More research is needed to determine why the disparity in black newborn mortality exists.
Black newborns have a significantly higher mortality rate if their attending physicians are white rather than black, recent research indicates.
In the 2018 America's Health Rankings Annual Report, the United States ranked No. 33 out of 36 Organization for Economic Co-operation and Development (OECD) countries for infant mortality. In 2018, the U.S. infant mortality rate was 5.9 deaths per 1,000 live births, and the average infant mortality rate in all OECD countries was 3.9 deaths per 1,000 live births.
The recent research examined 1.8 million hospital births in Florida from 1992 to 2015. The study includes several key data points.
When black neonates are cared for by black physicians as opposed to white physicians, their in-hospital death rate is a third lower
This disparity manifests more strongly in more complicated cases and when hospitals deliver more black babies
The extent of the mortality rate reduction when black physicians care for black babies would correspond to preventing the in-hospital deaths of about 1,400 black newborns nationally each year
Physician race was not associated with an effect on the mortality rate of white neonates
The next step for researchers is to determine the mechanism that determines why black newborns have a lower mortality rate when cared for by black physicians, the lead author of the recent study told HealthLeaders.
"What this research calls for is getting into the primary setting and saying, 'What is it that these doctors, teams, and organizations are doing differently in higher and lower quality locations, and promulgating the successful behaviors from the high-quality locations to those that are struggling," said Brad Greenwood, PhD, MBA, MIT, associate professor of information systems and operations management sciences at George Mason University in Fairfax, Virginia.
"There are a lot of potential explanations—most likely it is not just one. What this work calls attention to is the fact that we need to look at locations that are performing higher and locations that are not performing as well, and figure out what the organizational team and individual behaviors are that are resulting in these disparities."
The finding that there was no significant impact on newborn mortality for white babies based on the race of the attending physician may be related to medical training in the United States, Greenwood said.
"Most medical training and most knowledge generation happens with white patients. So, you have a situation where the knowledge generation is happening with white patients—doctors are educated specifically with the presentations of white patients."
The recent study should not be interpreted as calling for black newborns to only have black physicians, he said. "This perspective calls for creating some type of Jim Crow medical system, which is exactly the wrong interpretation. … The important question is what is driving this disparity. What are black doctors doing differently than their white colleagues? That might come down to the individual level, it could come down to the team level, or it could come down to the organizational level."
Research articles indicate there are several effective decontamination methods for N95 respirator masks, including vaporized hydrogen peroxide.
N95 respirator masks have been in limited supply since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, and sterilization is a primary strategy to address shortages of this key personal protection equipment.
N95 respirator masks, which filter at least 95% of 0.3-μm particles, are the gold standard for protection against airborne pathogens such as the novel coronavirus. To conserve supplies of N95 respirator masks, the Centers for Disease Control and Prevention recommends that the masks be used by healthcare workers at highest risk of contracting infection or experiencing complications of infection.
Research on sterilizing N95 respirator masks for reuse includes four recent articles.
Used N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide maintain their filtration efficiency, according to a study published by JAMA Internal Medicine. Steam sterilization distorted 1860 N95 respirator masks, rendering them unsuitable for reuse; however, steam sterilization of 1870+ Aura face masks was effective, with the masks retaining more than 95% fitted filtration efficiency after a single sterilization cycle, the study found.
The JAMA Internal Medicine study also found that N95 respirator masks as many as 11 years past their expiration date maintained their filtration efficiency.
A recent research article, which was published in JAMA Otolaryngology—Head & Neck Surgery, identifies four decontamination methods that can recycle N95 masks without compromising the fit of the masks or the filtering material. The sterilization methods identified are ultraviolet germicidal irradiation, vaporized hydrogen peroxide, steam treatment, and dry heat treatment.
Two recent studies show steam can effectively decontaminate medical masks including N95 respirator masks.
A research team in China published a study in the Journal of Medical Virology on using steam to sanitize surgical masks and N95 respirators. The sanitization process, which used avian coronavirus of infectious bronchitis virus to mimic the novel coronavirus, was simple. Contaminated masks were placed in plastic bags and steamed over boiling tap water in a kitchen pot.
