January 2023 Newsletter

Welcome to the January 2023 Newsletter for Santa Monica Primary Care – our first newsletter of the New Year!

In this issue, we are going to cover the current state COVID cases and will share our practice experience with COVID plus trends in LA County at large. 

We will also highlight a couple of initiatives that we have planned for 2023.

COVID-19 at Santa Monica Primary Care and in LA County

Readers may find it surprising that we actually saw less COVID in December than we did in November. COVID-19 cases in our practice decreased by more than 50% month over month (Graph below). After managing 27 cases in November (one of which required hospital level care), December brought 13 cases.  Of these 3 (23%) were repeat infections.

As I collated Los Angeles County numbers I noticed that we are on row 1035 of the spreadsheet. Little did I imagine in March of 2020 when I began collating the case counts that we would find ourselves in Year 3 of the pandemic.

Cases in Los Angeles County show essentially the same trend, although press reports relying heavily on guidance from County officials would lead one to believe otherwise (link: https://abc7.com/coronavirus-los-angeles-la-covid-cases-new-years-eve/12629266/).  Cases in the County also dropped nearly 50% from 34.5 to 19.8 new daily cases per 100,000 population between from the start until the end of December. 

What County officials are not talking about, however, are persistently elevated COVID mortality rates, despite a decline in cases (Figure below).

In 2020, the average mortality rate was 0.37 deaths per 100,000 population per day.  In 2021 this rose to 0.41 daily deaths per 100,000 population (largely driven by rates >2 in January and early February before vaccines were widely available).

So where would you expect mortality rates to be in 2022 given widespread vaccination, boosters and effective treatments such as Paxlovid.  Much lower, right?  Would 90% be a reasonable assumption – I would think so given that clinical trials have shown up to a 94% reduction in mortality risk with 3 mRNA vaccine doses during Omicron (link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7112e1.htm?s_cid=mm7112e1_w)

Instead we are really only seeing about a 50% reduction in mortality, as at the end of 2022 the mean number of daily deaths stood at 0.18 daily deaths per 100,000 population. Yet I’ve seen little substantive discussion from the County attempting to understand who is dying of COVID and why that is occuring, but instead a dogged / singular focus on reducing cases (which is sound public health policy as reducing cases reduces mortality but there seems to be some subtlety that they are missing). 

One question which I would like to put to Dr. Ferrar is as follows:  Why in July of 2022 was the mortality rate 0.16 with a case rate of 61.8 but in December there was a mortality rate of 0.12 with a case rate of 19.8?

Paxlovid Prescription Trends and “Rebound”

Given the strong clinical data on the significant reduction in long COVID among those treated with Paxlovid (covered in December’s newsletter), utilization rates of this medication have gone up in our practice . Of the 13 individuals who tested positive for COVID-19 in December, 7 elected to begin Paxlovid (53%). Similarly, in November 17 of 27 (63%) took Paxlovid. In October only 3 of 13 cases (23%) chose to begin the antiviral.

The biggest downside of Paxlovid is the “rebound” phenomenon with a return of symptoms and again testing positive, usually about two weeks after the initial positive test. Overall about 25% of the patients for whom we have prescribed Paxlovid experience clinical and testing rebound of the disease but in December only 1 of 7 treated rebounded.

The biggest upsides of Paxlovid include a rapid clinical response where those treated are feeling better, faster – usually in 1-2 days after starting the medication. There is also strong clinical evidence of an up to 30% reduction in the risk of long COVID symptoms as well.

Two New Initiatives in 2023

Each year I try to do “one new thing” in the practice, although it always seems to be more than one. So in the spirit of realism, I will highlight the two new things we will introduce in 2023.

Get DNAbled Program

In 2022 we took our first foray into formal genetic risk analysis with the Galleri cancer screen, based on DNA methylation patterns. While this remains a viable next step (but not a replacement for) routine cancer screening (e.g. mammography, prostate examinations / PSA, and colonoscopy) this year we will also offer a comprehensive pathway for full genome scanning via a partnership with DNAbled – https://getdnabled.com/our-program.html .

For additional detail,see also: https://drbretsky.com/genomic-analysis/

Aledade

In 2023 our Medicare Shared Savings Program will begin formally as part of our ongoing collaboration with Aledade to improve both quality of care and value of care. The lynchpin for this effort will be the annual wellness examination – software developed by Aledade integrates to our Electronic Medical Record platform and identifies patients that are due for such as well as any gaps in their care. Specific emphasis will be on hypertension, diabetes and women’s health initially. Further, with their support, we will seek to manage transitions of care – such as from the hospital to skilled nursing facility and back home. Or, even better, find opportunities to keep patients out of the hospital entirely.

 

We have spent much of 2022 in a slow ramp up position for this effort which will be considerable as Medicare-age patients are a much higher proportion of our practice at Santa Monica Primary Care than most general scope practices – reflecting the age structure of the geographic area.  We have a parallel program already with Anthem Blue Cross that has been running in 2022 and will continue into 2023.  For more information on the transformative work that Aledade is doing with practices across the country, check them out at https://www.aledade.com/our-solutions

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered a couple of COVID topics.

In the first, “Observed Over Expected” we attempted to quantify the true population rates of COVID infection given that the overwhelming majority of cases are now diagnosed by home antigen testing – something that is no longer reportable to the Country Health Department.  The link for this blog is: https://drbretsky.com/13-december-2022-blog-post-observed-over-expected/ 

In our second effort, we covered yet again another Board of Supervisors foray into COVID policy, something I always find interesting because the Health Department falls under the governing scope of the LA Board of Supervisors. Nevertheless, Supervisor Hahn chose to give her thoughts to Fox 11 News.  That link: https://drbretsky.com/15-december-2022-on-protecting-yourself/ 

Variants, Variants and more Variants

Both BA.4 and BA.5 (included in the currently available bivalent booster which has been administered to a whopping 15% of the eligible population over the age of 5) are occupying a smaller and smaller proportion of currently circulating and forecasted variants.  

For Region 9 (which includes Arizona, California, Hawaii and Pacific Territories), BA.5 makes up only 3.9% of currently circulating variants as compared to 90.1% in early August. BQ.1 and BQ.1.1 are estimated to comprise 31.1% (holding steady, was 31.5% in early December) and 40.6 (rising from 31.1% in early December) respectively of the total population of variants (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions). KBB and KBB.1.5 comprise 7.6% and 7.0% of the total.

A late November CDC study suggests that the bivalent booster provided additional (but not great) protection against symptomatic SARS-CoV2 infection, even in time periods where BA.4/BA.5 sublineages (including BQ1 and BQ1.1) predominated. In this study including over 350,000 (of whom a shocking 25% were unvaccinated) the bivalent vaccine efficacy topped out at 56% (for reference, seasonal influenza vaccine is about 50% effective) amongst those 18-49 who were more than 8 months out from their prior booster. For the highest risk group (those 65+), the bivalent booster was only 43% effective when given 8 months or more after the prior booster. If given within 2-3 months, it was 28% effective. Link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7148e1.htm?s (Note that Table 3 is the most useful representation of their data).

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