 *Below is ongoing analysis and advisories of news and alerts related to COVID-19 (Coronavirus) from Lauren Hedde, DO and Mark Turshen, MD of Direct Doctors. This post will be continuously updated as news and advisories of this issue are disseminated.* 7/6/2020 - 1:10pm EST By: Lauren Hedde, DO Travel and quarantine: There is a required 14-day quarantine for anyone coming to Rhode Island from any state with 5% or greater positivity rate. As an exception to that rule, you will not have to quarantine if you have had a negative coronavirus test within the past 72 hours. If you are a Rhode Islander who travels to a place where cases are spiking, you should quarantine for 14 days. As an exception, you will be able to sign up for an asymptomatic test (if you don’t have symptoms) by going to portal.ri.gov. If you test negative, you won’t have to quarantine. For people visiting Rhode Island from out of state, RIDOH recommends They get tested for COVID-19 in their home state, if possible. However, people from out of state can find a place for asymptomatic testing on RIDOH’s website. The individual being tested, or their insurance, would be billed for the testing. Rhode Island is not offering free testing to out-of-state travelers at this time. If you receive a test after arriving in Rhode Island and get a negative result, you can stop quarantining." 6/18/2020 - 1:07pm EST By: Lauren Hedde, DO ASYMPTOMATIC TESTING Testing for patients WITHOUT symptoms will take place in the parking lots of: Stop & Shop Cranston: 275 Warwick Ave Stop & Shop Pawtucket: 368-398 Cottage St. Stop & Shop Providence: 850 Manton Ave. and 333 W. River St. Asymptomatic workers who can schedule tests include child care workers, barbers, cosmetologists, gym and exercise trainers, personal care services (nail technicians, massage therapists, tattoo artists, estheticians, cosmeticians, manicurists, body piercers, and tanning facility staff), public transit drivers, and restaurant workers. In addition, people who have recently attended a large protest or demonstration are encouraged to get tested. Eligible Rhode Islanders can schedule an asymptomatic test at one of the four Stop & Shop stores by visiting portal.ri.gov or calling 401-222-8022 Monday – Friday 8:30 a.m.- 4:30 p.m. SYMPTOMATIC TESTING People with COVID-19 symptoms will not be tested at these locations and should contact their primary care provider or respiratory clinic to schedule an appointment for testing. 6/12/2020 - 2:06pm EST By Lauren Hedde, DO Governor Raimondo released the state's new 3-pronged testing strategy: 1) Rapidly test every Rhode Islander that is symptomatic 2) Quickly react and deploy infection control for outbreaks within (4) hours 3) Create and expand early warning testing system by testing key groups of asymptomatic Rhode Islanders. A new "Early Warning Testing System" has been put in place, with an important focus on communities of color, encouraging first responders and employees of close-contact businesses, child care centers, and congregate care settings to schedule a free test at one of the Rhode Island National Guard sites (RIC and CCRI). The goal is to be testing 900 people per day that are asymptomatic. The free test can be scheduled online or by calling 401-222-8022. 5/5/2020 - 1:29pm EST By Lauren Hedde, DO These days we are getting many questions and requests about having COVID antibody testing done. A little background. Antibodies - to be clear - are the proteins formed by your body when you have had exposure to an illness. In this case, we are talking about sars-cov2 antibodies. There are two main types of antibodies to any given infection that we want you to be aware of - IgM and IgG. IgM usually forms early, within days of illness and then goes away fairly quickly, whereas IgG takes more time, usually weeks to develop but lasts a lifetime (or usually that is the case with lots of infections). Currently, lots of tests are coming out to test these antibodies, which in theory sounds like a great way to find out if your mysterious February cold was actually COVID! Unfortunately, it is not that simple. And at the moment, the message from the RI DOH, is to wait except in very rare cases where a patient has very straight forward COVID symptoms but two swabs have come back negative. I get that this is very frustrating to many patients who want to know if they "had it" already. So here is some more info on why! The accuracy of a test like this depends on how many people in a community have it. So, in a place like NYC where there were lots of people with the disease, the test is much more accurate. In a place like RI, where we don't think the prevalence has been as high, the results would be less accurate. Meaning, there is a much higher chance of false positives (patients who have a positive result of antibodies but never actually had COVID) and false negatives (patients who have a negative results of antibodies, but did actually have COVID). The more false results you have, the less accurate the test is and the harder it is to know how well results can be "trusted." The other issue is that the coronavirus, sars-cov2 