Researchers at Houston Methodist Research Institute in Houston published a steam sanitization study for N95 respirator masks in the journal Infection Control & Hospital Epidemiology. The study featured five test subjects to verify mask fit after the decontamination process and a more sophisticated steam treatment method than the Chinese study.
Opening a new hospital during a pandemic involves several difficulties, including staff training with infection prevention measures in place.
How do you open a new hospital in the middle of a deadly pandemic?
That has been the challenge faced at St. Louis-based SSM Health, which is set to open SSM Health Saint Louis University Hospital on Sept. 1. The new $550 million, 802,000 square foot facility has been in the works for five years.
The coronavirus disease 2019 (COVID-19) pandemic has created several hurdles for the project, says Kelly Baumer, MBA, vice president of clinical services at SSM Health Saint Louis University Hospital.
Training more than 2,000 staff to occupy the new academic medical center during the pandemic was particularly vexing, she says.
"Prior to the COVID-19 pandemic, we had plans for how we were going to train masses of people. When the pandemic became a reality for us and we still needed to get all of these people trained, we had to reconsider how we were going to do training because we could not have large groups of people in classrooms. We moved as much of our training as possible to virtual training."
Baumer says there is a wide range of training needs when opening a new hospital, including learning about physical plant features such as oxygen shut-off valves, practicing patient evacuation plans, and training physicians and nurses how to use new equipment.
"There is also training for workflows. We put teams together over the past couple of years to design playbooks for the various departments. The playbooks define how employees will function in their new spaces. We had to take staff members to the new facility and let them role play with the new workflows. We had to walk through the work processes and walk through how patients enter the facility," she says.
The workflow training and staff tours of the new facility had to be broken down into multiple small groups for infection control safety, Baumer says. "Everybody had to wear masks, social distance, and practice good hand hygiene."
In addition to altering training plans, SSM Health had to make changes to waiting rooms and workspaces, she says. To promote social distancing, some furniture was removed from waiting rooms and changes were made to crowded work areas. "In some areas of the hospital, several people work together sitting close to each other. We have installed Plexiglas so staff can work safely in their normal workspaces."
The pandemic made it impossible to have celebration events with crowds, Baumer says. "We have a lot of excitement in our community and among our staff, but we couldn't have traditional ribbon cuttings because we couldn't have large groups of people present. We looked at what kinds of celebrations we could do virtually but still maintain the excitement."
Hospital designed for infectious disease emergencies
The new hospital has features that are designed to cope with infectious disease outbreaks, she says.
"We have gone through earlier outbreaks such as Ebola and H1N1; so, as an academic medical center, we are constantly thinking about infectious diseases. The design of the new facility includes having separate areas of the hospital if we need to quarantine some patients. We have areas in our emergency department and some of the patient floors where we can isolate patients."
During the COVID-19 pandemic, many hospitals across the county have struggled to have enough patient care space with negative air pressure to avoid the airborne spread of the novel coronavirus. SSM Health's new hospital has extensive negative pressure capabilities, Baumer says.
"This new facility has a very sophisticated building automation system, so we can make several areas of the hospital negative pressure relatively easily. It's not only patient rooms that need to have negative pressure but also operating rooms and the morgue area. In the new facility, we can have all of those things in place."
Although there is a looming nationwide physician shortage, the more pressing clinician workforce problem is the distribution of doctors, a Stanford researcher says.
Recent research on rural emergency physicians reflects a maldistribution of physicians nationwide, the lead author of the study told HealthLeaders.
Physician demand will grow significantly higher than supply through 2033, according to a report published earlier this year by the Association of American Medical Colleges. The AAMC report projects the shortfall at as many as 139,000 physicians by 2033.
The recent research, which was published in the Annals of Emergency Medicine, shows there is a shortage of emergency physicians in rural areas of the country. The study includes two key findings:
Compared to 2008, the total number of clinically active emergency physicians has increased by nearly 10,000, but emergency physician density per 100,000 of U.S. population has decreased in large rural (-0.4) and small rural (-3.7) areas.
