Santa Barbara Doctors ExtraCare – October 2020 Newsletter

October 2020 ExtraCare Newsletter

The calendar says that it’s finally fall, but it sure doesn’t feel like it. With temperatures in the 80s all weekend, we encourage you to get out and enjoy the final days of summer.

This month, we are sharing an article proving Remdesivir’s usefulness in fighting COVID-19. We also remind you to continue staying up-to-date on preventative healthcare.

On a housekeeping note, as many of you have heard, Jeneva has left her position as practice manager at the 229 office. We are excited to announce that Kristina Quebedeaux will be joining our ExtraCare family on Monday, October 19. Feel free to give her a call and introduce yourselves to make her feel at home.

In the meantime, stay happy and healthy

Final Words on Remdesivir

The race for treatment options in this pandemic has highlighted a rise and fall of multiple candidates. With the completion of several well-designed randomized control trials, we’re finally teasing apart science from speculation with regards to multiple drugs used in the hospital setting. It’s important to note the vital importance of evidence based medicine in these discussions: This is the art, and act, of challenging patients with a medication that makes biochemical sense while vigorously eliminating outside influences and tracking outcomes over time. Simply stated, they take time to complete and then more time to analyze statistics.

The highlight of today is remdesvir, an antiviral drug that’s shown promise since its introduction back in May, and one that we’ve discussed previously in our newsletter. A final completed statistical analysis by Dr J.H. Beigel et al was just printed in the October 14 issue of the New England Journal of Medicine (NEJM).

Remdesivir was chosen as an early therapeutic candidate in May because of its ability to inhibit RNA Polymerase, the enzyme responsible for viral replication of SARS-CoV1 in a test tube. Far from evidence, this was the spring board for Dr Beigel and researchers at the NIH to develop the Adaptive Covid-19 Trial (ACT-1) which was a double blinded randomized control trial that put 541 patients into the remdesivir group, and 521 in a placebo group. Doubled blinded means that neither the patient nor the physician knows if the treatment was given; this a critical feature to minimize bias and statistical confusion. The primary question of the study was “time to recovery” which is well visualized in the curves below. Note that multiple pulmonary indices were significantly improved at day 28 as compared to placebo.

By virtue of a large sample size, researchers were able to break down these 2 treatment arms into “subgroups” to find important associations. Note the following table allows visualization of confidence intervals (depicted by the width of the bars) with recovery rate ratios > 1 supportive of a remdesavir benefit. All elements solely to the right of the dotted line indicate statistical significance, and those with the most significant remdesivir improvement include men and women with early symptoms severe enough to necessitate oxygen administration.

Cumulatively, these data suggest that remdesivir may not only reduce the severity of Covid-19 when started early in the right patient population, but may play a key role in reducing the need for mechanical ventilation and reducing overall health care costs, including the average number of hospital days.

In response to this trial, Pulmonologists and Infectious Disease specialists at Cottage Hospital are regularly using remdesivir at dosing specified in this trial to best treat patients with at least moderate Covid symptomology.

With this article published in NEJM just yesterday its quite clear that we’re literally on the front line together to find best practice solutions to the most challenging healthcare crisis of our generation.

Reduction in preventive healthcare during COVID

The COVID-19 pandemic hit all of us hard in mid-March, turning our lives upside-down and creating unprecedented uncertainty. This affected the outpatient medical community as well by forcing us to close our doors to in person care in order preserve PPE for the frontline workers. In addition, our professional organizations and public health organizations urged us to place all preventative healthcare on hold. Our office was forced to close its doors and transition solely to a virtual health care delivery system, gradually introducing in person visits over the ensuing few months.

The end result of this process is that patients across the country missed their preventative health exams and cancer screenings.

A recent article published in JAMA Network Open highlights some of the concerns of the medical community related to this delayed or missed primary care.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2771191

The researchers analyzed data from the National Disease and Therapeutic Index, a nationally representative audit of outpatient visits conducted by the health care technology company IQVIA.
The researchers estimated there were 27 million fewer visits during the second quarter of 2020 compared with the second quarters of 2018 and 2019, representing a 21.4% decline.
Office-based visits declined by 50% during this period, meanwhile, telehealth visits increased from 1.4 million visits to 35 million visits.

During primary care consultations, the researchers observed substantial reductions in blood pressure and cholesterol evaluations during the second quarter of 2020 vs. 2018 and 2019 levels. They found a 50.1% reduction in BP evaluations and 36.9% reduction in cholesterol evaluations during primary care consultation. In addition, there was a 26% decline in visits for new medications during the second quarter of 2020 compared with 2018 and 2019 levels.

The long term implications of this study remain to be seen, but our concern is that these reductions in cardiovascular risk factor modifications could result in higher cardiovascular event and death rates in the future.

Another concern about delayed primary care involves missed cancer screening. Data from various radiological organizations highlight the fact that mammogram and chest CT lung cancer screenings have decreased dramatically in the second and third quarters of 2020. In addition, due to the concern of COVID spread during colonoscopy procedures, colon cancer screening procedures have dramatically reduced. Studies have already been published from several European countries noting significant decreases in new cancer diagnoses during the COVID pandemic and some even go as far as predicting a 20% rise in cancer mortality as a result of the pandemic.

At Santa Barbara Doctors, our focus is on preventative healthcare. We have modified our office procedures to create a safe environment for our patients. We realize that some of our patients may have missed their preventative health exams as a result of this pandemic and urge those patients to contact us to reschedule.

Breast screening study volumes are measured against the prior year’s matched-period volume as a result of the coronavirus disease 2019 pandemic for three high-surge academic medical systems (AMSs; solid line), three low-surge AMSs (dotted line), and a large national private practice coalition (dashed line). Precipitous drops in volume were seen across the board in all three types of systems. Presumably, this is related to the screening or elective nature of such studies.

Our mailing address is:

Barbara A. Hrach M.D. FACP

229 W Pueblo St

Santa Barbara, CA 93105-3804

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