MD, MPH, president of the American College of Physicians.
Andrew Bazemore, MD, MPH, senior vice president of research and policy for the American Board of Family Medicine, agreed. “Seeing retail clinics finally embrace the promise of coordination and comprehensiveness in primary care is a promising step. It’s good to see CVS, Walmart, and Walgreens embracing the notion that they have to do more than just urgent care. On the flip side, it’s a source of competition for longstanding primary care clinics.”
Jeff Kagan, MD, an internist in Newington, Conn., noted that during the pandemic the booming demand for primary care has reduced competition from alternative care settings.
“But if this was not pandemic times, it would be very different. There are more urgent care walk-in clinics that do some primary care, and they are pulling away patients.”
New alternative care settings
The number of retail health centers has leveled off at around 2,000 clinics, about the same as in 2016. But CVS, which has around half that total, is now adding HealthHUB facilities, which offer nonemergency care. CVS had 800 of these quasi-primary care clinics in the first quarter of 2021 and planned to have 1,000 by the end of 2021, according to Managed Healthcare Executive.
Walgreens closed 150 of its retail clinics while partnering with VillageMD to develop 600 VillageMD clinics that are larger than its current in-store offices. The chain plans to build these clinics adjacent to Walgreens stores in 30 markets over the next 4 years. Currently, Walgreens has more than 50 VillageMD clinics, mostly in Sunbelt states.
Walmart opened the first of its new expanded-service clinics in 2019. Now it has clinics in Georgia, Arkansas, Texas, and Florida. These Walmart Health locations offer urgent care, primary care, labs, x-ray, and mental health therapy, as well as dental, optical, and hearing services.
The number of urgent care centers (UCCs), meanwhile, has mushroomed during the last decade. With the addition of 400-500 centers every year since 2014, there were 9,279 UCCs in the United States as of June 2019, according to the Urgent Care Association.
These UCCs usually have on-staff physicians. In contrast, most retail clinics are staffed by nurse practitioners. Another big difference is that in retail clinics, two-thirds of the patients – many of them young and healthy – have no regular primary care clinician; only a third of UCC patients don’t have a personal physician.
Because of these rootless patients, competition from retail clinics “is no big deal” to some primary care practices, said Ateev Mehrotra, MD, a Harvard Medical School professor in Boston who has studied alternative care settings. On the other hand, he asked, why do so few UCC patients have a regular physician? That raises the question of how many of these patients would go to a primary care office if there were no retail clinics or UCCs.
Economic pressure on practices
Dr. Grumet’s point about retail clinics and UCCs depriving his practice of easy, lucrative visits is widely echoed among his peers. The fee-for-service payment system based on Medicare rates exacerbates the problem. As Dr. Abraham pointed out, when primary care doctors see a higher percentage of patients with complicated problems, the doctors don’t get compensated fairly for those visits.
Minor acute care, Dr. Abraham noted, is “easier work for the same pay. When I review 100 pages of records for someone who was hospitalized and figure out their 10 different problems and 20 medications, I get paid virtually the same as if I treated a diabetic with a common cold or a foot laceration. The complexity of thought is not factored completely into the reimbursement. And we use the easier visits to offset the more complex ones.”
What happened to continuity of care?
The fragmentation of care between primary care practices and alternative care settings also “diminishes the primary care function,” Dr. Bazemore said.
“Primary care is supposed to be first contact, covering most of what a patient needs – comprehensive, coordinated, and continuous,” he observed. “When you fragment and separate an urgent care function from the rest, so it’s not done in the context of that first contact, you weaken the primary care component without enhancing its function.”
Observers doubt the advent of larger retail clinics that provide more services is likely to solve this problem. In Dr. Mehrotra’s view, CVS’ HealthHUBs “are all about supporting primary care. But are they really? Who are the patients supposed to come back to? This is a critical point: When you ask patients who’s in charge of their care, what are they going to say?”
Retail clinics and urgent care centers have a similar issue, Dr. Grumet said. “If you see patients in the office, and they have problems late at night, they can call you. There’s a continuity of care you don’t get in alternative care settings. The real goal in those places is to get patients in, assess them, and get them out. Which is fine – for minor things. But for someone who needs more comprehensive care, it’s not so good.”
This is why the ACP advised against the provision of chronic care in alternative care settings, said Dr. Abraham. “The problem with retail clinics is they’ve expanded into chronic care management in one or more episodes that require care, but not true continuity of care. When you go to a primary care physician’s office, we discuss more than just acute problems or chronic health issues; we talk about wellness, lifestyle, preventive services, vaccines, and your family. Relationship-building occurs, which transcends more than care interaction. In a setting where you get your care and you leave, longitudinal, holistic care doesn’t build.”
Dr. Kagan put it more succinctly: “Sometimes urgent care walk-in clinics get in over their head [with chronic care]. They like the guy who has high blood pressure and comes in once or twice a year for a prescription refill. But they’re not involved with the guy who has much more trouble.”
None of the urgent care doctors he knows of are taking long-term responsibility for their patients, Dr. Kagan added. “They don’t schedule follow-ups. They’ll see a patient for something, then say: ‘If you’re not better, come back and see me in a couple of weeks.’ ”
Two flavors of urgent care
Dr. Kagan has seen another type of doctor-patient relationship since he sold his practice to Hartford HealthCare 2 years ago. Hartford HealthCare owns 50% of an urgent care group called GoHealth.
“If our Hartford HealthCare patients can’t get into the office, we encourage them to go to a GoHealth facility,” he noted. “It’s not competition; it’s like one of our colleagues. We use the same EMR, so I can see everything that happens. I can even send someone who needs an x-ray to a GoHealth Center just for that.”
Moreover, GoHealth provides only urgent care. “So if it’s one of my patients, they refer them back to me for follow-up. And if somebody wanders in there without a primary care physician, they’ll hook them up with a Hartford HealthCare clinician.”
Dr. Bazemore has had a similar experience. He practices 1 day a week in his residency clinic in Fairfax, Va., which is owned by the Inova Health System. Inova created an adjoining urgent care facility that is open 7 days a week and uses the same EMR as Dr. Bazemore’s clinic.
This is the kind of relationship that Dr. Abraham would like to see between alternative care settings and traditional primary care practices: complementary rather than competitive. However, he questions the motives of hospital systems that own urgent care centers.
“Health care systems are starting these urgent care centers because they want to cash in on the same market,” he said. “I’m not convinced that their goal is to feed their primary care doctors. That is a potential advantage, but they also feed their specialists and try to blend procedures and other lucrative aspects of care into their system.”
What pharmacy chains are up to
Pharmacy chains have their own ulterior motives, Dr. Abraham noted. They built retail clinics for the same reason they sell drugs: to increase sales of consumer goods in their stores. Dr. Bazemore added that retail clinics also aim “to achieve a certain patient volume and incentivize what’s purchased in the pharmacy.”
Exacerbating the situation, CVS now owns Aetna, one of the biggest health insurers. Dr. Kagan believed that CVS’ new emphasis on HealthHUBs may be related to that. “CVS seems to be closing drugstores and opening up more primary care places, and now that they own Aetna, they’re trying to make Aetna patients go to CVS when they have a problem,” he said. Aetna patients are now required to fill their prescriptions at CVS.
Walmart has said it plans to open expanded-service clinics in locales that don’t have sufficient primary care, especially rural areas. The experts we consulted agree that Walmart won’t stop there if its new model is successful. In fact, Dr. Bazemore noted, competition from the new generation of in-store clinics is likely to be in areas where there are plenty of primary care doctors.
“For economic reasons, you’re going to see more of these clinics fill spaces where there’s already a sufficiency [of primary care] – starting with wealthy suburban areas,” Dr. Bazemore said. “Where you have a Walmart, Walgreens, or CVS, you tend to find more purchasers. I don’t know that it’s necessarily the answer to our access problems.”
What should primary care doctors do?
The obvious response of primary care practices to competition from retail clinics and urgent care centers that are open 7 days a week, 12 hours a day, is to expand their hours. In addition, they can introduce same-day scheduling or reserve a block of time every day for walk-in patients.
That’s the approach that Dr. Grumet took in his private practice. “When my patients called me, I tried to deal with it right away. So it was baffling that some of them went to retail clinics.”
Actually, it’s not so baffling, Dr. Abraham said, when you consider that retail clinics are part of a one-stop-shopping experience that will become even more all-encompassing in stores that add quasi-primary care clinics. “You can pick up the consumables you need, you can pick up prescriptions, and you can see your physician without having to make multiple stops. It’s a great idea for pharmacies.”
How about telemedicine? A lot of acute care similar to that provided in alternative care settings can be offered during virtual visits, noted Dr. Bazemore. However, the pharmacy chains have been providing telemedicine for years, using third-party services. And while the convenience of virtual visits appeals to some patients, that’s no guarantee they won’t go to retail clinics.
Reaching out to patients with reminders about the need for checkups and preventive visits, either by phone or through a patient portal, is another technique that practices can use to retain patients. A recent Press Ganey poll showed that people value this kind of communication. But it hardly seems sufficient to hold off the competitive assault of pharmacy chains.
A flaw in the pharmacies’ strategy, however, could eventually come back to bite them: Because the new, larger clinics don’t provide comprehensive care, people will eventually have to turn to traditional primary care – if it’s still around.
“Here’s the problem,” Dr. Grumet explained. “If you’re going to do [in-store primary care], you have to take ownership of the patient and manage everything. You have to be a full-fledged primary care practice with on-call hours and ER coverage. Otherwise, you’re taking bits and pieces – probably low-hanging fruit – to make money, and taking those away from the primary care practice. Which means you’re taking them from the people who should be doing the job.”
A version of this article first appeared on Medscape.com.
Jordan Grumet, MD, an internist in Northbrook, Ill., left his private practice about 2 years ago, partly because of competition from local retail clinics.
“We were always fighting the pharmacy clinics,” he said. “My generation of doctors was brought up to think we should have a one-stop shop. That was the idea behind being a primary care doctor. So it was very destructive to know your patients were going to another provider.”
Local retail clinics and urgent care centers were also co-opting many of the minor acute care visits that help primary care practices survive. “The number of visits for flu shots and simple medical problems drops,” said Dr. Grumet, who is now an end-of-life-care consultant and also works in hospices. “That can put downward economic pressure on primary care practices.”
Competition for primary care practices is ready to heat up even more, and the environment may soon become even more threatening for primary care doctors. Over the last year, the two largest pharmacy chains – CVS and Walgreens – announced their intentions to build larger retail clinics that will offer many aspects of traditional primary care. Walmart will also be doing the same.
How many geographical areas will be affected is unknown. However,
“There will be more competition, no question,” said George Abraham, MD, MPH, president of the American College of Physicians.
Andrew Bazemore, MD, MPH, senior vice president of research and policy for the American Board of Family Medicine, agreed. “Seeing retail clinics finally embrace the promise of coordination and comprehensiveness in primary care is a promising step. It’s good to see CVS, Walmart, and Walgreens embracing the notion that they have to do more than just urgent care. On the flip side, it’s a source of competition for longstanding primary care clinics.”
Jeff Kagan, MD, an internist in Newington, Conn., noted that during the pandemic the booming demand for primary care has reduced competition from alternative care settings.
“But if this was not pandemic times, it would be very different. There are more urgent care walk-in clinics that do some primary care, and they are pulling away patients.”
New alternative care settings
The number of retail health centers has leveled off at around 2,000 clinics, about the same as in 2016. But CVS, which has around half that total, is now adding HealthHUB facilities, which offer nonemergency care. CVS had 800 of these quasi-primary care clinics in the first quarter of 2021 and planned to have 1,000 by the end of 2021, according to Managed Healthcare Executive.
Walgreens closed 150 of its retail clinics while partnering with VillageMD to develop 600 VillageMD clinics that are larger than its current in-store offices. The chain plans to build these clinics adjacent to Walgreens stores in 30 markets over the next 4 years. Currently, Walgreens has more than 50 VillageMD clinics, mostly in Sunbelt states.
Walmart opened the first of its new expanded-service clinics in 2019. Now it has clinics in Georgia, Arkansas, Texas, and Florida. These Walmart Health locations offer urgent care, primary care, labs, x-ray, and mental health therapy, as well as dental, optical, and hearing services.
The number of urgent care centers (UCCs), meanwhile, has mushroomed during the last decade. With the addition of 400-500 centers every year since 2014, there were 9,279 UCCs in the United States as of June 2019, according to the Urgent Care Association.
These UCCs usually have on-staff physicians. In contrast, most retail clinics are staffed by nurse practitioners. Another big difference is that in retail clinics, two-thirds of the patients – many of them young and healthy – have no regular primary care clinician; only a third of UCC patients don’t have a personal physician.
Because of these rootless patients, competition from retail clinics “is no big deal” to some primary care practices, said Ateev Mehrotra, MD, a Harvard Medical School professor in Boston who has studied alternative care settings. On the other hand, he asked, why do so few UCC patients have a regular physician? That raises the question of how many of these patients would go to a primary care office if there were no retail clinics or UCCs.
Economic pressure on practices
Dr. Grumet’s point about retail clinics and UCCs depriving his practice of easy, lucrative visits is widely echoed among his peers. The fee-for-service payment system based on Medicare rates exacerbates the problem. As Dr. Abraham pointed out, when primary care doctors see a higher percentage of patients with complicated problems, the doctors don’t get compensated fairly for those visits.