This year, most (92%) emergency physicians practice in urban areas, with 6% practicing in large rural areas and 2% practicing in small rural areas.
"In the context of the work that we have done, there is a maldistribution of physicians in the United States. We see compared to the 2008 data, the situation in 2020 is more pronounced, with a decrease of physicians in the large rural and small rural areas," said the lead author of the study, Christopher Bennett, MD, MA, an assistant professor of emergency medicine at Stanford University School of Medicine in Stanford, California.
The study also found there are more emergency physicians approaching retirement age in rural areas compared to urban areas. This year, the median age of emergency physicians in urban areas is 50, and the median age of emergency physicians in large rural areas is 58 and 62 in small rural areas.
"The thing that is concerning about the number of emergency physicians in rural areas who are approaching retirement age is that you would presume to see in 10 to 20 years in the future that these are physicians who will no longer be working clinically. Given that there is concurrently a tendency for newer medical school graduates to work in more urban areas, that will likely compound the density difference in rural areas," Bennett said.
Although his team's research shows there is a mainly a distribution problem now in the U.S. physician workforce rather than a nationwide shortage, Bennett said several factors such as the aging of the general population will likely result in a widespread shortage of clinicians.
"The AAMC's projected shortage is in the context of a growing population, a growing population of older people who are going to see doctors more often, a population of people who need both primary and specialty care, and limited support for graduate medical education," he said.
Addressing the rural emergency physician shortage
It will take a multifaceted approach to increase the number of emergency physicians practicing in rural areas of the country, Bennett said. He said those strategies include:
Training more emergency physicians in rural areas, with the hope that more young doctors will end up practicing in rural areas
Offering financial incentives to practice in rural areas such as student loan forgiveness and higher salaries
Federal support to incentivize emergency physicians to work in rural areas
"The number and distribution of doctors is a complex national issue; and if we are going to increase the number of emergency physicians practicing in rural areas, it is going to take national-level interventions. It is a complex problem, and it is going to take a complex solution to fix it," Bennett said.
The essential elements of providing primary care to patients via telemedicine include an affordable financial model and exceptional patient experience.
A San Francisco–based telehealth provider is on a mission to transform primary care services for patients and their physicians.
The coronavirus disease 2019 (COVID-19) pandemic has accelerated adoption of telehealth services at health systems, hospitals, and physician practices. Many payers, including the Centers for Medicare & Medicaid Services, have expanded coverage of telemedicine.
PlushCare has been providing primary care telehealth services to patients since its founding five years ago.
"Our median patient age is 40 years old. We are at parity with what a typical primary care provider can do. We deal with urgent care visits, preventative care, and we also take care of patients with chronic conditions such as high blood pressure, asthma, depression, anxiety, and high cholesterol. We have treated more than 3,500 unique diagnoses," says Ryan McQuaid, co-founder and CEO of PlushCare.
PlushCare, which has a nationwide patient population of more than 200,000, employs more than 100 physicians. The COVID-19 pandemic has boosted demand for PlushCare's services, with a 400% increase in telehealth visit volume, McQuaid says.
The business model at PlushCare features five elements.
1. Financing mechanism
The financial model at PlushCare includes a monthly patient membership fee set at $14.99. "The membership fee is for all of the benefits that our patients are getting that are not billable through insurance. When you compare Plushcare to people paying $10,000 a year for a concierge doctor, it is extremely reasonable," McQuaid says.
In addition, there are payment mechanisms for virtual visits, he says. "Patients can pay cash or use their flexible spending account or health savings account. We also are contracted with most of the major health plans. For patients with health insurance, they pay the primary care copay that they would typically pay for a bricks-and-mortar primary care practice visit."
2. Patient experience
An exceptional patient experience is a foundational aspect of PlushCare, McQuaid says. "We have seen that providing what we consider a 'wow' patient experience is incredibly valuable for people getting excited and telling their friends and family members about us. Our net promoter score has consistently been at 90, and the average primary care physician office across the United States is about 3, which is according to the Advisory Board. Our focus on the patient experience is huge."
