September 2022 Newsletter
Welcome to the September 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss COVID-19 prevalence in Los Angeles County and try to predict its future, in the context of the new bivalent booster and an inevitable Winter surge. We will also cover medical records sharing and ‘interoperability’ between electronic systems and healthcare providers.
COVID-19 in LA County and the Practice during August 2022
COVID-19 cases in our practice have begun to slow slightly – a trend consistent with that seen nationally and in Los Angeles County. In August we had 12 new cases (3 were 2nd infections) with clusters at the beginning of the month (8/1-8/3), the middle (8/16-8/16) and the end (8/29-8/31). This is a somewhat different pattern than we had seen in July (18 cases, 3 were 2nd infection), June (29 cases, 3 were 2nd infections) and May (33 infections, 3 were 2nd infections) where cases accumulated at a steady clip of about one new case a day.
Trying to figure out what is occurring in terms of case rates at the County level is a bit more difficult. Firstly, LA County continues to have a significant lag in reporting with case numbers only current to 8/24/2022. Secondly, a significant proportion of positive tests will be from home testing which the County specifically does not include in their tabulations. Despite such, COVID-19 case rates for the month of August 2022 were the highest they have been in any pandemic for the month of August. For the week ending August 24th, 2022 set the high bar at 61.2 new daily cases per 100,000 population compared with 27.4 in 2021 and 18.4 in 2020. Current case rates are about twice as high currently as they were last year.
Given the difficulty in case ascertainment, another metric that can be considered is mortality rate. The mortality rate currently is 3 times what it was at the end of August 2021 (0.04 daily deaths per 100,000 population in 2021 versus 0.12 in 2022). Current mortality rates are about three times as high currently as they were last year.
Nationally, the BA.5 variant remains the overwhelmingly dominant circulating viral strain.. BA.5 now accounts for 88.7% of the variants isolated as opposed to 81.9% in July and 54% in June. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions
BA.5 Bivalent Booster and Predicting the Future
On August 31st, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose, to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. It is important to note that the bivalent booster will contain genetic recipes for both the original COVID strain as well as BA.4 and BA.5. The Moderna bivalent vaccine is authorized as a single booster for those aged 18 years and above, and Pfizer is approved for those 12 and older.
The question moving forward is just how effective the new booster formulation will be – both in terms of boosting neutralizing antibody levels but, more critically, in preventing infection. While there have been no human studies of the bivalent vaccine going to trial, a study of an earlier BA.1 + ancestral strain booster (2nd booster) showed improved neutralizing antibody levels as compared to the monovalent (original). Antibody levels among those with no prior COVID infection were 2372 with the bivalent booster as compared to 1473 with the monovalent booster. It is interesting to see that these levels are quite a bit lower than what we have been seeing in the practice, with most individuals having levels between 3000-6000 after a primary series + one or two boosters. Whether or not these neutralizing antibodies are of sufficient quantity and specificity to prevent infection remains to be seen.
The future is not too difficult to predict, as seen from the prevalence chart below. I think we have every reason to expect another Winter surge – most likely beginning mid December and lasting through January.
Blogs This Month
Our blog posts this month included a two part series on changes at the CDC. There is also a more lengthy essay on Monkeypox (which appears to be decreasing in frequency, at least in Los Angeles).
Structural Changes at the CDC (Parts 1 & 2):
https://drbretsky.com/29-august-2022-blog-post-major-changes-in-cdc-announced-part-1-of-2/
https://drbretsky.com/30-august-2022-blog-post-major-changes-in-cdc-announced-part-2-of-2/
Monkeypox:
On Medical Record Sharing and Interoperability
One question I have gotten a lot this month has been about medical record sharing and, specifically, if our office receives outside consultation notes, imaging and studies. The short answer is – sometimes (even if you specifically request it from the consulting physician) but it is a process that we are working to improve.
Traditionally, consulting physicians or specialists have communicated directly with a patient’s primary care provider in the form of a consult ‘note’. Many of the more experienced specialists will not only send their clinic / chart note but also a cover letter summarizing their findings and recommendations. Sadly, with the advent of Electronic Medical Records, this tradition has largely been lost. One would think that notes would be automatically routed to the referring or primary care physician but this too does not always happen.
The term ‘interoperability’ is used as a catchall phrase by health insurers and EMR vendors to describe a “system architecture that allows for the electronic sharing of patient information between different EHR systems and healthcare providers.” The idea being that information passes between the doctors providing patient care seamlessly. Responsibility for such was intended to fall to health insurance companies, permitting data exchange should an individual change insurance. However, the current administration has decided to defer enforcement of this responsibility citing the COVID-19 pandemic (link, if you are fascinated by this: https://www.cms.gov/blog/interoperability-and-connected-health-care-system).
What we have done as a practice is begun to set up processes to physically go and look for our patients’ information. One such mechanism comes through our collaboration with Aledade (www.aledade.com) which we have discussed in previous newsletters. In addition to their quality of care metrics tracking, Aledade software includes an interface that alerts us as to any hospitalization or Emergency Department visit, prompting us to follow-up on that event.
One way that patients can further help with interoperability is to ensure that on their CareEverywhere or MyChart account that Dr. Bretsky is listed as their primary care provider. We have started a process in the Cedars / Providence / UCLA systems of adding our office contact information manually so that reports are automatically sent to us. But patients themselves can double check that we are listed as Primary Care Providers (often these listings are outdated or include other providers, such as OB/GYN).
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