Minor acute care, Dr. Abraham noted, is “easier work for the same pay. When I review 100 pages of records for someone who was hospitalized and figure out their 10 different problems and 20 medications, I get paid virtually the same as if I treated a diabetic with a common cold or a foot laceration. The complexity of thought is not factored completely into the reimbursement. And we use the easier visits to offset the more complex ones.”
What happened to continuity of care?
The fragmentation of care between primary care practices and alternative care settings also “diminishes the primary care function,” Dr. Bazemore said.
“Primary care is supposed to be first contact, covering most of what a patient needs – comprehensive, coordinated, and continuous,” he observed. “When you fragment and separate an urgent care function from the rest, so it’s not done in the context of that first contact, you weaken the primary care component without enhancing its function.”
Observers doubt the advent of larger retail clinics that provide more services is likely to solve this problem. In Dr. Mehrotra’s view, CVS’ HealthHUBs “are all about supporting primary care. But are they really? Who are the patients supposed to come back to? This is a critical point: When you ask patients who’s in charge of their care, what are they going to say?”
Retail clinics and urgent care centers have a similar issue, Dr. Grumet said. “If you see patients in the office, and they have problems late at night, they can call you. There’s a continuity of care you don’t get in alternative care settings. The real goal in those places is to get patients in, assess them, and get them out. Which is fine – for minor things. But for someone who needs more comprehensive care, it’s not so good.”
This is why the ACP advised against the provision of chronic care in alternative care settings, said Dr. Abraham. “The problem with retail clinics is they’ve expanded into chronic care management in one or more episodes that require care, but not true continuity of care. When you go to a primary care physician’s office, we discuss more than just acute problems or chronic health issues; we talk about wellness, lifestyle, preventive services, vaccines, and your family. Relationship-building occurs, which transcends more than care interaction. In a setting where you get your care and you leave, longitudinal, holistic care doesn’t build.”
Dr. Kagan put it more succinctly: “Sometimes urgent care walk-in clinics get in over their head [with chronic care]. They like the guy who has high blood pressure and comes in once or twice a year for a prescription refill. But they’re not involved with the guy who has much more trouble.”
None of the urgent care doctors he knows of are taking long-term responsibility for their patients, Dr. Kagan added. “They don’t schedule follow-ups. They’ll see a patient for something, then say: ‘If you’re not better, come back and see me in a couple of weeks.’ ”
Two flavors of urgent care
Dr. Kagan has seen another type of doctor-patient relationship since he sold his practice to Hartford HealthCare 2 years ago. Hartford HealthCare owns 50% of an urgent care group called GoHealth.
“If our Hartford HealthCare patients can’t get into the office, we encourage them to go to a GoHealth facility,” he noted. “It’s not competition; it’s like one of our colleagues. We use the same EMR, so I can see everything that happens. I can even send someone who needs an x-ray to a GoHealth Center just for that.”
Moreover, GoHealth provides only urgent care. “So if it’s one of my patients, they refer them back to me for follow-up. And if somebody wanders in there without a primary care physician, they’ll hook them up with a Hartford HealthCare clinician.”
Dr. Bazemore has had a similar experience. He practices 1 day a week in his residency clinic in Fairfax, Va., which is owned by the Inova Health System. Inova created an adjoining urgent care facility that is open 7 days a week and uses the same EMR as Dr. Bazemore’s clinic.
This is the kind of relationship that Dr. Abraham would like to see between alternative care settings and traditional primary care practices: complementary rather than competitive. However, he questions the motives of hospital systems that own urgent care centers.
“Health care systems are starting these urgent care centers because they want to cash in on the same market,” he said. “I’m not convinced that their goal is to feed their primary care doctors. That is a potential advantage, but they also feed their specialists and try to blend procedures and other lucrative aspects of care into their system.”
What pharmacy chains are up to
Pharmacy chains have their own ulterior motives, Dr. Abraham noted. They built retail clinics for the same reason they sell drugs: to increase sales of consumer goods in their stores. Dr. Bazemore added that retail clinics also aim “to achieve a certain patient volume and incentivize what’s purchased in the pharmacy.”
Exacerbating the situation, CVS now owns Aetna, one of the biggest health insurers. Dr. Kagan believed that CVS’ new emphasis on HealthHUBs may be related to that. “CVS seems to be closing drugstores and opening up more primary care places, and now that they own Aetna, they’re trying to make Aetna patients go to CVS when they have a problem,” he said. Aetna patients are now required to fill their prescriptions at CVS.
Walmart has said it plans to open expanded-service clinics in locales that don’t have sufficient primary care, especially rural areas. The experts we consulted agree that Walmart won’t stop there if its new model is successful. In fact, Dr. Bazemore noted, competition from the new generation of in-store clinics is likely to be in areas where there are plenty of primary care doctors.
“For economic reasons, you’re going to see more of these clinics fill spaces where there’s already a sufficiency [of primary care] – starting with wealthy suburban areas,” Dr. Bazemore said. “Where you have a Walmart, Walgreens, or CVS, you tend to find more purchasers. I don’t know that it’s necessarily the answer to our access problems.”
What should primary care doctors do?
The obvious response of primary care practices to competition from retail clinics and urgent care centers that are open 7 days a week, 12 hours a day, is to expand their hours. In addition, they can introduce same-day scheduling or reserve a block of time every day for walk-in patients.
That’s the approach that Dr. Grumet took in his private practice. “When my patients called me, I tried to deal with it right away. So it was baffling that some of them went to retail clinics.”
Actually, it’s not so baffling, Dr. Abraham said, when you consider that retail clinics are part of a one-stop-shopping experience that will become even more all-encompassing in stores that add quasi-primary care clinics. “You can pick up the consumables you need, you can pick up prescriptions, and you can see your physician without having to make multiple stops. It’s a great idea for pharmacies.”
How about telemedicine? A lot of acute care similar to that provided in alternative care settings can be offered during virtual visits, noted Dr. Bazemore. However, the pharmacy chains have been providing telemedicine for years, using third-party services. And while the convenience of virtual visits appeals to some patients, that’s no guarantee they won’t go to retail clinics.
Reaching out to patients with reminders about the need for checkups and preventive visits, either by phone or through a patient portal, is another technique that practices can use to retain patients. A recent Press Ganey poll showed that people value this kind of communication. But it hardly seems sufficient to hold off the competitive assault of pharmacy chains.
A flaw in the pharmacies’ strategy, however, could eventually come back to bite them: Because the new, larger clinics don’t provide comprehensive care, people will eventually have to turn to traditional primary care – if it’s still around.
“Here’s the problem,” Dr. Grumet explained. “If you’re going to do [in-store primary care], you have to take ownership of the patient and manage everything. You have to be a full-fledged primary care practice with on-call hours and ER coverage. Otherwise, you’re taking bits and pieces – probably low-hanging fruit – to make money, and taking those away from the primary care practice. Which means you’re taking them from the people who should be doing the job.”
A version of this article first appeared on Medscape.com.
Multiple Sclerosis: Etiology
Your money. Your voice. Your wellness.
I was a third-year gastroenterology fellow when I realized that something had to change. I was on a one-way trip to burnout.
I went through medical school with the sole goal of becoming an excellent physician. Like many physicians, I was six figures deep in student loan debt by the end of training. I remember clearly being told, “You are going to be physicians. Money won’t be a problem.” In fact, in 2021, money remains a taboo topic in medicine, and most of medical education remains void of the fundamentals of money management.
Although I was surrounded by some of the most brilliant minds in medicine, burnout was spreading like a wave. Physicians are becoming increasingly broken, burned out by a system through which we have vowed to care for our patients: For better or for worse. We are required to attend lectures about burnout, yet nothing about money or finances. We can all agree that talking about resilience and burnout during odd hours of the morning are ironic measures that by themselves have done nothing to help us through the crisis that exists.
I noticed that there seemed to be a difference between physicians who had their finances in order and those who didn’t. This eventually made sense as I became more aware of the data that now exists. Healthy financial practices can lead to financial independence, which may in turn decrease burnout-associated stressors.1 This is what we need.
My observation about the difference in satisfaction between physicians led me to decide to explore that path for myself. My hypothesis? Empowering myself financially is an anti-burnout tool that will improve my satisfaction, longevity in medicine, and my well-being. I traded my financial illiteracy for empowerment and I am now on a mission to help physicians become financially empowered. This is an important step toward preventing and recovering from burnout. The surprising part is that it is not difficult. You need to be committed. Our math literacy is already higher than needed. When we physicians are financially independent, we will have the ability to practice medicine in a way that is healthy. In a world where physician suicide, burnout, and dissatisfaction continue to rise, there is an urgent call to financial action. This is a critical key that will help us change the future of medicine.
In this article, I am going to share four myths that are preventing physicians from truly managing their finances.
1. I love medicine. I have no plans of leaving: I love gastroenterology. The ability to use our critical internal medicine skills as well as intervene procedurally is truly a privilege. As a gastroenterologist with a focus on inflammatory bowel diseases, I have the honor of walking patients through seasons of life and making decisions that truly impact their lives. It is an honor. I also believe that good money management allows physicians to become even better physicians. The platforms of medicine continue to change. According to Physician Advocacy Institute, about 70% of physicians report being employed.2 As physicians graduate from training, joining large hospitals, physician autonomy in the practice of medicine is affected. To ensure that we continue to practice medicine at the fullest extent of our oath, it is essential that our finances allow us the ability and capacity to fulfill that oath. Furthermore, the pandemic has shown that physician income is not pandemic-proof. Having a healthy emergency fund and diversifying our income sources is critical as we move forward.
2. I have a financial adviser or planner. They will figure it out for me: Financial advisers and planners are hired professionals with varied levels of training and expertise. A great financial adviser can be an important part of your team. A team that is led by you, the CEO, because no one will care about your finances as much as you do. Investing the time to learn the basics can pay dividends. When I started my financial education journey, I was completely illiterate. I knew I wanted to have money but didn’t know how. One of the first things in my financial competency journey was to hire a financial adviser. Unfortunately, as I learned more about money, I realized that my investments favored him more than they did me. Coincidentally, we had similar starting balances in a different self-management investment account. At the end of our time together, our self-managed funds fared better than his actively picked funds. As humans, we assume that actively picking investments and stocks would be better than passive investments. Based on experience and data, investing in boring, diverse funds such as index funds averagely do better than actively managed funds. Is it wrong then to hire an adviser? No, but you are still the CEO of you-incorporated. Choosing to completely delegate to someone else, avoiding the basic education that would allow you to better screen for effectiveness and competence, may in fact be negligence. After empowering themselves financially, some physicians who have gone through my money curriculum have chosen to keep their advisers; others chose to self-manage. The key is giving yourself the gift of choice: Choosing to have an adviser because you want to rather than because you thought you had no choice.
3. Money management looks complicated. This is one of the most common statements I get for why physicians avoid their own money management. I remember the complex biochemical pathways we learned in medical school. Those were hard and complicated. We chose to stay the course because we believed that, with repetition and simplifying, it would eventually become less difficult. Why then is it any different with money? A physician shared a discussion she once had with a banker. She was told, “Doctors are bad with money.” When did we become the stereotype for being bad with money? If we can learn channelopathies and memorize mechanisms and save lives, we can do money. We have to start somewhere. We may not get it the first time. However, as physicians, we are the more persistent people and are excellent examples of what happens when you commit to learning something new. After coaching hundreds of physicians regarding money management, I have concluded that physicians are not bad with money. We simply may not be committed to learning it. Once we commit, the rest becomes history.
4. I don’t have time. For practicing gastroenterologists dealing with post-lockdown influx of patients, the days can be long. As a gastroenterologist who is also a parent, I know firsthand how time can be tight. When we had two children, we were busy. We thought we were at our capacity on time with two children. Then we had a third. Suddenly, life with two children looked easier than with three. As humans, we have the capacity to create. Things take exactly how much time we commit to them. If I give myself a month to write an article, I will write it in a month. If I give myself 2 weeks, I will be done in 2 weeks. The key is to remember that we all have 24 hours. David Frankel is the author of “The Freedom Formula: How to Succeed in Business Without Sacrificing Your Family, Health, or Life.”3 He analyzed a poll of business owners. He showed that they were wasting an average of 21.8 hours per week. Many times, we talk about our to-do list. We don’t talk enough about our “to don’t list.” This refers to the list of things we need to stop doing so that we can spend time on things that give or add value to our lives. Starting with as little as 30 minutes per day or per week dedicated to learning and/or managing our finances, the result will compound.
As the platform of medicine continues to evolve, it is important for astute gastroenterologists to be part of these conversations. When we are confident in our finances, they become a vehicle that gives strength to the power of our voice. We are less likely to overwork and more likely to find joy and meaning within and outside medicine.
If we want to care for our patients at a high level and keep our oath to do no harm, we have to remember that includes doing no harm to self as well.
Money management tools and empowering ourselves financially should be an essential component of our training; until then, the onus is on you to learn, so that you can be well.
Your voice matters. Your wellness matters. Your time matters. Your money matters.
Dr. Alli-Akintade is a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center. She is the CEO of MoneyFitMD, a financial empowerment coaching platform for female physicians. She is also the host of The MoneyFitMD podcast.
References
1. Royce TJ et al. Pract Radiat Oncol. Jul-Aug 2019;9(4):231-8.
2. Physician Advocacy Institute. “COVID-19’s Impact on Acquisitions of Physician Practices and Physician Employment 2019-2020.” 2021 Jun.
3. Finkel D. “New Study Shows You’re Wasting 21.8 hours a Week.” Inc.com. 2018 Mar 1.
I was a third-year gastroenterology fellow when I realized that something had to change. I was on a one-way trip to burnout.