PlushCare offers patients 24/7 access to a physician.
"From a patient perspective, the way we work is you can go on our website or download our app, then book a video visit with your physician. Patients select a dedicated primary care provider with whom they have an ongoing relationship. Our clinicians do not work 24 hours a day, seven days a week; so if a patient has an urgent need on the weekend and their primary care physician typically works Monday through Friday, the patient can see one of his or her colleagues to get immediate help," he says.
PlushCare employs more than 40 care coordinators to help patients with a range of issues, McQuaid says. "Patients can use in-app messaging to talk with their care coordinators. So, if a patient's prescription did not show up at a pharmacy, or if a patient needs help finding a specialist who is in-network and highly rated, our care coordinators can help patients figure that out. It is a concierge-like service."
There are also registered nurses available to help patients, he says. "If patients have a question that does not necessarily need contact with their dedicated primary care providers, they can contact a registered nurse who can respond to any questions."
From a technology perspective, PlushCare has a world-class patient app, McQuaid says. "When you think of healthcare, technology, and apps, you often do not think of great consumer experiences. We hired some of the best product folks, designers, and engineers who came from consumer-focused companies such as Amazon. They focused on building an amazing consumer experience."
3. Physician experience
A crucial element of providing a good patient experience is promoting a positive physician experience, he says. "We feel it is important for physicians to feel happy and not to be burdened by bureaucracy or imputing information into an electronic health record. We use technology to make functioning as a physician seamless."
PlushCare developed a physician-friendly electronic health record, McQuaid says. "We built our own electronic health record because a virtual primary care EHR did not exist when we founded PlushCare. Similar to the consumer side, we got amazing designers, engineers, and product specialists who had built fantastic consumer experiences to build our electronic health record, which our physicians love."
For example, PlushCare's EHR is designed specifically for primary care, so it is not bloated to support many specialties. The EHR also is configured to decrease paperwork for physicians, with forms and coding completed behind the scenes by a tech-enabled administrative team.
In addition to building an innovative EHR for physicians, PlushCare's billing processes reduce the administrative burden on clinicians, he says. "We have removed physicians from the billing process as much as we possibly can. The goal is to remove everything that is distracting our physicians from building a relationship with their patients and taking care of their patients."
PlushCare's company culture includes making sure physicians feel they are part of a community, McQuaid says. "When you talk with our doctors, one thing they love is the community we have established—they are able to share information absolutely seamlessly. It may not be what you would think because everybody is working virtually, but our management team has done an awesome job at creating a community for our physicians."
4. Top-notch physicians
Employing high-quality physicians has been one of the keys to success at PlushCare, he says. "All of our physicians are recruited from the Top 50 medical institutions in the country and, on average, they have 15 years of experience."
Building a team of excellent physicians has appealed to patients, McQuaid says. "When you think of professional services—whether you want a lawyer, or a physician, or a management consultant, or an investment banker—everybody wants the best. By having high-quality doctors, we instill trust in patients that they are going to get an amazing doctor at PlushCare."
5. Physician-patient relationship
PlushCare has focused on building relationships between patients and their primary care physicians, he says. "To optimize the physician-patient relationship in telehealth, it really is a longitudinal primary care experience, in which the patient sees the same physician over time and builds a relationship with the physician on an ongoing basis."
Since the first phase of the coronavirus pandemic in the United States erupted in March, HealthLeaders has published more than 70 clinical care stories on the outbreak.
The coronavirus disease 2019 (COVID-19) pandemic has been the most momentous clinical care story of the year.
Here are the Top 10 HealthLeaders clinical care COVID-19 stories so far in 2020:
1. Healthcare worker mental health: During the COVID-19 pandemic, the mental health needs of healthcare workers should not be overlooked, a disaster response expert says.
2. Home-based medical care: The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of Landmark Health.
3.Infection prevention: After months of grappling with the novel coronavirus, infection preventionists have developed several best practices for tackling the germ, the president-elect of the Association for Professionals in Infection Control and Epidemiology says.