which causes COVID, is one of 5 coronaviruses that circulate in the US and the tests may overlap and result positive for patients who have had one of the other strains, rather than the current sars-cov2 strain. All of the above means, patients could get a results of "I had COVID" and either have actually had a different coronavirus that does not give immunity to COVID or not actually have had it at all (false positive). If we were to test lots of patients who did not have a very clear COVID-like illness (fever, short of breath, chest pressure, cough), we would get lots more false positives. If those patients now feel comfortable ignoring social distancing or returning to activities that the governor suggest should be avoided, we would return to a spike of COVID activity, overwhelm our healthcare system, and infect lots more patients who may suffer greatly from this. Lastly, we have no idea how long the IgG antibody lasts, nor if it leads to longterm immunity. Folks in China and South Korea are now reporting "re-infection," which either means there is not longterm immunity for some patients, OR there is longterm immunity but those "positives" were false. 4/8/2020 - 4:15pm EST By Lauren Hedde, DO CONTACT LISTS - The Governor is suggesting all Rhode Islanders keep lists of contacts: where you went, who you saw in close contact, what you did. Track this, for example in the notes on your phone, and reference it if you test positive for COVID. This will help the Department of Health track cases more easily and help stop the spread! MASKS - The Governor and CDC are recommending everyone who leaves the house, especially to go to a store for essentials, wear a cloth covering to minimize potential for asymptomatic or mildly symptomatic spread (think, you probably just have allergies but it's COVID and you didn't know it!). - Wearing these prevents YOU from spreading it to others, if you were to have it unknowingly. ACCESS TO MENTAL HEALTH SERVICES IN RI - Adults call 401-414-LINK - For children, call 855-543-5465 RETURN TO WORK * this is updated information * - The RI DOH is now requiring patients be without fever for 3 days and have resolution of all other symptoms as well as be at least 7 days from the start of symptoms. - For folks who have tested positive for COVID, there is another testing option for return to work. Reach out to your PCP if this is you and you are unsure. TREATMENT We've gotten lots of questions about what meds should be and are being prescribed for COVID treatment as well as what meds should be stopped if you test positive. - ACEi/ARBS - media have been suggesting these medications (i.e. lisinopril, losartan, etc). may cause worse outcomes for patients taking them with COVID. - Currently the DOH and American Heart Association say do not discontinue these meds now or if someone becomes ill while taking them. - NSAIDS - there is no hard data that ibuprofen etc use does worsen COVID outcomes. RI DOH says to try tylenol, etc first and use NSAIDs judiciously for now if sick with cough/fever or proven COVID. - REMDESIVIR - this investigational IV drug is given only in hospitals. RI hospitals do have the option to use this experimentally. - HYDROXYCHLOROQUINE (Plaquenil) - this oral anti-malarial and autoimmune drug has shown some un-researched potential for treating patients with COVID. Currently there is no actual data to support this. We are all waiting to learn more at the moment. Both chloroquine and hydroxychloroquine can cause heart arrhythmias but fairly uncommon for short term use. RI doctors can now prescribe this off label for COVID-19 confirmed cases for patients who are more than moderately ill (i.e. to try to keep someone who is quite sick from needing the hospital) but not for mild to moderate self-limited cases of patients doing well on their own at home. This is especially an option for nursing home patients. SYMPTOM UPDATE - The loss of smell and taste does seem to be a common feature in COVID (though can be caused by lots of other viruses) but worth noting on the list of reasons to test if a patient has this plus other more well known COVID-19 symptoms. CVS RAPID TESTING - Remains available only for specific populations so contact your PCP for more information. 4/6/2020 - 3:42pm EST By Lauren Hedde, DO CVS Rapid Testing: - Only certain patients will qualify for rapid testing through CVS right now. - If you have no PCP, you can consider filling out this form to see if you qualify for it. - As of today, even if you qualify, there are no times available at the Twin River location for this test. Obviously, this will likely change each day as new dates/times are added. - If you have talked to your PCP, and they advise testing, CVS will honor that and you can skip the questionnaire and go straight to signing up for a time slot (once they become available). - Your PCP can still order the usual test (which takes 3-4 days for results) at one of the drive through locations throughout the state for the next day (which are currently available now). - As always, if you're not sure which route to go or if you aren't even sure you need testing, reach out to your PCP for advice! 4/2/2020 - 1:46pm EST By Mark Turshen, MD As of today, COVID testing has been extended to any patients with symptoms here in Rhode Island. Please note, this means you must be currently symptomatic to warrant testing. This is not testing to see if you previously had the virus. The symptoms of COVID-19 include any of these symptoms (some patients have only 1-2 of these and may be mild):