I went through medical school with the sole goal of becoming an excellent physician. Like many physicians, I was six figures deep in student loan debt by the end of training. I remember clearly being told, “You are going to be physicians. Money won’t be a problem.” In fact, in 2021, money remains a taboo topic in medicine, and most of medical education remains void of the fundamentals of money management.
Although I was surrounded by some of the most brilliant minds in medicine, burnout was spreading like a wave. Physicians are becoming increasingly broken, burned out by a system through which we have vowed to care for our patients: For better or for worse. We are required to attend lectures about burnout, yet nothing about money or finances. We can all agree that talking about resilience and burnout during odd hours of the morning are ironic measures that by themselves have done nothing to help us through the crisis that exists.
I noticed that there seemed to be a difference between physicians who had their finances in order and those who didn’t. This eventually made sense as I became more aware of the data that now exists. Healthy financial practices can lead to financial independence, which may in turn decrease burnout-associated stressors.1 This is what we need.
My observation about the difference in satisfaction between physicians led me to decide to explore that path for myself. My hypothesis? Empowering myself financially is an anti-burnout tool that will improve my satisfaction, longevity in medicine, and my well-being. I traded my financial illiteracy for empowerment and I am now on a mission to help physicians become financially empowered. This is an important step toward preventing and recovering from burnout. The surprising part is that it is not difficult. You need to be committed. Our math literacy is already higher than needed. When we physicians are financially independent, we will have the ability to practice medicine in a way that is healthy. In a world where physician suicide, burnout, and dissatisfaction continue to rise, there is an urgent call to financial action. This is a critical key that will help us change the future of medicine.
In this article, I am going to share four myths that are preventing physicians from truly managing their finances.
1. I love medicine. I have no plans of leaving: I love gastroenterology. The ability to use our critical internal medicine skills as well as intervene procedurally is truly a privilege. As a gastroenterologist with a focus on inflammatory bowel diseases, I have the honor of walking patients through seasons of life and making decisions that truly impact their lives. It is an honor. I also believe that good money management allows physicians to become even better physicians. The platforms of medicine continue to change. According to Physician Advocacy Institute, about 70% of physicians report being employed.2 As physicians graduate from training, joining large hospitals, physician autonomy in the practice of medicine is affected. To ensure that we continue to practice medicine at the fullest extent of our oath, it is essential that our finances allow us the ability and capacity to fulfill that oath. Furthermore, the pandemic has shown that physician income is not pandemic-proof. Having a healthy emergency fund and diversifying our income sources is critical as we move forward.
2. I have a financial adviser or planner. They will figure it out for me: Financial advisers and planners are hired professionals with varied levels of training and expertise. A great financial adviser can be an important part of your team. A team that is led by you, the CEO, because no one will care about your finances as much as you do. Investing the time to learn the basics can pay dividends. When I started my financial education journey, I was completely illiterate. I knew I wanted to have money but didn’t know how. One of the first things in my financial competency journey was to hire a financial adviser. Unfortunately, as I learned more about money, I realized that my investments favored him more than they did me. Coincidentally, we had similar starting balances in a different self-management investment account. At the end of our time together, our self-managed funds fared better than his actively picked funds. As humans, we assume that actively picking investments and stocks would be better than passive investments. Based on experience and data, investing in boring, diverse funds such as index funds averagely do better than actively managed funds. Is it wrong then to hire an adviser? No, but you are still the CEO of you-incorporated. Choosing to completely delegate to someone else, avoiding the basic education that would allow you to better screen for effectiveness and competence, may in fact be negligence. After empowering themselves financially, some physicians who have gone through my money curriculum have chosen to keep their advisers; others chose to self-manage. The key is giving yourself the gift of choice: Choosing to have an adviser because you want to rather than because you thought you had no choice.
3. Money management looks complicated. This is one of the most common statements I get for why physicians avoid their own money management. I remember the complex biochemical pathways we learned in medical school. Those were hard and complicated. We chose to stay the course because we believed that, with repetition and simplifying, it would eventually become less difficult. Why then is it any different with money? A physician shared a discussion she once had with a banker. She was told, “Doctors are bad with money.” When did we become the stereotype for being bad with money? If we can learn channelopathies and memorize mechanisms and save lives, we can do money. We have to start somewhere. We may not get it the first time. However, as physicians, we are the more persistent people and are excellent examples of what happens when you commit to learning something new. After coaching hundreds of physicians regarding money management, I have concluded that physicians are not bad with money. We simply may not be committed to learning it. Once we commit, the rest becomes history.
4. I don’t have time. For practicing gastroenterologists dealing with post-lockdown influx of patients, the days can be long. As a gastroenterologist who is also a parent, I know firsthand how time can be tight. When we had two children, we were busy. We thought we were at our capacity on time with two children. Then we had a third. Suddenly, life with two children looked easier than with three. As humans, we have the capacity to create. Things take exactly how much time we commit to them. If I give myself a month to write an article, I will write it in a month. If I give myself 2 weeks, I will be done in 2 weeks. The key is to remember that we all have 24 hours. David Frankel is the author of “The Freedom Formula: How to Succeed in Business Without Sacrificing Your Family, Health, or Life.”3 He analyzed a poll of business owners. He showed that they were wasting an average of 21.8 hours per week. Many times, we talk about our to-do list. We don’t talk enough about our “to don’t list.” This refers to the list of things we need to stop doing so that we can spend time on things that give or add value to our lives. Starting with as little as 30 minutes per day or per week dedicated to learning and/or managing our finances, the result will compound.
As the platform of medicine continues to evolve, it is important for astute gastroenterologists to be part of these conversations. When we are confident in our finances, they become a vehicle that gives strength to the power of our voice. We are less likely to overwork and more likely to find joy and meaning within and outside medicine.
If we want to care for our patients at a high level and keep our oath to do no harm, we have to remember that includes doing no harm to self as well.
Money management tools and empowering ourselves financially should be an essential component of our training; until then, the onus is on you to learn, so that you can be well.
Your voice matters. Your wellness matters. Your time matters. Your money matters.
Dr. Alli-Akintade is a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center. She is the CEO of MoneyFitMD, a financial empowerment coaching platform for female physicians. She is also the host of The MoneyFitMD podcast.
References
1. Royce TJ et al. Pract Radiat Oncol. Jul-Aug 2019;9(4):231-8.
2. Physician Advocacy Institute. “COVID-19’s Impact on Acquisitions of Physician Practices and Physician Employment 2019-2020.” 2021 Jun.
3. Finkel D. “New Study Shows You’re Wasting 21.8 hours a Week.” Inc.com. 2018 Mar 1.
I was a third-year gastroenterology fellow when I realized that something had to change. I was on a one-way trip to burnout.
I went through medical school with the sole goal of becoming an excellent physician. Like many physicians, I was six figures deep in student loan debt by the end of training. I remember clearly being told, “You are going to be physicians. Money won’t be a problem.” In fact, in 2021, money remains a taboo topic in medicine, and most of medical education remains void of the fundamentals of money management.
Although I was surrounded by some of the most brilliant minds in medicine, burnout was spreading like a wave. Physicians are becoming increasingly broken, burned out by a system through which we have vowed to care for our patients: For better or for worse. We are required to attend lectures about burnout, yet nothing about money or finances. We can all agree that talking about resilience and burnout during odd hours of the morning are ironic measures that by themselves have done nothing to help us through the crisis that exists.
I noticed that there seemed to be a difference between physicians who had their finances in order and those who didn’t. This eventually made sense as I became more aware of the data that now exists. Healthy financial practices can lead to financial independence, which may in turn decrease burnout-associated stressors.1 This is what we need.
My observation about the difference in satisfaction between physicians led me to decide to explore that path for myself. My hypothesis? Empowering myself financially is an anti-burnout tool that will improve my satisfaction, longevity in medicine, and my well-being. I traded my financial illiteracy for empowerment and I am now on a mission to help physicians become financially empowered. This is an important step toward preventing and recovering from burnout. The surprising part is that it is not difficult. You need to be committed. Our math literacy is already higher than needed. When we physicians are financially independent, we will have the ability to practice medicine in a way that is healthy. In a world where physician suicide, burnout, and dissatisfaction continue to rise, there is an urgent call to financial action. This is a critical key that will help us change the future of medicine.
In this article, I am going to share four myths that are preventing physicians from truly managing their finances.
1. I love medicine. I have no plans of leaving: I love gastroenterology. The ability to use our critical internal medicine skills as well as intervene procedurally is truly a privilege. As a gastroenterologist with a focus on inflammatory bowel diseases, I have the honor of walking patients through seasons of life and making decisions that truly impact their lives. It is an honor. I also believe that good money management allows physicians to become even better physicians. The platforms of medicine continue to change. According to Physician Advocacy Institute, about 70% of physicians report being employed.2 As physicians graduate from training, joining large hospitals, physician autonomy in the practice of medicine is affected. To ensure that we continue to practice medicine at the fullest extent of our oath, it is essential that our finances allow us the ability and capacity to fulfill that oath. Furthermore, the pandemic has shown that physician income is not pandemic-proof. Having a healthy emergency fund and diversifying our income sources is critical as we move forward.
2. I have a financial adviser or planner. They will figure it out for me: Financial advisers and planners are hired professionals with varied levels of training and expertise. A great financial adviser can be an important part of your team. A team that is led by you, the CEO, because no one will care about your finances as much as you do. Investing the time to learn the basics can pay dividends. When I started my financial education journey, I was completely illiterate. I knew I wanted to have money but didn’t know how. One of the first things in my financial competency journey was to hire a financial adviser. Unfortunately, as I learned more about money, I realized that my investments favored him more than they did me. Coincidentally, we had similar starting balances in a different self-management investment account. At the end of our time together, our self-managed funds fared better than his actively picked funds. As humans, we assume that actively picking investments and stocks would be better than passive investments. Based on experience and data, investing in boring, diverse funds such as index funds averagely do better than actively managed funds. Is it wrong then to hire an adviser? No, but you are still the CEO of you-incorporated. Choosing to completely delegate to someone else, avoiding the basic education that would allow you to better screen for effectiveness and competence, may in fact be negligence. After empowering themselves financially, some physicians who have gone through my money curriculum have chosen to keep their advisers; others chose to self-manage. The key is giving yourself the gift of choice: Choosing to have an adviser because you want to rather than because you thought you had no choice.
3. Money management looks complicated. This is one of the most common statements I get for why physicians avoid their own money management. I remember the complex biochemical pathways we learned in medical school. Those were hard and complicated. We chose to stay the course because we believed that, with repetition and simplifying, it would eventually become less difficult. Why then is it any different with money? A physician shared a discussion she once had with a banker. She was told, “Doctors are bad with money.” When did we become the stereotype for being bad with money? If we can learn channelopathies and memorize mechanisms and save lives, we can do money. We have to start somewhere. We may not get it the first time. However, as physicians, we are the more persistent people and are excellent examples of what happens when you commit to learning something new. After coaching hundreds of physicians regarding money management, I have concluded that physicians are not bad with money. We simply may not be committed to learning it. Once we commit, the rest becomes history.
4. I don’t have time. For practicing gastroenterologists dealing with post-lockdown influx of patients, the days can be long. As a gastroenterologist who is also a parent, I know firsthand how time can be tight. When we had two children, we were busy. We thought we were at our capacity on time with two children. Then we had a third. Suddenly, life with two children looked easier than with three. As humans, we have the capacity to create. Things take exactly how much time we commit to them. If I give myself a month to write an article, I will write it in a month. If I give myself 2 weeks, I will be done in 2 weeks. The key is to remember that we all have 24 hours. David Frankel is the author of “The Freedom Formula: How to Succeed in Business Without Sacrificing Your Family, Health, or Life.”3 He analyzed a poll of business owners. He showed that they were wasting an average of 21.8 hours per week. Many times, we talk about our to-do list. We don’t talk enough about our “to don’t list.” This refers to the list of things we need to stop doing so that we can spend time on things that give or add value to our lives. Starting with as little as 30 minutes per day or per week dedicated to learning and/or managing our finances, the result will compound.
As the platform of medicine continues to evolve, it is important for astute gastroenterologists to be part of these conversations. When we are confident in our finances, they become a vehicle that gives strength to the power of our voice. We are less likely to overwork and more likely to find joy and meaning within and outside medicine.
If we want to care for our patients at a high level and keep our oath to do no harm, we have to remember that includes doing no harm to self as well.
Money management tools and empowering ourselves financially should be an essential component of our training; until then, the onus is on you to learn, so that you can be well.
Your voice matters. Your wellness matters. Your time matters. Your money matters.
Dr. Alli-Akintade is a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center. She is the CEO of MoneyFitMD, a financial empowerment coaching platform for female physicians. She is also the host of The MoneyFitMD podcast.
References
1. Royce TJ et al. Pract Radiat Oncol. Jul-Aug 2019;9(4):231-8.
2. Physician Advocacy Institute. “COVID-19’s Impact on Acquisitions of Physician Practices and Physician Employment 2019-2020.” 2021 Jun.
3. Finkel D. “New Study Shows You’re Wasting 21.8 hours a Week.” Inc.com. 2018 Mar 1.
Castration Resistant Prostate Cancer
COVID-19–associated ocular mucormycosis outbreak case study reveals high-risk group for deadly complication
Earlier this year, hospitals in India were dealing not only with the coronavirus pandemic but also with a surge in a potentially lethal fungal infection in patients previously treated for COVID-19. Mucormycosis, also known as black fungus, is typically a rare infection, but India had recorded more than 45,000 cases as of July 2021.