4.Respiratory therapists: With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
5. Preparing for a surge: WakeMed Health & Hospitals was spared a dramatic impact in the first wave of the coronavirus pandemic and is ready if a second wave hits.
6. Managing a surge: It was a nightmare scenario. Emergency rooms were overwhelmed with coronavirus patients—sick patients walking through the door and dozens of seriously ill boarded patients awaiting inpatient beds. In some metropolis hospitals, demand for ICU beds exceeded supply.
7. Alternative to ventilator care: Nasal high flow therapy is a less invasive alternative to ventilator care for many seriously ill coronavirus patients, UnityPoint Health experts say.
8. Care rationing: In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist says.
9. Life support: After all other conventional treatments have failed, extracorporeal membrane oxygenation (ECMO) life support can be a coronavirus patient's last hope for recovery.
10. Rural hospitals: In response to the coronavirus pandemic, an Indiana-based rural hospital succeeded in boosting staff, increasing bed space, and securing essential equipment such as ventilators.
The Personal Health Inventory self-assessment has been adapted from a self-assessment tool that clinicians use to help patients with chronic illness.
Clinicians and other healthcare workers can complete a two-minute self-assessment to gauge their wellbeing and help prevent burnout.
Research published in September 2018 indicated that nearly half of physicians nationwide were experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
"Number One, you need to pay attention to yourself. If you are wounded, it is very difficult to help patients or your fellow staff members," says Wayne Jonas, MD, a family physician and executive director of the Samueli Foundation's Samueli Integrative Health Programs. The foundation is based in Corona del Mar, California.
The Personal Health Inventory self-assessment for healthcare workers has been adapted from what clinicians are trained to do with patients who have chronic disease to have the patients focus on their self-care and lifestyle for the management of their chronic illnesses.
"These assessments of patients are done about every three to six months, depending on the intensity of chronic disease. For clinicians, retaking the self-assessment in three months is a good idea," Jonas says.
The Personal Health Inventory self-assessment has four domains, with a set of simple questions in each domain that can be answered quickly.
1. External environment: The questions assess wellbeing-related factors in the workplace and the home.
2. Behavior and lifestyle: The questions include assessments of sleep and food intake.
3. Social and emotional: The questions focus on whether you are connecting with others and your level of social support.
4. Spiritual and mental: The questions help examine whether you are doing things that are meaningful for you and provide insight about whether you are doing things that are important in life such as developing abilities and talents.
Utilizing the self-assessment
"What you do is rate where you are in each of these four domains from one to five—you put a number down. You rate where you would like to build your self-care—where you want to see enhancements. If you have a very low score—three or below—that is a need area and where you should focus, especially if you have readiness to change. Then you reassess after three months and find out how the change is occurring," Jonas says.
The self-assessment tool is not a burnout assessment, he says. "What this self-assessment does is give clinicians a score on where they can take action in their lives. So, this is a self-care action assessment. It helps clinicians narrow down and isolate their core needs."
Once clinicians and other healthcare workers have done the self-assessment, they can look at the domain scores and pick one or two things at most, then set smart goals for specific improvements, Jonas says.
"We are trying to avoid burnout by doing this self-assessment—this is preemptive and about resilience. Resilience is not the entire solution for burnout—there need to be changes in the organizational environment, too. But resilience correlates quite well with risk for burnout. This self-assessment is a way to address burnout and to do a preemptive strike on burnout, especially in these very stressful times."
Coronavirus patients who are placed on ventilators need help from speech language pathologists such as restoring the ability to swallow.
Speech language pathologists are providing essential rehabilitation services to patients recovering from serious cases of coronavirus disease 2019 (COVID-19).
Many seriously ill COVID-19 patients are placed on ventilators due to acute respiratory distress syndrome. Speech language pathologists provide rehabilitation services for damage caused by mechanical ventilation, which includes injury to vocal cords from breathing tubes and deconditioning of the muscles needed for swallowing.