All patients should still contact their primary care physician if they do experience symptoms so they can help coordinate and order the test. There are 3 drive through testing sites now set up throughout the state, along with respiratory clinics for those who need exams and testing. Drive through testing can only be set up and ordered by your PCP. Respiratory clinic visits should be discussed with your PCP first as well. We often stress the importance of having a good PCP, and especially one you have a good relationship with and can contact easily. The current situation is certainly highlighting this point. 4/1/2020 - 2:52pm EST By Lauren Hedde, DO Who is at Risk? - Everyone is considered at risk for COVID now. - We have widespread community transmission throughout the United States. - The only way to lower your risk of contracting COVID now is to avoid close contact with other people. Stay home as much as possible. Quarantining - Anyone who you have close contact within 6 feet for a significant amount of time (i.e. those you live with), is considered a contact. If you test positive for COVID OR even if your doctor just thinks your symptoms are COVID-like, then your contacts need to quarantine for 14 days. - Anyone who had direct contact with a COVID+ patient, as early as two days before symptoms, must quarantine as well. Testing - More testing is coming soon for almost everyone who has symptoms - As we learn more about this, we will update you. It will still likely require a check-in with your doctor and order for the test. Advanced Directives - This is never an easy topic, but now more than ever, it is a good time to be sure your family knows your wishes should you become very ill. - Having a living will, power of attorney, and perhaps a MOLST. If you have questions about any of these your PCP can help! 3/31/2020 - 12:05pm EST By Mark Turshen, MD Given the changing guidelines on testing and some confusion around recent statements made by Governor Raimondo, we wanted to update everyone on who is currently eligible for COVID testing. This includes symptomatic patients only in the following patient categories: - hospitalized - nursing home/assisted living residents - healthcare workers including EMS - first responders (fire fighters, police officers, etc) - 65 years of age and older - those with underlying conditions placing them at higher risk (please talk to your doctor about whether this is you, conditions placing people at higher risk do not necessarily include all medical conditions) For patients who did not fit into one of the above categories with mild illnesses, the recommendations are still to stay at home, recover and not have testing done. 3/30/2020 - 2:17pm EST By Lauren Hedde, DO Can anyone get a COVID test who wants it now? No. You must first call your PCP and have an evaluation about your symptoms, risk factors, and work. If you are in the higher risk categories or are considered an essential worker your PCP can order the test and arrange a drive thru testing for you. If you are not considered in the high risk group, you will not have a test ordered for you and still will be urged to stay home and weather it without testing or visiting a clinic. If your symptoms are unclear, your PCP can help direct you to a respiratory clinic for a full evaluation, but that must be done with a call-ahead as well. Only patients with an order for COVID testing from a physician/NP/PA will get tested. Can I go to urgent care if I feel sick? No-one can just show up right now to any location without a visit being called in ahead of time and planned. Please call your PCP first. If you don't have a PCP, you may consider finding one now or calling the urgent care to see if they will help triage you over the phone. If I have COVID symptoms and don't get tested, do I have to quarantine? Yes! Many patients will never get the test but will have the diagnosis based on symptoms alone. Please do as anyone would with a positive test and stay home. This means isolating from all possible contacts and certainly not going out for at least 7 days since onset of symptoms and at least 3 days without a fever (and without any fever reducing meds). Your personal contacts should stay home in a 14 day quarantine until it is clear they do not have symptoms. 3/26/2020 - 2:38pm EST By: Lauren Hedde, DO