Now, a recent report suggests that patients with COVID-19–associated rhino-orbital cerebral mucormycosis (CAM) may have a higher mortality rate than previously estimated. The study was published Dec. 9 in JAMA Ophthalmology.
“The mortality indicators we observed, such as assisted ventilation and presence of severe orbital manifestations, can help physicians triage patients for emergency procedures, such as functional endoscopic sinus surgery (FESS), and administer systemic antifungal agents when in short supply,” the study authors wrote.
Mucormycosis usually infects immunocompromised patients. Previous research has found that poorly controlled diabetes – an epidemic in India – and use of high-dose systemic corticosteroids are two main risk factors for developing CAM. Even before COVID-19, India had a high incidence of mucormycosis compared to other countries, but cases exist around the world. In fact, on Dec. 17, the Centers for Disease Control and Prevention reported 10 isolated cases of COVID-19–associated mucormycosis identified in Arkansas hospitals between July and September 2021.
The disease can cause blurred vision, black lesions on the nose or inside of the mouth, and facial swelling. In rhino-orbital cerebral mucormycosis, extensive infection can necessitate orbital exenteration surgery, a disfiguring procedure that typically involves removal of the entire contents of the bony eye socket, as well as removal of the sinuses. Estimates for the mortality rate for this disease range from 14% to nearly 80%.
To better understand the cumulative morality rates for CAM and to identify additional risk factors, researchers reviewed the medical records of patients diagnosed and treated for CAM at a tertiary care multispecialty government hospital in Maharashtra, a state in the west-central region of India. The analysis included patients who died after admission or who had at minimum 30 days of documented follow-up. All diagnoses occurred between March 1 and May 30, 2021. All patients underwent comprehensive ophthalmic exams and routine blood workups.
Seventy-three patients were included in the study, with the average age of 53.5 years; 66% of the patients were male, and 74% of all patients had diabetes. Of the 47 individuals with available COVID-19 vaccination information, 89% had not had either shot of the vaccine, and 11% had the first dose. No patients in the cohort had received both doses of the vaccine; 87% of the patients were previously hospitalized for COVID-19, with 43 needing supplemental oxygen, 14 receiving noninvasive ventilation and ventilator support (NIV), and three requiring mechanical ventilation.
Patients developed CAM a median of 28 days after being discharged from the hospital for COVID-19 treatment; 26 patients died, 18 patients underwent FESS, and five underwent orbital exenteration. While 36% of patients died overall, the researchers found the cumulative probability of death from CAM rose from 26% at day 7 to 53% at day 21. They also found that the patients who died had more severe COVID-19, indicated by more days spent on supplemental oxygen (P = .003) and increased need for NIV or mechanical ventilation (P = .02) compared to patients who survived CAM. Those who died also had poorer visual acuity, with 35% of the group having no light perception during examination compared to 6% of surviving CAM patients (P = .02).
These findings are largely “confirmatory to what we previously knew, which is that [CAM] is a very bad disease with high morbidity and high mortality,” Ilan Schwartz, MD, PHD, an infectious disease physician at the University of Alberta, Edmonton, who researches emerging fungal infections, said in an interview. He was not involved with the research.
While larger studies looking at similar questions have been published, the new report has longer patient follow-up and is “better positioned to be able to estimate the mortality rate,” Dr. Schwartz noted. Even with 30 days of follow-up, “patients can have ongoing problems for many months, and so it’s possible that the true mortality rate is even higher, once you get beyond that period,” he added.
But Santosh G. Honavar, MD, the director of medical services at the Centre for Sight Eye Hospital in Hyderabad, India, also unaffiliated with the study, noted that the subset of patients included in the latest report may have had much more severe infection – and subsequently higher mortality rates – than a more generalized study in a broader patient population.
For example, a study by Mrittika Sen, PhD, Dr. Honavar, and their coauthors, published in the Indian Journal of Ophthalmology earlier this year, found a mortality rate of 14% when they examined the records of more than 2,800 patients across 102 treatment centers.
Taking that into account, “we believe that the actual mortality may be somewhere between the 14% reported by Sen et al. from the large Indian series and the 53% that we report at 3 weeks,” the JAMA Ophthalmology authors wrote.
Dr. Honavar also noted that the new report of severe infection outcomes identifies subgroups at higher risk of death due to CAM: those with severe COVID-19 infection or orbital disease. These groups “would need higher surveillance for mucormycosis, thus enabling early diagnosis and prompt initiation of amphotericin B upon diagnosis of mucormycosis,” he said in an interview. “These measures can possibly minimize the risk of death.”
Ongoing research on CAM cases will continue to inform knowledge and treatment of the disease, but there are still unanswered questions. “We still have a fairly unsatisfactory understanding of exactly why this [CAM] epidemic occurred and why it was so bad,” Dr. Schwartz noted. And while mucormycosis cases have seemed to drop off since the surge earlier this year, “I don’t think we’re out of the woods,” he added. “There’s a lot more awareness in India and around the world about this disease now, but we’re still quite vulnerable to seeing it again.”
Dr. Honavar is the editor-in-chief of the Indian Journal of Ophthalmology. Dr. Schwartz reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Earlier this year, hospitals in India were dealing not only with the coronavirus pandemic but also with a surge in a potentially lethal fungal infection in patients previously treated for COVID-19. Mucormycosis, also known as black fungus, is typically a rare infection, but India had recorded more than 45,000 cases as of July 2021.
Now, a recent report suggests that patients with COVID-19–associated rhino-orbital cerebral mucormycosis (CAM) may have a higher mortality rate than previously estimated. The study was published Dec. 9 in JAMA Ophthalmology.
“The mortality indicators we observed, such as assisted ventilation and presence of severe orbital manifestations, can help physicians triage patients for emergency procedures, such as functional endoscopic sinus surgery (FESS), and administer systemic antifungal agents when in short supply,” the study authors wrote.
Mucormycosis usually infects immunocompromised patients. Previous research has found that poorly controlled diabetes – an epidemic in India – and use of high-dose systemic corticosteroids are two main risk factors for developing CAM. Even before COVID-19, India had a high incidence of mucormycosis compared to other countries, but cases exist around the world. In fact, on Dec. 17, the Centers for Disease Control and Prevention reported 10 isolated cases of COVID-19–associated mucormycosis identified in Arkansas hospitals between July and September 2021.
The disease can cause blurred vision, black lesions on the nose or inside of the mouth, and facial swelling. In rhino-orbital cerebral mucormycosis, extensive infection can necessitate orbital exenteration surgery, a disfiguring procedure that typically involves removal of the entire contents of the bony eye socket, as well as removal of the sinuses. Estimates for the mortality rate for this disease range from 14% to nearly 80%.
To better understand the cumulative morality rates for CAM and to identify additional risk factors, researchers reviewed the medical records of patients diagnosed and treated for CAM at a tertiary care multispecialty government hospital in Maharashtra, a state in the west-central region of India. The analysis included patients who died after admission or who had at minimum 30 days of documented follow-up. All diagnoses occurred between March 1 and May 30, 2021. All patients underwent comprehensive ophthalmic exams and routine blood workups.
Seventy-three patients were included in the study, with the average age of 53.5 years; 66% of the patients were male, and 74% of all patients had diabetes. Of the 47 individuals with available COVID-19 vaccination information, 89% had not had either shot of the vaccine, and 11% had the first dose. No patients in the cohort had received both doses of the vaccine; 87% of the patients were previously hospitalized for COVID-19, with 43 needing supplemental oxygen, 14 receiving noninvasive ventilation and ventilator support (NIV), and three requiring mechanical ventilation.
Patients developed CAM a median of 28 days after being discharged from the hospital for COVID-19 treatment; 26 patients died, 18 patients underwent FESS, and five underwent orbital exenteration. While 36% of patients died overall, the researchers found the cumulative probability of death from CAM rose from 26% at day 7 to 53% at day 21. They also found that the patients who died had more severe COVID-19, indicated by more days spent on supplemental oxygen (P = .003) and increased need for NIV or mechanical ventilation (P = .02) compared to patients who survived CAM. Those who died also had poorer visual acuity, with 35% of the group having no light perception during examination compared to 6% of surviving CAM patients (P = .02).
These findings are largely “confirmatory to what we previously knew, which is that [CAM] is a very bad disease with high morbidity and high mortality,” Ilan Schwartz, MD, PHD, an infectious disease physician at the University of Alberta, Edmonton, who researches emerging fungal infections, said in an interview. He was not involved with the research.
While larger studies looking at similar questions have been published, the new report has longer patient follow-up and is “better positioned to be able to estimate the mortality rate,” Dr. Schwartz noted. Even with 30 days of follow-up, “patients can have ongoing problems for many months, and so it’s possible that the true mortality rate is even higher, once you get beyond that period,” he added.
But Santosh G. Honavar, MD, the director of medical services at the Centre for Sight Eye Hospital in Hyderabad, India, also unaffiliated with the study, noted that the subset of patients included in the latest report may have had much more severe infection – and subsequently higher mortality rates – than a more generalized study in a broader patient population.
For example, a study by Mrittika Sen, PhD, Dr. Honavar, and their coauthors, published in the Indian Journal of Ophthalmology earlier this year, found a mortality rate of 14% when they examined the records of more than 2,800 patients across 102 treatment centers.
Taking that into account, “we believe that the actual mortality may be somewhere between the 14% reported by Sen et al. from the large Indian series and the 53% that we report at 3 weeks,” the JAMA Ophthalmology authors wrote.
Dr. Honavar also noted that the new report of severe infection outcomes identifies subgroups at higher risk of death due to CAM: those with severe COVID-19 infection or orbital disease. These groups “would need higher surveillance for mucormycosis, thus enabling early diagnosis and prompt initiation of amphotericin B upon diagnosis of mucormycosis,” he said in an interview. “These measures can possibly minimize the risk of death.”
Ongoing research on CAM cases will continue to inform knowledge and treatment of the disease, but there are still unanswered questions. “We still have a fairly unsatisfactory understanding of exactly why this [CAM] epidemic occurred and why it was so bad,” Dr. Schwartz noted. And while mucormycosis cases have seemed to drop off since the surge earlier this year, “I don’t think we’re out of the woods,” he added. “There’s a lot more awareness in India and around the world about this disease now, but we’re still quite vulnerable to seeing it again.”
Dr. Honavar is the editor-in-chief of the Indian Journal of Ophthalmology. Dr. Schwartz reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Earlier this year, hospitals in India were dealing not only with the coronavirus pandemic but also with a surge in a potentially lethal fungal infection in patients previously treated for COVID-19. Mucormycosis, also known as black fungus, is typically a rare infection, but India had recorded more than 45,000 cases as of July 2021.
Now, a recent report suggests that patients with COVID-19–associated rhino-orbital cerebral mucormycosis (CAM) may have a higher mortality rate than previously estimated. The study was published Dec. 9 in JAMA Ophthalmology.
“The mortality indicators we observed, such as assisted ventilation and presence of severe orbital manifestations, can help physicians triage patients for emergency procedures, such as functional endoscopic sinus surgery (FESS), and administer systemic antifungal agents when in short supply,” the study authors wrote.
Mucormycosis usually infects immunocompromised patients. Previous research has found that poorly controlled diabetes – an epidemic in India – and use of high-dose systemic corticosteroids are two main risk factors for developing CAM. Even before COVID-19, India had a high incidence of mucormycosis compared to other countries, but cases exist around the world. In fact, on Dec. 17, the Centers for Disease Control and Prevention reported 10 isolated cases of COVID-19–associated mucormycosis identified in Arkansas hospitals between July and September 2021.
The disease can cause blurred vision, black lesions on the nose or inside of the mouth, and facial swelling. In rhino-orbital cerebral mucormycosis, extensive infection can necessitate orbital exenteration surgery, a disfiguring procedure that typically involves removal of the entire contents of the bony eye socket, as well as removal of the sinuses. Estimates for the mortality rate for this disease range from 14% to nearly 80%.
To better understand the cumulative morality rates for CAM and to identify additional risk factors, researchers reviewed the medical records of patients diagnosed and treated for CAM at a tertiary care multispecialty government hospital in Maharashtra, a state in the west-central region of India. The analysis included patients who died after admission or who had at minimum 30 days of documented follow-up. All diagnoses occurred between March 1 and May 30, 2021. All patients underwent comprehensive ophthalmic exams and routine blood workups.
Seventy-three patients were included in the study, with the average age of 53.5 years; 66% of the patients were male, and 74% of all patients had diabetes. Of the 47 individuals with available COVID-19 vaccination information, 89% had not had either shot of the vaccine, and 11% had the first dose. No patients in the cohort had received both doses of the vaccine; 87% of the patients were previously hospitalized for COVID-19, with 43 needing supplemental oxygen, 14 receiving noninvasive ventilation and ventilator support (NIV), and three requiring mechanical ventilation.
Patients developed CAM a median of 28 days after being discharged from the hospital for COVID-19 treatment; 26 patients died, 18 patients underwent FESS, and five underwent orbital exenteration. While 36% of patients died overall, the researchers found the cumulative probability of death from CAM rose from 26% at day 7 to 53% at day 21. They also found that the patients who died had more severe COVID-19, indicated by more days spent on supplemental oxygen (P = .003) and increased need for NIV or mechanical ventilation (P = .02) compared to patients who survived CAM. Those who died also had poorer visual acuity, with 35% of the group having no light perception during examination compared to 6% of surviving CAM patients (P = .02).