"Those patients who end up in the ICU either have a tracheostomy, or they have a tube that is pushed down through their vocal cords to have an airway to help them breathe. Then they are placed on a ventilator to help save their lives. They are on a machine that is helping them breathe, potentially for weeks. They are bedridden and they have a tube down their throat, so they lose their ability to eat and swallow," says Rinki Desai, MS, a speech language pathologist and adult outpatient lead at the University of Mississippi Medical Center's Voice and Swallowing Center in Jackson, Mississippi.
Rehabilitating patients' ability to swallow is a primary service provided by speech language pathologists, she says. "About 90% of what we do in the field of medical speech language pathology is treating swallowing disorders. For example, patients who experience a stroke can have trouble with swallowing, breathing, speech-language communication, and cognition. So, on a given day in a hospital ward or ICU, that is the kind of care that we provide."
COVID-19 patients who are placed on a ventilators need speech language pathologists to regain key functions, Desai says.
"These patients are not swallowing. They are not able to communicate verbally, and they have a significant impact on their voice. If a patient goes anywhere beyond two days on a ventilator, there can be significant injuries. For COVID-19 patients, the most immediate impairment that speech language pathologists treat in the ICU is helping patients communicate while they are on a ventilator using a white board or gestures. Once patients are off the ventilator, we help them breathe, swallow, and use their voice again."
There are three main categories of rehabilitation services that speech language pathologists provide to COVID-19 patients who require mechanical ventilation, she says.
1. Swallowing: "We start patients with swallowing ice chips, then gradually get them to the point where they can eat by mouth. We make sure they are safe, with efficient swallowing. We also help with respiratory-swallowing coordination."
2. Communication: "If patients have trouble communicating, we will provide specific therapies to get their communication back. Typically, they lose their voice because of the damage to their vocal cords. In those cases, we have very specific voice therapy techniques and exercises to help patients get their voice back as soon as possible."
3. Cognition: "If patients have trouble with memory, orientation, loss of consciousness, or delirium, our goal is to help patients regain function. We help them process and follow commands. We help them to get back to being as independent as possible with activities of daily living before they leave the hospital."
Pandemic challenge
In the early phase of the coronavirus pandemic, shortages of personal protective equipment (PPE) posed a significant challenge for speech language pathologists and their seriously ill COVID-19 patients, Desai says.
"We did not have enough personal protective equipment, so we had to limit the number of people going into patient rooms. We had to make a decision—who are the most essential people who need to go into the patient rooms? It was the pulmonologists, the ICU physicians, and the ICU nurses. So, we were dealing with rehab professionals not being able to see patients quite a bit—sometimes until they were COVID-19 negative."
Delaying the rehabilitation services that speech language pathologists provide to COVID-19 patients increased length of stay in ICUs, she says. "For every day a patient is in an ICU, the patient is bedridden and deconditioning, and it takes about a week to recover function."
Fortunately, University of Mississippi Medical Center was able to secure adequate supplies of PPE, Desai says.
"Now that we have enough PPE—we have our N95 masks, face shields, and other equipment—speech language pathologists are going in right away even if the patient has tested positive for COVID-19. We start therapy as soon as we can because we want to minimize deconditioning and weakness. We want patients to start eating and using their voice muscles as soon as possible."
New research indicates that sterilized and expired N95 respirator masks offer effective protection against coronavirus infection for healthcare workers.
N95 respirator masks as many as 11 years past their expiration date and used N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide maintain their filtration efficiency, new research shows.
Limited supply of personal protective equipment was one of the most daunting challenges for U.S. healthcare organizations in the early phase of the coronavirus pandemic. Shortages of N95 respirator masks, which filter at least 95% of 0.3-μm particles and are the gold standard for protection against airborne pathogens, were particularly vexing for healthcare workers and their employers.
The new research, which was published by JAMA Internal Medicine, tested the fitted filtration efficiency (FFE) of 29 fitted facemasks. The fitted facemasks included N95 respirator masks, surgical masks with ties, and procedure masks with ear loops.
The FFE tests were conducted from April to June in a custom-built exposure chamber at the U.S. Environmental Protection Agency Human Studies Facility in Chapel Hill, North Carolina. The testing followed the Occupational Safety and Health Administration's Modified Ambient Aerosol CNC Quantitative Fit Testing Protocol For Filtering Facepiece. Three sterilization methods were tested on used N95 respirator masks: ethylene oxide, steam, and vaporized hydrogen peroxide.