3/24/2020 - 11:17am EST By: Mark Turshen, MD - Despite all the recent hype around the use of both Hydroxychloroquine (Plaquenil) and Azithromycin in the treatment of COVID-19, there is currently not enough evidence that any governing bodies are recommending these routinely, either for outpatient treatment OR prevention. Unfortunately, because of the hype, it has actually become difficult for patients routinely on Hydroxychloroquine, for things like lupus and other autoimmune disorders, to get their medications. So please keep this in mind when thinking about "prevention," and when stocking up on items that others may need. - For all patients who routinely get seasonal allergies in the spring, this would be a great time to start your preventive measures. Whether that includes natural remedies, flonase, claritin/zyrtec/allegra, etc, getting a head start on symptom control may help to prevent a large number of patients getting allergy symptoms that could be confused with viral symptoms over the next month or so! - As always, things are changing rapidly so we will continue to try to keep you updated in real time. 3/20/2020 - 11:48am EST By: Mark Turshen, MD - The CDC and RI Department of Health continue to recommend all patients with mild symptoms simply stay home and recover. Given the limited tests available, they are prioritizing testing for severely ill and/or high risk patients. Anyone with symptoms should stay home to rest, hydrate, use over the counter remedies for specific symptoms and help to reduce the spread. - For those currently still working outside the home with symptoms, the return to work policy is currently: * at least 72 hours fever free without the use of medications, AND * symptom free from respiratory symptoms, including resolution of cough, AND * at least 7 days since the start of any symptoms - While COVID is greatly affecting our older patients and folks with chronic illnesses, young and healthy patients are also having complications. We implore our younger population to heed the warnings and advice on social distancing. - If you have any N95 masks or other PPE (personal protective equipment), please donate them to the department of health ASAP. - As you've seen the last few days, things are changing rapidly so we will do our best to continue to update you in real time. 3/16/2020 - 9:56am EST By Lauren Hedde, DO Why You and Everyone you know Should Social Distance NOW Two weeks ago I did not know what “social distancing” was. Today I can’t look at facebook or turn on the news without hearing it. Here’s my perspective as a physician on what it is and what to do NOW. Facts we know about COVID-19:
If you social distance, you are:
When you social distance effectively, you slow the spread by asymptomatic viral carries (kids, young healthy adults) to those at higher risk of serious illness. When you prevent those higher risk patients from getting sick, you slow the curve. But what is all this talk about flattening the curve? The graph below says it all. If we can slow the spread, we can slow the pace of folks getting sick (i.e. the blue curve showing the pace of illness spreading with use of protective measures - i.e. social distancing). If we do not listen to our local government and medical community, and we keep sharing space with others, we will spread this much faster (i.e. at the pace it happened in Italy). If we spread this faster, the curve will look like the red one. It will quickly reach a pace where the 10-15% of those who get sick that need hospital and ICU care will overwhelm the amount of beds, intensive care personnel, and ventilators we have in RI and in the US. This is a dire situation - the oldest and sickest will not get the ventilators because they will be rationed to those with the “best chance” of recovery. It will put more strain on doctors, nurses and respiratory therapists, who are at highest risk of illness from exposures. Many of those folks who care for our sickest patients will get sick and be unable to help. The sooner we all realize that the inconveniences of social distancing will prevent a complete overwhelm of our healthcare system, the sooner we can get the curve to start flattening. As you can see here, we’re in the “exponential growth phase.” We are tracking along countries like Italy and South Korea where social distancing was not enacted quickly. If we can change that curve, and enact rapid social distancing, we can have better success as has happened in Japan and Singapore. 3/14/2020 - 3:26pm EST By: Lauren Hedde, DO Blue Cross Blue Shield of RI has temporarily changed their policy so members can refill prescriptions earlier than the standard 30 days. This applies to all medications except a few, such as opioids. For medications that treat chronic conditions, members may have access to a 90-day refill. Upon request, members can obtain a six-month supply of their prescription. 