These findings are largely “confirmatory to what we previously knew, which is that [CAM] is a very bad disease with high morbidity and high mortality,” Ilan Schwartz, MD, PHD, an infectious disease physician at the University of Alberta, Edmonton, who researches emerging fungal infections, said in an interview. He was not involved with the research.
While larger studies looking at similar questions have been published, the new report has longer patient follow-up and is “better positioned to be able to estimate the mortality rate,” Dr. Schwartz noted. Even with 30 days of follow-up, “patients can have ongoing problems for many months, and so it’s possible that the true mortality rate is even higher, once you get beyond that period,” he added.
But Santosh G. Honavar, MD, the director of medical services at the Centre for Sight Eye Hospital in Hyderabad, India, also unaffiliated with the study, noted that the subset of patients included in the latest report may have had much more severe infection – and subsequently higher mortality rates – than a more generalized study in a broader patient population.
For example, a study by Mrittika Sen, PhD, Dr. Honavar, and their coauthors, published in the Indian Journal of Ophthalmology earlier this year, found a mortality rate of 14% when they examined the records of more than 2,800 patients across 102 treatment centers.
Taking that into account, “we believe that the actual mortality may be somewhere between the 14% reported by Sen et al. from the large Indian series and the 53% that we report at 3 weeks,” the JAMA Ophthalmology authors wrote.
Dr. Honavar also noted that the new report of severe infection outcomes identifies subgroups at higher risk of death due to CAM: those with severe COVID-19 infection or orbital disease. These groups “would need higher surveillance for mucormycosis, thus enabling early diagnosis and prompt initiation of amphotericin B upon diagnosis of mucormycosis,” he said in an interview. “These measures can possibly minimize the risk of death.”
Ongoing research on CAM cases will continue to inform knowledge and treatment of the disease, but there are still unanswered questions. “We still have a fairly unsatisfactory understanding of exactly why this [CAM] epidemic occurred and why it was so bad,” Dr. Schwartz noted. And while mucormycosis cases have seemed to drop off since the surge earlier this year, “I don’t think we’re out of the woods,” he added. “There’s a lot more awareness in India and around the world about this disease now, but we’re still quite vulnerable to seeing it again.”
Dr. Honavar is the editor-in-chief of the Indian Journal of Ophthalmology. Dr. Schwartz reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA OPHTHALMOLOGY
Does atopic dermatitis pose an increased risk of acquiring COVID-19?
According to the best available evidence, patients with atopic dermatitis (AD) do not appear to face an increased risk of acquiring COVID-19 or becoming hospitalized because of the virus.
“This is an area that will continue to evolve, and further understanding will improve the health care advice that we provide to our patients,” Jacob P. Thyssen, MD, PhD, DmSci, said at the Revolutionizing Atopic Dermatitis virtual symposium. “The general recommendation for now is to continue systemic AD treatments during the pandemic, but the risk of acquiring COVID-19 is different for different drugs.”
According to Thyssen, professor of dermatology at the University of Copenhagen, early management guidance from the European Task Force on Atopic Dermatitis (ETFAD), the European Academy of Allergy and Clinical Immunology (EAACI), and the International Eczema Council (IEC) state that patients with AD who are on biologics or immunosuppressants should continue treatment if they are not infected with COVID-19. For example, the EIC statement says that the IEC “does not recommend temporary interruption of systemic AD treatments affecting the immune system in patients without COVID-19 infection or in those who have COVID-19 but are asymptomatic or have only mild symptoms.”
Guidelines from the EAACI recommend that patients with AD who become infected with COVID-19 withhold biologic treatment for a minimum of 2 weeks until they have recovered and/or have a negative SARS-CoV-2 test.
“However, if you have more severe respiratory disease, the advice to dermatologists is to consult with an infectious medicine specialist or a pulmonologist,” Dr. Thyssen said. “That’s out of our specialty realm. But in terms of AD, there’s no reason to stop treatment as long as the patient has mild symptoms or is asymptomatic. AD patients treated with immunosuppressive agents may have a higher risk of COVID-19 complications. Treatment with traditional immunosuppressant medications does increase the risk of infections. But what about COVID-19?”
Traditional systemic immunosuppressive therapies in AD with azathioprine, cyclosporine, and methotrexate suppress the immune system for 1-3 months, Dr. Thyssen continued. “We do know that vaccination response is reduced when using these agents,” he said. “The half-life of dupilumab [Dupixent] is 12-21 days. It takes about 13 weeks before dupilumab is completely out of the system, but it’s such a targeted therapy that it doesn’t lead to any broad immunosuppression.”
Meanwhile, the half-life of JAK inhibitors such as baricitinib (Olumiant) is about 13 hours. “It’s a broader immune suppressant because there will be off-target effects if you have a high dose, but it’s much more specific than the traditional immunosuppressants,” he said. “We now have JAK1 and JAK2 inhibitors in AD, which do not interfere with vaccine responses to the same degree as traditional immunosuppressants.”
To evaluate the risk for COVID-19 in patients with AD, researchers from the Center for Dermatology Research at the University of Manchester, United Kingdom, performed a cross-sectional study of 13,162 dermatology patients seen in the U.K. between June 2018 and Feb. 2021. Of the 13,162 patients, 624 (4.7%) had AD. They found that 4.8% of patients without a history of COVID-19 infection had AD, compared with 3.4% with a history of COVID-19. The risk for COVID-19 in patients with AD was similar to that of controls (adjusted odds ratio, 0.67).
Authors of a separate cross-sectional study published in May evaluated the health insurance medical records of 269,299 patients who were tested for SARS-CoV-2 across University of California Medical Centers. Of these, 3.6% had a positive test for SARS-CoV-2. Of 5,387 patients with AD, the infection rate was 2.9%, which was lower than in those without AD (3.7%; P = .0063). Hospitalization and mortality were not increased in patients with AD.
Another study, a case-control of more than 4.6 million HMO patients in Israel, found that the intake of systemic corticosteroids, older age, comorbid cardiovascular diseases, metabolic syndrome, and COPD were independent predictors of COVID-19–associated hospitalization. Mortality as a result of COVID-19 was independently predicted by metabolic syndrome and COPD but not by any AD-related variables.
“So, for our AD patients out there, there is no need to fear that they develop a COVID-19 infection or have a severe course, but we do have a few medications that would slightly increase the risk,” Dr. Thyssen said.
In another analysis, researchers evaluated Symphony Health–derived data from the COVID-19 Research Database to evaluate the risk for COVID-19 infection in adults with AD. The AD cohort included 39,417 patients, and the cohort without AD included 397,293 patients. Among AD patients, 8,180 were prescribed prednisone, 2,793 were prescribed dupilumab, 714 were prescribed methotrexate, and 512 were prescribed cyclosporine. The risk for COVID-19 was slightly increased in the AD cohort compared with the non-AD cohort (adjusted incidence rate ratio [IRR], 1.18; P < .0001).
“There can be various explanations for this,” Dr. Thyssen said. “I still think we should maintain that AD itself is not a risk factor for COVID-19, but some of the medications may slightly increase the risk.”
In other findings, the investigators observed that treatment with dupilumab versus no systemic medication decreased the risk for COVID-19 by 34% (adjusted IRR, 0.66; P < .0001), as did methotrexate by 18% (adjusted IRR 0.82; P = .32). However, compared with no systemic medication, the use of prednisone slightly increased the risk of COVID-19 (adjusted IRR, 1.13; P = .03), as did the use of cyclosporine (adjusted IRR, 1.20; P = .32) and azathioprine (adjusted IRR, 1.61; P = .16).
More recently, researchers evaluated the records of 1,237 patients with moderate-to-severe AD (aged 9-95 years) to assess the self-reported severity of COVID-19 symptoms among those who received dupilumab versus other treatments.
Of the 1,237 patients with AD, 632 were on dupilumab, 107 were on other systemic treatments, and 498 were on limited or no treatment. Patients treated with dupilumab were less likely to report moderate-to-severe COVID-19 symptoms compared with patients who were on other systemic treatments, or limited/no treatments.
Vaccines and AD
Dr. Thyssen pointed out that the risk-benefit ratio of currently approved COVID-19 vaccines is better than the risk for an infection with SARS-CoV-2. “AD is not a contraindication to vaccination,” he said. “COVID-19 vaccine does not cause AD worsening since the vaccination response is mainly Th1 skewed.” He added that systemic immunosuppressants and JAK inhibitors used to treat AD may attenuate the vaccination response, but no attenuation is expected with dupilumab. “The half-life of JAK inhibitors is so short that vaccination followed by 1 week of pause treatment is a good strategy for patients.”
Dr. Thyssen disclosed that he is a speaker, advisory board member, and/or investigator for Asian, Arena, Almirall, AbbVie, Eli Lilly, LEO Pharma, Pfizer, Regeneron, and Sanofi-Genzyme.
A version of this article first appeared on Medscape.com.
According to the best available evidence, patients with atopic dermatitis (AD) do not appear to face an increased risk of acquiring COVID-19 or becoming hospitalized because of the virus.
“This is an area that will continue to evolve, and further understanding will improve the health care advice that we provide to our patients,” Jacob P. Thyssen, MD, PhD, DmSci, said at the Revolutionizing Atopic Dermatitis virtual symposium. “The general recommendation for now is to continue systemic AD treatments during the pandemic, but the risk of acquiring COVID-19 is different for different drugs.”
According to Thyssen, professor of dermatology at the University of Copenhagen, early management guidance from the European Task Force on Atopic Dermatitis (ETFAD), the European Academy of Allergy and Clinical Immunology (EAACI), and the International Eczema Council (IEC) state that patients with AD who are on biologics or immunosuppressants should continue treatment if they are not infected with COVID-19. For example, the EIC statement says that the IEC “does not recommend temporary interruption of systemic AD treatments affecting the immune system in patients without COVID-19 infection or in those who have COVID-19 but are asymptomatic or have only mild symptoms.”
Guidelines from the EAACI recommend that patients with AD who become infected with COVID-19 withhold biologic treatment for a minimum of 2 weeks until they have recovered and/or have a negative SARS-CoV-2 test.
“However, if you have more severe respiratory disease, the advice to dermatologists is to consult with an infectious medicine specialist or a pulmonologist,” Dr. Thyssen said. “That’s out of our specialty realm. But in terms of AD, there’s no reason to stop treatment as long as the patient has mild symptoms or is asymptomatic. AD patients treated with immunosuppressive agents may have a higher risk of COVID-19 complications. Treatment with traditional immunosuppressant medications does increase the risk of infections. But what about COVID-19?”
Traditional systemic immunosuppressive therapies in AD with azathioprine, cyclosporine, and methotrexate suppress the immune system for 1-3 months, Dr. Thyssen continued. “We do know that vaccination response is reduced when using these agents,” he said. “The half-life of dupilumab [Dupixent] is 12-21 days. It takes about 13 weeks before dupilumab is completely out of the system, but it’s such a targeted therapy that it doesn’t lead to any broad immunosuppression.”
Meanwhile, the half-life of JAK inhibitors such as baricitinib (Olumiant) is about 13 hours. “It’s a broader immune suppressant because there will be off-target effects if you have a high dose, but it’s much more specific than the traditional immunosuppressants,” he said. “We now have JAK1 and JAK2 inhibitors in AD, which do not interfere with vaccine responses to the same degree as traditional immunosuppressants.”
To evaluate the risk for COVID-19 in patients with AD, researchers from the Center for Dermatology Research at the University of Manchester, United Kingdom, performed a cross-sectional study of 13,162 dermatology patients seen in the U.K. between June 2018 and Feb. 2021. Of the 13,162 patients, 624 (4.7%) had AD. They found that 4.8% of patients without a history of COVID-19 infection had AD, compared with 3.4% with a history of COVID-19. The risk for COVID-19 in patients with AD was similar to that of controls (adjusted odds ratio, 0.67).
Authors of a separate cross-sectional study published in May evaluated the health insurance medical records of 269,299 patients who were tested for SARS-CoV-2 across University of California Medical Centers. Of these, 3.6% had a positive test for SARS-CoV-2. Of 5,387 patients with AD, the infection rate was 2.9%, which was lower than in those without AD (3.7%; P = .0063). Hospitalization and mortality were not increased in patients with AD.
Another study, a case-control of more than 4.6 million HMO patients in Israel, found that the intake of systemic corticosteroids, older age, comorbid cardiovascular diseases, metabolic syndrome, and COPD were independent predictors of COVID-19–associated hospitalization. Mortality as a result of COVID-19 was independently predicted by metabolic syndrome and COPD but not by any AD-related variables.
“So, for our AD patients out there, there is no need to fear that they develop a COVID-19 infection or have a severe course, but we do have a few medications that would slightly increase the risk,” Dr. Thyssen said.
In another analysis, researchers evaluated Symphony Health–derived data from the COVID-19 Research Database to evaluate the risk for COVID-19 infection in adults with AD. The AD cohort included 39,417 patients, and the cohort without AD included 397,293 patients. Among AD patients, 8,180 were prescribed prednisone, 2,793 were prescribed dupilumab, 714 were prescribed methotrexate, and 512 were prescribed cyclosporine. The risk for COVID-19 was slightly increased in the AD cohort compared with the non-AD cohort (adjusted incidence rate ratio [IRR], 1.18; P < .0001).
“There can be various explanations for this,” Dr. Thyssen said. “I still think we should maintain that AD itself is not a risk factor for COVID-19, but some of the medications may slightly increase the risk.”