The research generated several key findings:
N95 respirator masks as many as 11 years past their expiration date retained FFEs more than 95%
N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide retained FFEs more than 95%
Steam sterilization distorted 1860 N95 respirator masks, rendering them unsuitable for reuse
Steam sterilization of 1870+ Aura face masks was effective, with the masks retaining more than 95% FFE after a single sterilization cycle
Chinese-made KN95 respirator masks did not achieve 95% FFE: the Jia Hu Kang KN95 mask with ear loops posted an 85.1% FFE and the Guangdong Fei Fan KN95 posted a 53.2% FFE
N95 respirator masks that were the wrong size for study participants still had substantial protection, with FFE results between 90% and 95%
The mean FFE score for surgical masks with ties was 71.5%
Procedure masks with ear loops had the lowest mean FFE score, at 38.1%
Interpreting the results
New N95 respirator masks are not the only effective face-covering option for clinicians working with coronavirus disease 2019 (COVID-19) patients, the co-authors of the new study wrote.
"This quality-improvement study evaluating 29 face mask alternatives for use by clinicians interacting with patients during the COVID-19 pandemic found that expired N95 respirators and sterilized, used N95 respirators can be used when new N95 respirators are not available. Other alternatives may provide less effective filtration," they wrote.
Sterilization with ethylene oxide (EtO) has one drawback, the co-authors wrote. "A potential disadvantage of EtO sterilization is that the wearer may be exposed to residual EtO within the face mask."
An editorial that accompanied the new study says N95 respirator masks may be preferred in clinical settings with the potential for coronavirus exposure, but they are not necessarily essential.
"Importantly, no documented SARS-CoV-2 outbreaks have been linked to settings in which surgical masks were assiduously used in lieu of N95 masks, which suggests that even if airborne transmission is a considerable contributor to SARS-CoV-2 transmission, surgical masks are likely sufficient to prevent it. Because the infectious dose of virus required to cause clinical infection also remains unknown, it is possible that blocking most, even if not all, viral particles through masks with lower filtration efficiencies of submicron particles is sufficient to prevent disease in the vast majority of cases."
Thomas Ely says doctors of osteopathic medicine are helping to address physician shortages in rural and underserved areas of the country.
The new president of the American Osteopathic Association has prescriptions for U.S. healthcare.
Thomas Ely, DO, assumes his leadership role at the AOA with several momentous challenges facing physicians, including the deadliest pandemic in a century, high burnout rates, and a looming physician shortage.
An Army veteran, Ely served as an aeromedical evacuation pilot early in his military career. He worked for the Army Surgeon General before earning his doctor of osteopathy degree from what is now Kansas City University of Medicine and Biosciences College of Osteopathic Medicine.
He cofounded a private practice in Clarksville, Tennessee, that later helped form a large physician-led multispecialty medical group. He has experience in hospital leadership, including working as chief of medical staff, director of medical affairs, and chief medical officer. When Ely was installed as AOA president last month, he was working as a healthcare consultant.
Ely recently talked with HealthLeaders about the goals of his AOA presidency and the challenges facing U.S. physicians. The following is a lightly edited transcript of that conversation.
HealthLeaders: Besides the coronavirus disease 2019 (COVID-19) pandemic, what are the top priorities of your AOA presidency?
Ely: I have three major goals.
I want to continue the expansion of our osteopathic community. I want to enhance the American Osteopathic Association's and osteopathic medicine's public health mission. And I want to continue to secure the future of our profession.
When I say expansion of the osteopathic community, osteopathic medicine is the fastest growing healthcare profession in the country. We have grown 63% in the past decade, and more than 300% over the past three decades. Despite this growth, many regions of the country are suffering from physician shortages, particularly in rural and underserved areas.
With respect to the public health mission, I would like to focus on vaccination and immunization. Everyone must get the flu vaccine this fall. And we must encourage families to continue the routine care and immunizations that protect them from disease. When there is a vaccine ready for COVID-19, we need everyone to get that, too.