3/12/2020 - 10:34am EST By: Mark Turshen, MD As we have been fielding many questions and visit requests related to concern for coronarvirus (COVID-19), we wanted to reach out with some information for some common concerns. - What does it cause? COVID-19 causes a spectrum of illness from a mildly symptomatic cold to a severe febrile respiratory illness (breathing trouble, high fever). Older patients and those with known medical co-morbidities are considered at higher risk of complex infections (however we don't have enough info to know who exactly those patients are). - What should I do if I know I have been exposed? You should call us (or your own PCP) and let us know and we will contact the DOH and communicate a plan with you. You should stay home. The CDC defines exposure as close contact with someone with a positive test for COVID - "being within approximately 6 feet of a COVID-19 case for a prolonged period of time; this can occur while caring for, living with, visiting or sharing healthcare waiting area or room." - What should I do if I have mild to moderate symptoms of a cold/flu? You should stay home. We are happy to chat remotely with our patients and advise you on symptomatic treatment options but we will not suggest you come in for a visit. The CDC wants patients to stay home (out of work, school, and offices) unless severely ill (see below) to prevent other exposures. We do not have protective masks/gear here because they have sold out and are being kept for the healthcare workers who really need them at the hospitals. If you are not a Direct Doctors patient, contact your PCP for more information. - What should I do if I have severe symptoms (difficulty breathing) of a cold/flu? Obviously call 911 first for emergencies. Otherwise, please reach out to us directly (or your own PCP) and let us know what symptoms you are experiencing. We can help guide you for testing and treatment at a local emergency room where they have the correct triage and protective equipment procedures in place. We will call them first to tell them you are coming if we both agree that is the right step. - Where do I get tested for COVID and do I need testing? At the moment you will only be tested for COVID if you have severe illness OR known exposure to COVID + are now having symptoms. Known exposures can include travel to Japan, Iran, China, South Korea, or Italy within the 2 weeks prior to symptom development. This test is not being done in our office. We will discuss with you where to go if needed. - If I have symptoms, how do I know if they are severe? Please reach out to us first (or your own PCP) so we can help identify via text/email/call if your symptoms are severe or mild/moderate. Severe will include breathing difficulties like shortness of breath. - Should I be afraid of COVID? This is a virus caused by a coronavirus. We have other viruses like the common cold which are the same subtype of virus. Most patients will have a mildly symptomatic cold, which is nothing to be afraid of. However, if you are older and/or have medical conditions, it is probably wise to stay home more than normal, avoid big/crowded events, and continue good hand-washing practices to keep yourself and your family healthy. As always, if you are a Direct Doctors patient we are here to help answer your questions! - Where do I get more info if I want it? We will do our best to update you on any new guidance but we suggest focusing on the CDC and RIDOH websites for your information.  The other night I was chatting with my husband (who is a primary care doc in “the system”) about the differences between what I do and what he does. We realized, the biggest differentiator between how we practice has to do with what incentivizes us. We can all pretend we don’t get swayed by incentives, but if we put that aside - here is the real difference.
At a traditional fee-for-service practice, doctors have to bring you into the office in order to get paid. In other words, if you aren’t seen for a visit, they cannot send a bill to your insurance company, so they cannot bring money into their practice. For example, any portal messages you send are not billable if they spend time responding. Currently, phone calls aren’t able to be billed either. Ultimately, they are incentivized to keep bringing you into the office. Do healthy people want to go to their doctor’s office all the time? Most do not. Not that traditional FFS doctors are trying to keep you unwell, but you can see where the incentive lies in terms of visits. The other night I was chatting with my husband (who is a primary care doc in “the system”) about the differences between what I do and what he does. We realized, the biggest differentiator between how we practice has to do with what incentivizes us. We can all pretend we don’t get swayed by incentives, but if we put that aside - here is the real difference.
At a traditional fee-for-service practice, doctors have to bring you into the office in order to get paid. In other words, if you aren’t seen for a visit, they cannot send a bill to your insurance company, so they cannot bring money into their practice. For example, any portal messages you send are not billable if they spend time responding. Currently, phone calls aren’t able to be billed either. Ultimately, they are incentivized to keep bringing you into the office. Do healthy people want to go to their doctor’s office all the time? Most do not. Not that traditional FFS doctors are trying to keep you unwell, but you can see where the incentive lies in terms of visits. |
AuthorLauren Hedde, DO; James Hedde, DO and Mark Turshen, MD are Family Physicians and Co- Founders of Direct Doctors, Inc. a Direct Primary Care Practice. Archives
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