In other findings, the investigators observed that treatment with dupilumab versus no systemic medication decreased the risk for COVID-19 by 34% (adjusted IRR, 0.66; P < .0001), as did methotrexate by 18% (adjusted IRR 0.82; P = .32). However, compared with no systemic medication, the use of prednisone slightly increased the risk of COVID-19 (adjusted IRR, 1.13; P = .03), as did the use of cyclosporine (adjusted IRR, 1.20; P = .32) and azathioprine (adjusted IRR, 1.61; P = .16).
More recently, researchers evaluated the records of 1,237 patients with moderate-to-severe AD (aged 9-95 years) to assess the self-reported severity of COVID-19 symptoms among those who received dupilumab versus other treatments.
Of the 1,237 patients with AD, 632 were on dupilumab, 107 were on other systemic treatments, and 498 were on limited or no treatment. Patients treated with dupilumab were less likely to report moderate-to-severe COVID-19 symptoms compared with patients who were on other systemic treatments, or limited/no treatments.
Vaccines and AD
Dr. Thyssen pointed out that the risk-benefit ratio of currently approved COVID-19 vaccines is better than the risk for an infection with SARS-CoV-2. “AD is not a contraindication to vaccination,” he said. “COVID-19 vaccine does not cause AD worsening since the vaccination response is mainly Th1 skewed.” He added that systemic immunosuppressants and JAK inhibitors used to treat AD may attenuate the vaccination response, but no attenuation is expected with dupilumab. “The half-life of JAK inhibitors is so short that vaccination followed by 1 week of pause treatment is a good strategy for patients.”
Dr. Thyssen disclosed that he is a speaker, advisory board member, and/or investigator for Asian, Arena, Almirall, AbbVie, Eli Lilly, LEO Pharma, Pfizer, Regeneron, and Sanofi-Genzyme.
A version of this article first appeared on Medscape.com.
According to the best available evidence, patients with atopic dermatitis (AD) do not appear to face an increased risk of acquiring COVID-19 or becoming hospitalized because of the virus.
“This is an area that will continue to evolve, and further understanding will improve the health care advice that we provide to our patients,” Jacob P. Thyssen, MD, PhD, DmSci, said at the Revolutionizing Atopic Dermatitis virtual symposium. “The general recommendation for now is to continue systemic AD treatments during the pandemic, but the risk of acquiring COVID-19 is different for different drugs.”
According to Thyssen, professor of dermatology at the University of Copenhagen, early management guidance from the European Task Force on Atopic Dermatitis (ETFAD), the European Academy of Allergy and Clinical Immunology (EAACI), and the International Eczema Council (IEC) state that patients with AD who are on biologics or immunosuppressants should continue treatment if they are not infected with COVID-19. For example, the EIC statement says that the IEC “does not recommend temporary interruption of systemic AD treatments affecting the immune system in patients without COVID-19 infection or in those who have COVID-19 but are asymptomatic or have only mild symptoms.”
Guidelines from the EAACI recommend that patients with AD who become infected with COVID-19 withhold biologic treatment for a minimum of 2 weeks until they have recovered and/or have a negative SARS-CoV-2 test.
“However, if you have more severe respiratory disease, the advice to dermatologists is to consult with an infectious medicine specialist or a pulmonologist,” Dr. Thyssen said. “That’s out of our specialty realm. But in terms of AD, there’s no reason to stop treatment as long as the patient has mild symptoms or is asymptomatic. AD patients treated with immunosuppressive agents may have a higher risk of COVID-19 complications. Treatment with traditional immunosuppressant medications does increase the risk of infections. But what about COVID-19?”
Traditional systemic immunosuppressive therapies in AD with azathioprine, cyclosporine, and methotrexate suppress the immune system for 1-3 months, Dr. Thyssen continued. “We do know that vaccination response is reduced when using these agents,” he said. “The half-life of dupilumab [Dupixent] is 12-21 days. It takes about 13 weeks before dupilumab is completely out of the system, but it’s such a targeted therapy that it doesn’t lead to any broad immunosuppression.”
Meanwhile, the half-life of JAK inhibitors such as baricitinib (Olumiant) is about 13 hours. “It’s a broader immune suppressant because there will be off-target effects if you have a high dose, but it’s much more specific than the traditional immunosuppressants,” he said. “We now have JAK1 and JAK2 inhibitors in AD, which do not interfere with vaccine responses to the same degree as traditional immunosuppressants.”
To evaluate the risk for COVID-19 in patients with AD, researchers from the Center for Dermatology Research at the University of Manchester, United Kingdom, performed a cross-sectional study of 13,162 dermatology patients seen in the U.K. between June 2018 and Feb. 2021. Of the 13,162 patients, 624 (4.7%) had AD. They found that 4.8% of patients without a history of COVID-19 infection had AD, compared with 3.4% with a history of COVID-19. The risk for COVID-19 in patients with AD was similar to that of controls (adjusted odds ratio, 0.67).
Authors of a separate cross-sectional study published in May evaluated the health insurance medical records of 269,299 patients who were tested for SARS-CoV-2 across University of California Medical Centers. Of these, 3.6% had a positive test for SARS-CoV-2. Of 5,387 patients with AD, the infection rate was 2.9%, which was lower than in those without AD (3.7%; P = .0063). Hospitalization and mortality were not increased in patients with AD.
Another study, a case-control of more than 4.6 million HMO patients in Israel, found that the intake of systemic corticosteroids, older age, comorbid cardiovascular diseases, metabolic syndrome, and COPD were independent predictors of COVID-19–associated hospitalization. Mortality as a result of COVID-19 was independently predicted by metabolic syndrome and COPD but not by any AD-related variables.
“So, for our AD patients out there, there is no need to fear that they develop a COVID-19 infection or have a severe course, but we do have a few medications that would slightly increase the risk,” Dr. Thyssen said.
In another analysis, researchers evaluated Symphony Health–derived data from the COVID-19 Research Database to evaluate the risk for COVID-19 infection in adults with AD. The AD cohort included 39,417 patients, and the cohort without AD included 397,293 patients. Among AD patients, 8,180 were prescribed prednisone, 2,793 were prescribed dupilumab, 714 were prescribed methotrexate, and 512 were prescribed cyclosporine. The risk for COVID-19 was slightly increased in the AD cohort compared with the non-AD cohort (adjusted incidence rate ratio [IRR], 1.18; P < .0001).
“There can be various explanations for this,” Dr. Thyssen said. “I still think we should maintain that AD itself is not a risk factor for COVID-19, but some of the medications may slightly increase the risk.”
In other findings, the investigators observed that treatment with dupilumab versus no systemic medication decreased the risk for COVID-19 by 34% (adjusted IRR, 0.66; P < .0001), as did methotrexate by 18% (adjusted IRR 0.82; P = .32). However, compared with no systemic medication, the use of prednisone slightly increased the risk of COVID-19 (adjusted IRR, 1.13; P = .03), as did the use of cyclosporine (adjusted IRR, 1.20; P = .32) and azathioprine (adjusted IRR, 1.61; P = .16).
More recently, researchers evaluated the records of 1,237 patients with moderate-to-severe AD (aged 9-95 years) to assess the self-reported severity of COVID-19 symptoms among those who received dupilumab versus other treatments.
Of the 1,237 patients with AD, 632 were on dupilumab, 107 were on other systemic treatments, and 498 were on limited or no treatment. Patients treated with dupilumab were less likely to report moderate-to-severe COVID-19 symptoms compared with patients who were on other systemic treatments, or limited/no treatments.
Vaccines and AD
Dr. Thyssen pointed out that the risk-benefit ratio of currently approved COVID-19 vaccines is better than the risk for an infection with SARS-CoV-2. “AD is not a contraindication to vaccination,” he said. “COVID-19 vaccine does not cause AD worsening since the vaccination response is mainly Th1 skewed.” He added that systemic immunosuppressants and JAK inhibitors used to treat AD may attenuate the vaccination response, but no attenuation is expected with dupilumab. “The half-life of JAK inhibitors is so short that vaccination followed by 1 week of pause treatment is a good strategy for patients.”
Dr. Thyssen disclosed that he is a speaker, advisory board member, and/or investigator for Asian, Arena, Almirall, AbbVie, Eli Lilly, LEO Pharma, Pfizer, Regeneron, and Sanofi-Genzyme.
A version of this article first appeared on Medscape.com.
FROM REVOLUTIONIZING AD 2021
COVID-19 vaccinations in people with HIV reflect general rates despite higher mortality risk, study says
Around the world, people with HIV show variations in COVID-19 vaccination rates similar to those seen in the general population, raising concerns because of their increased risk for morbidity and mortality from COVID-19 infection.
“To our knowledge, this analysis presents the first and largest investigation of vaccination rates among people with HIV,” reported the authors in research published in the Journal of Infectious Diseases.
The findings reflect data on nearly 7,000 people with HIV participating in the REPRIEVE clinical trial. As of July, COVID-19 vaccination rates ranged from a high of 71% in higher income regions to just 18% in sub-Saharan Africa and bottomed out at 0% in Haiti.
“This disparity in COVID-19 vaccination rates among people with HIV across income regions may increase morbidity from COVID-19 in the most vulnerable HIV populations,” the authors noted.
In general, people with HIV have been shown in recent research to have as much as 29% higher odds of morality from COVID-19 than the general population, and a 20% higher odds of hospitalization, hence their need for vaccination is especially pressing.
To understand the vaccination rates, the authors looked at data from the ongoing REPRIEVE trial, designed to investigate primary cardiovascular prevention worldwide among people with HIV. The trial includes data on COVID-19 vaccination status, providing a unique opportunity to capture those rates.
The study specifically included 6,952 people with HIV aged 40-75 years and on stable antiretroviral therapy (ART), without known cardiovascular disease, and a low to moderate atherosclerotic cardiovascular disease (ASCVD) risk.
The diverse participants with HIV were from 12 countries, including 66% who were people of color, as well as 32% women. Countries represented include Brazil (n = 1,042), Botswana (n = 273), Canada (n = 123), Haiti (n = 136), India (n = 469), Peru (n = 142), South Africa (n = 527), Spain (n = 198), Thailand (n = 582), Uganda (n = 175), United States (n = 3,162), and Zimbabwe (n = 123).
With vaccination defined as having received at least one vaccine shot, the overall cumulative COVID-19 vaccination rate in the study was 55% through July 2021.
By region, the highest cumulative rates were in the high-income countries of the United States and Canada (71%), followed by Latin America and the Caribbean (59%) – all consistent with the general population in these areas
Lower cumulative vaccination rates were observed in South Asia (49%), Southeast/East Asia (41%), and sub-Saharan Africa (18%), also reflecting the regional vaccination rates.
The United States had the highest country-specific COVID-19 vaccination rate of 72%, followed by Peru (69%) and Brazil (63%). Countries with the lowest vaccination rates were South Africa (18%), Uganda (3%), and Haiti (0%).
Of note, South Africa and Botswana have the largest share of deaths from HIV/AIDS, and both had very low COVID-19 vaccination rates in general, compared with high-income countries.
Overall, factors linked to the likelihood of being vaccinated included residing in the high-income U.S./Canada Global Burden of Disease superregion, as well as being White, male, older, having a higher body mass index (BMI), a higher ASCVD risk score, and longer duration of ART.
Participants’ decisions regarding COVID-19 vaccination in the study were made individually and were not based on any study-related recommendations or requirements, the authors noted.
Vaccination rates were higher among men than women in most regions, with the exception of sub-Saharan Africa. Vaccination rates were higher among Whites than Blacks in the U.S./Canada high-income region, with a high proportion of participants from the United States.
“It was surprising to us – and unfortunate – that in the high-income superregion vaccination rates were higher among individuals who identified as White than those who identified as Black and among men,” senior author Steven K. Grinspoon, MD, said in an interview.
“Given data for higher morbidity from COVID-19 among people of color with HIV, this disparity is likely to have significant public health implications,” said Dr. Grinspoon, a professor of medicine at Harvard Medical School and chief of the metabolism unit at Massachusetts General Hospital, both in Boston.
Newer data from the REPRIEVE study through October has shown continued steady increases in the cumulative vaccination rates in all regions, Dr. Grinspoon noted, with the largest increases in the Southeast/East Asia, South Asia, and sub-Saharan Africa, whereas a leveling off of rates was observed in the high-income regions.
Overall, “it is encouraging that rates among people with HIV are similar to and, in many regions, higher than the general population,” Dr. Grinspoon said.
However, with the data showing a higher risk for COVID-19 death in people with HIV, “it is critical that people with HIV, representing a vulnerable and immunocompromised population, be vaccinated for COVID-19,” Dr. Grinspoon said.
Commenting on the study, Monica Gandhi, MD, MPH, director of the Gladstone Center for AIDS Research at the University of California, San Francisco, agreed that “it is encouraging that these rates are as high as the general population, showing that there is not excess hesitancy among those living with HIV.”
Unlike other immunocompromised groups, people with HIV were not necessarily prioritized for vaccination, since antiretroviral therapy can reconstitute the immune system, “so I am not surprised the [vaccination] rates aren’t higher,” Dr. Gandhi, who was not involved with the study, said in an interview.
Nevertheless, “it is important that those with risk factors for more severe disease, such as higher BMI and higher cardiovascular disease, are prioritized for COVID-19 vaccination, [as] these are important groups in which to increase rates,” she said.
“The take-home message is that we have to increase our rates of vaccination in this critically important population,” Dr. Gandhi emphasized. “Global vaccine equity is paramount given that the burden of HIV infections remains in sub-Saharan Africa.”