With the potential combination of influenza virus on top of COVID-19, both could kill you. People need to avoid the risk of having that combination.
To secure the future of our profession, I think a lot about our students. One of the great things that has come to fruition is the transition to a single graduate medical education system in this country. Osteopathic physicians and allopathic physicians all now are competing for quality, post-graduate training under a common system.
HL: What are the top challenges facing physicians?
Ely: The first challenge is related to independent physician practices, especially primary care practices because they have experienced devastating economic effects from the pandemic.
The established parameters of physician compensation must be addressed. Physicians should be compensated for their judgment and their outcomes. Payers must recognize that physician practices are different, depending on their specialty, the type of practice, the location of practices, and, most importantly, the makeup of their patients.
The second challenge is personal wellness and self-care. If physicians can schedule patients, they can schedule self-care for themselves and their families. They must take care of themselves if we are going to get through this pandemic.
The third challenge is to make sure that our patients continue to be seen for their chronic medical conditions such as diabetes, heart failure, chronic obstructive pulmonary disease, and renal failure. Most importantly, we need to make sure our patients keep their children current on vaccinations and immunizations.
Finally, the opioid crisis has not gone away. We need to continue to provide care and support for patients impacted by this crisis. Many communities in this country are reeling from the double blows of the opioid epidemic and the COVID-19 pandemic. In 2018, there were more than 67,000 people who died from drug overdoses, and in 2019 that number was higher.
Ely: Healthcare professionals are showing significant rates of post-traumatic stress, anxiety, insomnia, and depression, according to new National Institutes of Health research. Not only are our physicians faced with unprecedented levels of death and suffering during this pandemic, many are losing their colleagues and family members. This is truly a devasting time for the entire healthcare community.
There is one thing I tell every graduating medical student that I see and that I tell osteopathic physicians on an ongoing basis: They must take care of themselves. Significant numbers of physicians will—at some time in their practice life and especially during this pandemic—have periods of dysthymia. If that ever occurs, I advise them to reach out to another physician. Don't sit there alone because there is a strong likelihood that any physician they reach out to has encountered the same thing in his or her life, and can give advice on immediate and best steps to take.
Fortunately, there are some good resources available. I would encourage anyone on the frontlines of the pandemic to reach out to the Physician Support Line. It is a free, confidential service that supports the mental health of doctors and medical students.
HL: The Association of American Medical Colleges is predicting there will be a shortage of as many as 139,000 physicians by 2033. How can the physician shortage be addressed?
Ely: When I applied to medical school in 1976, there were only eight osteopathic medical schools. We now have 38 medical schools located on 59 campuses. We are the fastest growing healthcare profession in the country. One out of four medical school students in the United States are in osteopathic medical school.
I am excited about the future growth of osteopathic medicine and how we can help meet the needs of our nation. We are graduating from 7,000 to 8,000 new osteopathic physicians a year. Over the next decade, that is at least 70,000 new physicians. We are projected to rise to as much as 22% of the U.S. physician population by 2030; whereas, right now we are only representing 12% to 13%. That is growth for us.
Our osteopathic medical schools are situated in health deserts—rural health areas and other underserved areas. Almost 60% of osteopathic physicians practice in primary care specialties—family medicine, internal medicine, pediatrics, obstetrics, and gynecology. We tend to go where the need is.
We have medical schools in East Tennessee, Idaho, West Virginia, Alabama, Mississippi, Louisiana, New Mexico, East Texas, and Kentucky. These schools are mainly in rural areas. Our students will do some of their practice training in those areas; and we hope to recruit many of our students from those areas, so they will practice there.
We also have ways of expanding care. The main way is through physician-led, team-based care.
To meet the healthcare needs in our country, we support a team-based approach to medical care, with the physician as the leader of that team. A physician-led, physician-directed model recognizes the growth and expertise of nonphysician clinicians. We totally support their rights to practice within their scope of practice and the scope of practice they are allowed under state statutes, with appropriate physician involvement. Healthcare professionals can work together at the top of their skill sets.
