Physician Workforce Response to the COVID-19 Pandemic at an Academic Medical Center.

OBJECTIVES: The aim of this study was to describe the planning, implementation, and outcome of an acute care physician supplemental workforce during the local coronavirus disease 2019 (COVID-19) surge at a 771-bed academic medical center, from March 25 to May 5, 2020, in New Jersey, United States. METHODS: The Department of Medicine sought participation by "independent" and redeployed "employed" physicians to provide acute hospital care, as well as assistance with occupational health and family communication. Plans addressed training, compensation, clinical privileges, malpractice, and collaboration with the existing hospitalist service. RESULTS: Redeployed employed physicians (81% internists) selected either acute care (n = 68; median age, 52 y [range, 32-72 y]; 28% female) or non-face-to-face supportive roles (n = 69; median age, 52 y [range, 32-84 y]; 28% female). The redeployed physician group totaled 474 twelve-h daytime shifts typically caring for 10 patients per day. Six employed physicians refused redeployment, and only 3 independent physicians participated (all acute care). Of note, COVID-19 infection occurred in 10 hospitalists and intensivists, and in several redeployed physicians. CONCLUSIONS: Successful physician workforce staffing for medical disasters, such as the COVID-19 pandemic, requires consideration of personal risk, as well as medicolegal, financial, and clinical competency issues.

Implementing a Review Process to Facilitate and Prioritize COVID-19 Research: Staying One Step Ahead of the Pandemic.

The first coronavirus disease 2019 (COVID-19) patient in the state of New Jersey (NJ) was admitted on March 2, 2020. With the number of hospitalized patients increasing exponentially in the following days and no established treatment approaches, research was to play a significant role in this fight. To facilitate review of all COVID-19 research proposals in a large health care network in NJ, we established the COVID-19 Research Review Committee (RRC) and implemented a peer-review process prior to the Institutional Review Board submission. The RRC was tasked with processing, soliciting, reviewing, and prioritizing research proposals and was comprised of a multidisciplinary group of reviewers. Within a 9-week period, three network-wide requests for proposals were released with 238 proposals submitted and 93 approved, an approval rate of 39%. The establishment of the RRC helped ensure scientific merit, better utilization of resources, collaborations across disciplines and network hospitals, and compliance with applicable regulatory and ethical standard.

Persistence of symptoms and quality of life at 35 days after hospitalization for COVID-19 infection.

BACKGROUND: Characterizing the prevalence and persistence of symptoms associated with COVID-19 infection following hospitalization and their impact is essential to planning post-acute community-based clinical services. This study seeks to identify persistent COVID-19 symptoms in patients 35 days post-hospitalization and their impact on quality of life, health, physical, mental, and psychosocial function. METHODS AND FINDINGS: This prospective cohort study used the PROMIS® Instruments to identify symptoms and quality of life parameters in consecutively enrolled patients between March 22 and April 16, 2020, in New Jersey. The 183 patients (median age 57 years; 61.5% male, 54.1% white) reported persistent symptoms at 35 days, including fatigue (55.0%), dyspnea (45.3%), muscular pain (51%), associated with a lower odds rating general health (41.5%, OR 0.093 [95% CI: 0.026, 0.329], p = 0.0002), quality of life (39.8%; OR 0.116 [95% CI: 0.038, 0.364], p = 0.0002), physical health (38.7%, OR 0.055 [95% CI: 0.016, 0.193], p <0.0001), mental health (43.7%, OR 0.093 [95% CI: 0.021, 0.418], p = 0.0019) and social active role (38.7%, OR 0.095 [95% CI: 0.031, 0.291], p<0.0001), as very good/excellent, particularly adults aged 65 to 75 years (OR 8·666 [95% CI: 2·216, 33·884], p = 0·0019). CONCLUSIONS: COVID-19 symptoms commonly persist to 35 days, impacting quality of life, health, physical and mental function. Early post-acute evaluation of symptoms and their impact on function is necessary to plan community-based services.

Hydroxychloroquine and tocilizumab therapy in COVID-19 patients-An observational study.

Hydroxychloroquine has been touted as a potential COVID-19 treatment. Tocilizumab, an inhibitor of IL-6, has also been proposed as a treatment of critically ill patients. In this retrospective observational cohort study drawn from electronic health records we sought to describe the association between mortality and hydroxychloroquine or tocilizumab therapy among hospitalized COVID-19 patients. Patients were hospitalized at a 13-hospital network spanning New Jersey USA between March 1, 2020 and April 22, 2020 with positive polymerase chain reaction results for SARS-CoV-2. Follow up was through May 5, 2020. Among 2512 hospitalized patients with COVID-19 there have been 547 deaths (22%), 1539 (61%) discharges and 426 (17%) remain hospitalized. 1914 (76%) received at least one dose of hydroxychloroquine and 1473 (59%) received hydroxychloroquine with azithromycin. After adjusting for imbalances via propensity modeling, compared to receiving neither drug, there were no significant differences in associated mortality for patients receiving any hydroxychloroquine during the hospitalization (HR, 0.99 [95% CI, 0.80-1.22]), hydroxychloroquine alone (HR, 1.02 [95% CI, 0.83-1.27]), or hydroxychloroquine with azithromycin (HR, 0.98 [95% CI, 0.75-1.28]). The 30-day unadjusted mortality for patients receiving hydroxychloroquine alone, azithromycin alone, the combination or neither drug was 25%, 20%, 18%, and 20%, respectively. Among 547 evaluable ICU patients, including 134 receiving tocilizumab in the ICU, an exploratory analysis found a trend towards an improved survival association with tocilizumab treatment (adjusted HR, 0.76 [95% CI, 0.57-1.00]), with 30 day unadjusted mortality with and without tocilizumab of 46% versus 56%. This observational cohort study suggests hydroxychloroquine, either alone or in combination with azithromycin, was not associated with a survival benefit among hospitalized COVID-19 patients. Tocilizumab demonstrated a trend association towards reduced mortality among ICU patients. Our findings are limited to hospitalized patients and must be interpreted with caution while awaiting results of randomized trials. Trial Registration: Clinicaltrials.gov Identifier: NCT04347993.

Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans.

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS-recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office-based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS-led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi-specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145-150, 2019.