The study received support from the National Institutes of Health and funding from Kowa Pharmaceuticals and Gilead Sciences. The authors and Dr. Gandhi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Around the world, people with HIV show variations in COVID-19 vaccination rates similar to those seen in the general population, raising concerns because of their increased risk for morbidity and mortality from COVID-19 infection.
“To our knowledge, this analysis presents the first and largest investigation of vaccination rates among people with HIV,” reported the authors in research published in the Journal of Infectious Diseases.
The findings reflect data on nearly 7,000 people with HIV participating in the REPRIEVE clinical trial. As of July, COVID-19 vaccination rates ranged from a high of 71% in higher income regions to just 18% in sub-Saharan Africa and bottomed out at 0% in Haiti.
“This disparity in COVID-19 vaccination rates among people with HIV across income regions may increase morbidity from COVID-19 in the most vulnerable HIV populations,” the authors noted.
In general, people with HIV have been shown in recent research to have as much as 29% higher odds of morality from COVID-19 than the general population, and a 20% higher odds of hospitalization, hence their need for vaccination is especially pressing.
To understand the vaccination rates, the authors looked at data from the ongoing REPRIEVE trial, designed to investigate primary cardiovascular prevention worldwide among people with HIV. The trial includes data on COVID-19 vaccination status, providing a unique opportunity to capture those rates.
The study specifically included 6,952 people with HIV aged 40-75 years and on stable antiretroviral therapy (ART), without known cardiovascular disease, and a low to moderate atherosclerotic cardiovascular disease (ASCVD) risk.
The diverse participants with HIV were from 12 countries, including 66% who were people of color, as well as 32% women. Countries represented include Brazil (n = 1,042), Botswana (n = 273), Canada (n = 123), Haiti (n = 136), India (n = 469), Peru (n = 142), South Africa (n = 527), Spain (n = 198), Thailand (n = 582), Uganda (n = 175), United States (n = 3,162), and Zimbabwe (n = 123).
With vaccination defined as having received at least one vaccine shot, the overall cumulative COVID-19 vaccination rate in the study was 55% through July 2021.
By region, the highest cumulative rates were in the high-income countries of the United States and Canada (71%), followed by Latin America and the Caribbean (59%) – all consistent with the general population in these areas
Lower cumulative vaccination rates were observed in South Asia (49%), Southeast/East Asia (41%), and sub-Saharan Africa (18%), also reflecting the regional vaccination rates.
The United States had the highest country-specific COVID-19 vaccination rate of 72%, followed by Peru (69%) and Brazil (63%). Countries with the lowest vaccination rates were South Africa (18%), Uganda (3%), and Haiti (0%).
Of note, South Africa and Botswana have the largest share of deaths from HIV/AIDS, and both had very low COVID-19 vaccination rates in general, compared with high-income countries.
Overall, factors linked to the likelihood of being vaccinated included residing in the high-income U.S./Canada Global Burden of Disease superregion, as well as being White, male, older, having a higher body mass index (BMI), a higher ASCVD risk score, and longer duration of ART.
Participants’ decisions regarding COVID-19 vaccination in the study were made individually and were not based on any study-related recommendations or requirements, the authors noted.
Vaccination rates were higher among men than women in most regions, with the exception of sub-Saharan Africa. Vaccination rates were higher among Whites than Blacks in the U.S./Canada high-income region, with a high proportion of participants from the United States.
“It was surprising to us – and unfortunate – that in the high-income superregion vaccination rates were higher among individuals who identified as White than those who identified as Black and among men,” senior author Steven K. Grinspoon, MD, said in an interview.
“Given data for higher morbidity from COVID-19 among people of color with HIV, this disparity is likely to have significant public health implications,” said Dr. Grinspoon, a professor of medicine at Harvard Medical School and chief of the metabolism unit at Massachusetts General Hospital, both in Boston.
Newer data from the REPRIEVE study through October has shown continued steady increases in the cumulative vaccination rates in all regions, Dr. Grinspoon noted, with the largest increases in the Southeast/East Asia, South Asia, and sub-Saharan Africa, whereas a leveling off of rates was observed in the high-income regions.
Overall, “it is encouraging that rates among people with HIV are similar to and, in many regions, higher than the general population,” Dr. Grinspoon said.
However, with the data showing a higher risk for COVID-19 death in people with HIV, “it is critical that people with HIV, representing a vulnerable and immunocompromised population, be vaccinated for COVID-19,” Dr. Grinspoon said.
Commenting on the study, Monica Gandhi, MD, MPH, director of the Gladstone Center for AIDS Research at the University of California, San Francisco, agreed that “it is encouraging that these rates are as high as the general population, showing that there is not excess hesitancy among those living with HIV.”
Unlike other immunocompromised groups, people with HIV were not necessarily prioritized for vaccination, since antiretroviral therapy can reconstitute the immune system, “so I am not surprised the [vaccination] rates aren’t higher,” Dr. Gandhi, who was not involved with the study, said in an interview.
Nevertheless, “it is important that those with risk factors for more severe disease, such as higher BMI and higher cardiovascular disease, are prioritized for COVID-19 vaccination, [as] these are important groups in which to increase rates,” she said.
“The take-home message is that we have to increase our rates of vaccination in this critically important population,” Dr. Gandhi emphasized. “Global vaccine equity is paramount given that the burden of HIV infections remains in sub-Saharan Africa.”
The study received support from the National Institutes of Health and funding from Kowa Pharmaceuticals and Gilead Sciences. The authors and Dr. Gandhi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Around the world, people with HIV show variations in COVID-19 vaccination rates similar to those seen in the general population, raising concerns because of their increased risk for morbidity and mortality from COVID-19 infection.
“To our knowledge, this analysis presents the first and largest investigation of vaccination rates among people with HIV,” reported the authors in research published in the Journal of Infectious Diseases.
The findings reflect data on nearly 7,000 people with HIV participating in the REPRIEVE clinical trial. As of July, COVID-19 vaccination rates ranged from a high of 71% in higher income regions to just 18% in sub-Saharan Africa and bottomed out at 0% in Haiti.
“This disparity in COVID-19 vaccination rates among people with HIV across income regions may increase morbidity from COVID-19 in the most vulnerable HIV populations,” the authors noted.
In general, people with HIV have been shown in recent research to have as much as 29% higher odds of morality from COVID-19 than the general population, and a 20% higher odds of hospitalization, hence their need for vaccination is especially pressing.
To understand the vaccination rates, the authors looked at data from the ongoing REPRIEVE trial, designed to investigate primary cardiovascular prevention worldwide among people with HIV. The trial includes data on COVID-19 vaccination status, providing a unique opportunity to capture those rates.
The study specifically included 6,952 people with HIV aged 40-75 years and on stable antiretroviral therapy (ART), without known cardiovascular disease, and a low to moderate atherosclerotic cardiovascular disease (ASCVD) risk.
The diverse participants with HIV were from 12 countries, including 66% who were people of color, as well as 32% women. Countries represented include Brazil (n = 1,042), Botswana (n = 273), Canada (n = 123), Haiti (n = 136), India (n = 469), Peru (n = 142), South Africa (n = 527), Spain (n = 198), Thailand (n = 582), Uganda (n = 175), United States (n = 3,162), and Zimbabwe (n = 123).
With vaccination defined as having received at least one vaccine shot, the overall cumulative COVID-19 vaccination rate in the study was 55% through July 2021.
By region, the highest cumulative rates were in the high-income countries of the United States and Canada (71%), followed by Latin America and the Caribbean (59%) – all consistent with the general population in these areas
Lower cumulative vaccination rates were observed in South Asia (49%), Southeast/East Asia (41%), and sub-Saharan Africa (18%), also reflecting the regional vaccination rates.
The United States had the highest country-specific COVID-19 vaccination rate of 72%, followed by Peru (69%) and Brazil (63%). Countries with the lowest vaccination rates were South Africa (18%), Uganda (3%), and Haiti (0%).
Of note, South Africa and Botswana have the largest share of deaths from HIV/AIDS, and both had very low COVID-19 vaccination rates in general, compared with high-income countries.
Overall, factors linked to the likelihood of being vaccinated included residing in the high-income U.S./Canada Global Burden of Disease superregion, as well as being White, male, older, having a higher body mass index (BMI), a higher ASCVD risk score, and longer duration of ART.
Participants’ decisions regarding COVID-19 vaccination in the study were made individually and were not based on any study-related recommendations or requirements, the authors noted.
Vaccination rates were higher among men than women in most regions, with the exception of sub-Saharan Africa. Vaccination rates were higher among Whites than Blacks in the U.S./Canada high-income region, with a high proportion of participants from the United States.
“It was surprising to us – and unfortunate – that in the high-income superregion vaccination rates were higher among individuals who identified as White than those who identified as Black and among men,” senior author Steven K. Grinspoon, MD, said in an interview.
“Given data for higher morbidity from COVID-19 among people of color with HIV, this disparity is likely to have significant public health implications,” said Dr. Grinspoon, a professor of medicine at Harvard Medical School and chief of the metabolism unit at Massachusetts General Hospital, both in Boston.
Newer data from the REPRIEVE study through October has shown continued steady increases in the cumulative vaccination rates in all regions, Dr. Grinspoon noted, with the largest increases in the Southeast/East Asia, South Asia, and sub-Saharan Africa, whereas a leveling off of rates was observed in the high-income regions.
Overall, “it is encouraging that rates among people with HIV are similar to and, in many regions, higher than the general population,” Dr. Grinspoon said.
However, with the data showing a higher risk for COVID-19 death in people with HIV, “it is critical that people with HIV, representing a vulnerable and immunocompromised population, be vaccinated for COVID-19,” Dr. Grinspoon said.
Commenting on the study, Monica Gandhi, MD, MPH, director of the Gladstone Center for AIDS Research at the University of California, San Francisco, agreed that “it is encouraging that these rates are as high as the general population, showing that there is not excess hesitancy among those living with HIV.”
Unlike other immunocompromised groups, people with HIV were not necessarily prioritized for vaccination, since antiretroviral therapy can reconstitute the immune system, “so I am not surprised the [vaccination] rates aren’t higher,” Dr. Gandhi, who was not involved with the study, said in an interview.
Nevertheless, “it is important that those with risk factors for more severe disease, such as higher BMI and higher cardiovascular disease, are prioritized for COVID-19 vaccination, [as] these are important groups in which to increase rates,” she said.
“The take-home message is that we have to increase our rates of vaccination in this critically important population,” Dr. Gandhi emphasized. “Global vaccine equity is paramount given that the burden of HIV infections remains in sub-Saharan Africa.”
The study received support from the National Institutes of Health and funding from Kowa Pharmaceuticals and Gilead Sciences. The authors and Dr. Gandhi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF INFECTIOUS DISEASES
Clinical Edge Journal Scan Commentary: Prostate Cancer January 2022
Extensive efforts have been put forth to evaluate which patients may safely delay, or completely avoid, treatment for prostate cancer. However, identifying who can safely avoid treatment is challenging. Arcot et al. utilized the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men to determine whether those with prostate cancer grade group 1 with delayed treatment had increased need for secondary treatments, such as androgen deprivation or radiation therapy, compared with those with upfront surgery. There was a small decrease in the probability of being free from secondary treatment 24 months after diagnosis (96% vs. 93%), suggesting that such an approach is quite reasonable.
These two studies exemplify one of the ongoing points of discussion in treatment of early stage prostate cancer: whether upfront treatments are of net benefit for patients. The study by Wallis et al. further evaluated this point by conducting a prospective cohort study to evaluate the extent of regret of choice of treatment strategy amongst patients with prostate cancer. Out of this cohort of 2,072 men, 16% who underwent surgery, 11% who received radiation, and 7% who chose active surveillance reported regret regarding the treatment choice. However, when controlled for functional outcomes, the differences amongst treatment modalities were not statistically significant. However, perceived treatment efficacy and adverse effects were associated with regret when compared with patient expectations prior to treatment. This suggest that research and focus on shared decision-making in the clinic may be highly beneficial.
Extensive efforts have been put forth to evaluate which patients may safely delay, or completely avoid, treatment for prostate cancer. However, identifying who can safely avoid treatment is challenging. Arcot et al. utilized the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men to determine whether those with prostate cancer grade group 1 with delayed treatment had increased need for secondary treatments, such as androgen deprivation or radiation therapy, compared with those with upfront surgery. There was a small decrease in the probability of being free from secondary treatment 24 months after diagnosis (96% vs. 93%), suggesting that such an approach is quite reasonable.
These two studies exemplify one of the ongoing points of discussion in treatment of early stage prostate cancer: whether upfront treatments are of net benefit for patients. The study by Wallis et al. further evaluated this point by conducting a prospective cohort study to evaluate the extent of regret of choice of treatment strategy amongst patients with prostate cancer. Out of this cohort of 2,072 men, 16% who underwent surgery, 11% who received radiation, and 7% who chose active surveillance reported regret regarding the treatment choice. However, when controlled for functional outcomes, the differences amongst treatment modalities were not statistically significant. However, perceived treatment efficacy and adverse effects were associated with regret when compared with patient expectations prior to treatment. This suggest that research and focus on shared decision-making in the clinic may be highly beneficial.
Extensive efforts have been put forth to evaluate which patients may safely delay, or completely avoid, treatment for prostate cancer. However, identifying who can safely avoid treatment is challenging. Arcot et al. utilized the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men to determine whether those with prostate cancer grade group 1 with delayed treatment had increased need for secondary treatments, such as androgen deprivation or radiation therapy, compared with those with upfront surgery. There was a small decrease in the probability of being free from secondary treatment 24 months after diagnosis (96% vs. 93%), suggesting that such an approach is quite reasonable.
These two studies exemplify one of the ongoing points of discussion in treatment of early stage prostate cancer: whether upfront treatments are of net benefit for patients. The study by Wallis et al. further evaluated this point by conducting a prospective cohort study to evaluate the extent of regret of choice of treatment strategy amongst patients with prostate cancer. Out of this cohort of 2,072 men, 16% who underwent surgery, 11% who received radiation, and 7% who chose active surveillance reported regret regarding the treatment choice. However, when controlled for functional outcomes, the differences amongst treatment modalities were not statistically significant. However, perceived treatment efficacy and adverse effects were associated with regret when compared with patient expectations prior to treatment. This suggest that research and focus on shared decision-making in the clinic may be highly beneficial.
Clinical Edge Journal Scan Commentary: Breast Cancer January 2022
Oocyte and embryo cryopreservation are standard fertility preservation techniques, and gonadotropin-releasing hormone agonist (GnRHa) administration during chemotherapy is another strategy to preserve ovarian function. The phase 3 POEMS/S0230 study demonstrated higher pregnancy rates (5-year cumulative incidence 23.1% vs 12.2%, P = 0.03) among premenopausal patients with HR-negative early breast cancer who received GnRHa (goserelin) during chemotherapy vs chemotherapy alone. Furthermore, there was a trend towards improvement in survival outcomes with GnRHa + chemotherapy. Hypothetical concerns have existed regarding the safety of this approach, particularly in HR+ breast cancer. The PROMISE-GIM6 trial randomized 281 patients to receive chemotherapy alone or with GnRHa triptorelin (Lambertini et al) and found no difference in disease-free survival (DFS) or overall survival (OS) between GnRHa vs control groups (12-year DFS 65.7% vs 69.2%, HR 1.16; 12-year OS 81.2% vs 81.3%, HR 1.17). In patients with HR+ disease (80.4%), HR for DFS and OS was 1.02 and 1.12, respectively. The 12-year cumulative incidence of pregnancy was also higher in the GnRHa vs control group (6.5% vs 3.2%). These studies suggest no detrimental effect of GnRHa use during chemotherapy on long-term outcomes, including patients with HR+ disease, and support its role in ovarian protection.
COVID-19 has had various implications on breast cancer care, reflecting institutional policies, resources and patient preferences and potential concerns during the pandemic. A retrospective chart review of patients diagnosed at Mayo Clinic Rochester with a new breast cancer during vs pre-COVID-19, examined trends in diagnosis and treatment approaches during these times (Tonneson et al). Among 573 patients, there was no significant difference in clinical prognostic stage, although a slightly higher percentage of patients who presented with stage II-IV disease during COVID-19 vs pre-COVID-19 (29% vs 26%, P = 0.42). The use of neoadjuvant endocrine therapy (NET) significantly increased during COVID-19, and notably in patients with HR+/HER2- breast cancer (10% pre-COVID-19 vs 23% during COVID-19 (P = 0.001)) with a significant increase in stage I patients (7% vs 22%, P < 0.001). Various societies provided language to support neoadjuvant therapy as a bridge to surgical intervention during COVID-19 in the appropriate clinical scenarios. Extended follow-up of studies examining approaches utilized during the pandemic are desired to further define long-term impact on outcomes.
A pooled analysis of the PALOMA trials demonstrated progression-free survival benefit with palbociclib + endocrine therapy vs endocrine therapy alone in patients ≥65 years, and although myelosuppression was more common in patients ≥75 years, the combination remained well-tolerated. Ismail et al described real-world experience of palbociclib in older patients with advanced HR+ breast cancer. Among 598 patients, palbociclib dose reductions occurred in 33%, and those requiring a dose reduction were older vs those without dose reduction (median age 67 vs 63 years, P = 0.004). Despite higher frequency of dose reductions in older patients, this did not appear to compromise outcomes; time to next treatment was significantly longer (16.9 vs 11.6 months, P = 0.013) than younger patients but OS was similar (20.7 vs 26.7 months, P = 0.051). Although older patients may be at higher risk of toxicities due to co-morbidities or performance status limitations, palbociclib remains a valuable therapeutic option combined with endocrine therapy for advanced HR+/HER2- breast cancer.
References:
Francis PA, Pagani O, Fleming GF, et al; SOFT and TEXT Investigators and the International Breast Cancer Study Group. Tailoring adjuvant endocrine therapy for premenopausal breast cancer. N Engl J Med. 2018;379(2):122-137.
Moore HCF, Unger JM, Phillips K-A, et al. Final analysis of the prevention of early menopause study (POEMS)/SWOG Intergroup S0230. J Natl Cancer Inst. 2019;111(2):210–213.
Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. The COVID-19 pandemic breast cancer consortium. Breast Cancer Res Treat. 2020;181(3):487–97.
Rugo HS, Turner NC, Finn RS, et al. Palbociclib plus endocrine therapy in older women with HR+/HER2- advanced breast cancer: a pooled analysis of randomised PALOMA clinical studies. Eur J Cancer. 2018;101:123e33.
Oocyte and embryo cryopreservation are standard fertility preservation techniques, and gonadotropin-releasing hormone agonist (GnRHa) administration during chemotherapy is another strategy to preserve ovarian function. The phase 3 POEMS/S0230 study demonstrated higher pregnancy rates (5-year cumulative incidence 23.1% vs 12.2%, P = 0.03) among premenopausal patients with HR-negative early breast cancer who received GnRHa (goserelin) during chemotherapy vs chemotherapy alone. Furthermore, there was a trend towards improvement in survival outcomes with GnRHa + chemotherapy. Hypothetical concerns have existed regarding the safety of this approach, particularly in HR+ breast cancer. The PROMISE-GIM6 trial randomized 281 patients to receive chemotherapy alone or with GnRHa triptorelin (Lambertini et al) and found no difference in disease-free survival (DFS) or overall survival (OS) between GnRHa vs control groups (12-year DFS 65.7% vs 69.2%, HR 1.16; 12-year OS 81.2% vs 81.3%, HR 1.17). In patients with HR+ disease (80.4%), HR for DFS and OS was 1.02 and 1.12, respectively. The 12-year cumulative incidence of pregnancy was also higher in the GnRHa vs control group (6.5% vs 3.2%). These studies suggest no detrimental effect of GnRHa use during chemotherapy on long-term outcomes, including patients with HR+ disease, and support its role in ovarian protection.
COVID-19 has had various implications on breast cancer care, reflecting institutional policies, resources and patient preferences and potential concerns during the pandemic. A retrospective chart review of patients diagnosed at Mayo Clinic Rochester with a new breast cancer during vs pre-COVID-19, examined trends in diagnosis and treatment approaches during these times (Tonneson et al). Among 573 patients, there was no significant difference in clinical prognostic stage, although a slightly higher percentage of patients who presented with stage II-IV disease during COVID-19 vs pre-COVID-19 (29% vs 26%, P = 0.42). The use of neoadjuvant endocrine therapy (NET) significantly increased during COVID-19, and notably in patients with HR+/HER2- breast cancer (10% pre-COVID-19 vs 23% during COVID-19 (P = 0.001)) with a significant increase in stage I patients (7% vs 22%, P < 0.001). Various societies provided language to support neoadjuvant therapy as a bridge to surgical intervention during COVID-19 in the appropriate clinical scenarios. Extended follow-up of studies examining approaches utilized during the pandemic are desired to further define long-term impact on outcomes.
A pooled analysis of the PALOMA trials demonstrated progression-free survival benefit with palbociclib + endocrine therapy vs endocrine therapy alone in patients ≥65 years, and although myelosuppression was more common in patients ≥75 years, the combination remained well-tolerated. Ismail et al described real-world experience of palbociclib in older patients with advanced HR+ breast cancer. Among 598 patients, palbociclib dose reductions occurred in 33%, and those requiring a dose reduction were older vs those without dose reduction (median age 67 vs 63 years, P = 0.004). Despite higher frequency of dose reductions in older patients, this did not appear to compromise outcomes; time to next treatment was significantly longer (16.9 vs 11.6 months, P = 0.013) than younger patients but OS was similar (20.7 vs 26.7 months, P = 0.051). Although older patients may be at higher risk of toxicities due to co-morbidities or performance status limitations, palbociclib remains a valuable therapeutic option combined with endocrine therapy for advanced HR+/HER2- breast cancer.
References:
Francis PA, Pagani O, Fleming GF, et al; SOFT and TEXT Investigators and the International Breast Cancer Study Group. Tailoring adjuvant endocrine therapy for premenopausal breast cancer. N Engl J Med. 2018;379(2):122-137.
Moore HCF, Unger JM, Phillips K-A, et al. Final analysis of the prevention of early menopause study (POEMS)/SWOG Intergroup S0230. J Natl Cancer Inst. 2019;111(2):210–213.
Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. The COVID-19 pandemic breast cancer consortium. Breast Cancer Res Treat. 2020;181(3):487–97.
Rugo HS, Turner NC, Finn RS, et al. Palbociclib plus endocrine therapy in older women with HR+/HER2- advanced breast cancer: a pooled analysis of randomised PALOMA clinical studies. Eur J Cancer. 2018;101:123e33.
Oocyte and embryo cryopreservation are standard fertility preservation techniques, and gonadotropin-releasing hormone agonist (GnRHa) administration during chemotherapy is another strategy to preserve ovarian function. The phase 3 POEMS/S0230 study demonstrated higher pregnancy rates (5-year cumulative incidence 23.1% vs 12.2%, P = 0.03) among premenopausal patients with HR-negative early breast cancer who received GnRHa (goserelin) during chemotherapy vs chemotherapy alone. Furthermore, there was a trend towards improvement in survival outcomes with GnRHa + chemotherapy. Hypothetical concerns have existed regarding the safety of this approach, particularly in HR+ breast cancer. The PROMISE-GIM6 trial randomized 281 patients to receive chemotherapy alone or with GnRHa triptorelin (Lambertini et al) and found no difference in disease-free survival (DFS) or overall survival (OS) between GnRHa vs control groups (12-year DFS 65.7% vs 69.2%, HR 1.16; 12-year OS 81.2% vs 81.3%, HR 1.17). In patients with HR+ disease (80.4%), HR for DFS and OS was 1.02 and 1.12, respectively. The 12-year cumulative incidence of pregnancy was also higher in the GnRHa vs control group (6.5% vs 3.2%). These studies suggest no detrimental effect of GnRHa use during chemotherapy on long-term outcomes, including patients with HR+ disease, and support its role in ovarian protection.
COVID-19 has had various implications on breast cancer care, reflecting institutional policies, resources and patient preferences and potential concerns during the pandemic. A retrospective chart review of patients diagnosed at Mayo Clinic Rochester with a new breast cancer during vs pre-COVID-19, examined trends in diagnosis and treatment approaches during these times (Tonneson et al). Among 573 patients, there was no significant difference in clinical prognostic stage, although a slightly higher percentage of patients who presented with stage II-IV disease during COVID-19 vs pre-COVID-19 (29% vs 26%, P = 0.42). The use of neoadjuvant endocrine therapy (NET) significantly increased during COVID-19, and notably in patients with HR+/HER2- breast cancer (10% pre-COVID-19 vs 23% during COVID-19 (P = 0.001)) with a significant increase in stage I patients (7% vs 22%, P < 0.001). Various societies provided language to support neoadjuvant therapy as a bridge to surgical intervention during COVID-19 in the appropriate clinical scenarios. Extended follow-up of studies examining approaches utilized during the pandemic are desired to further define long-term impact on outcomes.
A pooled analysis of the PALOMA trials demonstrated progression-free survival benefit with palbociclib + endocrine therapy vs endocrine therapy alone in patients ≥65 years, and although myelosuppression was more common in patients ≥75 years, the combination remained well-tolerated. Ismail et al described real-world experience of palbociclib in older patients with advanced HR+ breast cancer. Among 598 patients, palbociclib dose reductions occurred in 33%, and those requiring a dose reduction were older vs those without dose reduction (median age 67 vs 63 years, P = 0.004). Despite higher frequency of dose reductions in older patients, this did not appear to compromise outcomes; time to next treatment was significantly longer (16.9 vs 11.6 months, P = 0.013) than younger patients but OS was similar (20.7 vs 26.7 months, P = 0.051). Although older patients may be at higher risk of toxicities due to co-morbidities or performance status limitations, palbociclib remains a valuable therapeutic option combined with endocrine therapy for advanced HR+/HER2- breast cancer.
References:
Francis PA, Pagani O, Fleming GF, et al; SOFT and TEXT Investigators and the International Breast Cancer Study Group. Tailoring adjuvant endocrine therapy for premenopausal breast cancer. N Engl J Med. 2018;379(2):122-137.
Moore HCF, Unger JM, Phillips K-A, et al. Final analysis of the prevention of early menopause study (POEMS)/SWOG Intergroup S0230. J Natl Cancer Inst. 2019;111(2):210–213.
Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. The COVID-19 pandemic breast cancer consortium. Breast Cancer Res Treat. 2020;181(3):487–97.
Rugo HS, Turner NC, Finn RS, et al. Palbociclib plus endocrine therapy in older women with HR+/HER2- advanced breast cancer: a pooled analysis of randomised PALOMA clinical studies. Eur J Cancer. 2018;101:123e33.