Monday, June 29, 2020

The impact of COVID-19 on childhood immunizations

- Natasha Pyzocha, DO

During COVID-19, routine preventive and non-emergency care has been a secondary priority in the minds of patients and physicians. With everyone being told to shelter-in-place, stay at home, and limit movement to essential activities, it is understandable that many parents delayed routine childhood immunizations due to possibly contracting COVID-19 at the doctor’s office. Luckily most COVID-19 cases in children have been mild, although reports of multisystem inflammatory syndrome may have scared parents to further delay well-child visits.

In May 2020, the Centers for Disease Control and Prevention (CDC) reported significant and concerning nationwide decreases in routine childhood vaccine ordering and administration due to COVID-19 in the United States. When comparing January to April of 2020 to 2019, childhood vaccines declined beginning the week after the national emergency declaration. Children younger than 24 months were less affected by missing immunizations than older children. From mid-March to mid-April 2020 in the U.S., there were 2.5 million fewer doses of routine non-influenza vaccinations ordered and 250,000 fewer doses of measles containing vaccines ordered when compared to 2019. This decrease in MMR administration in school-aged children is concerning. Internationally, the World Health Organization estimates that more than 100 million children could be currently vulnerable to measles.

A decline in vaccinations affects herd immunity and could spur outbreaks of other diseases, that, combined with COVID-19, would overwhelm healthcare systems. The CDC, American Academy of Family Physicians (AAFP), and American Academy of Pediatrics continue to recommend providing essential health services, including immunizations, during the COVID-19 pandemic. Normalizing and confirming the safety of vaccine administration is crucial given that a COVID-19 vaccine may be available soon and for the upcoming influenza season.

I have talked to many parents of healthy and sick children since the pandemic started. Many are scared of their child becoming sick from COVID-19 and think that the best way to protect them is to keep them at home. Parents have delayed treatment of serious etiologies because they are worried about disease transmission. Putting healthy children at risk for COVID-19 for the purpose of immunizations doesn’t seem intuitive to many parents, so education remains vital. If your practice doesn’t have a good system in place for immunization reminders, this is a great time to make this a primary focus.

Contact families whose children have missed vaccinations and encourage them to bring their child in for immunizations. Have patience and provide education as needed. Evidence has shown that community discussions, community meetings, and information campaigns may increase immunization uptake, so consider hosting a virtual forum for your patients. The AAFP has immunization resources, COVID-19 guidance for family physicians on preventive and non-urgent care during the pandemic, and a variety of practice tools that give advice on opening guidelines, expanding operations, and more. Proactively reassure patients of the steps your office has taken to maximize safety.

Continue to think outside of the box and share procedures you have developed to make childhood immunizations safe and convenient for patients. Have you continued seeing children up to age 24 months for an exam and immunizations? Did you implement virtual care visits for children older than 24 months and have them come in for parking lot vaccinations? Are you increasing the testing of your clinical staff to ensure they are not unknowingly spreading COVID-19? Many physicians are offering house calls to boost vaccinations or making these parking lot visits a reality. It is important to remain flexible and advocate for patients in a system where legislative or insurance rules can make navigation frustrating. Pioneering drive-through immunization clinics or having a drone deliver and administer a vaccine may seem like futuristic ideas, but may be increasingly feasible in this era of enhanced disease prevention precautions.


Dr. Pyzocha is one of AFP's 2020-21 Jay Siwek Medical Editing Fellows.

Monday, June 22, 2020

Guest Post: Advance Family Medicine with Practice-Based Research

- Jen Carroll, Director AAFP National Research Network and Christina Hester, Research Director AAFP National Research Network
The program name is lengthy: the Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation Initiative, also known as FMD RapSDI. The program goal is concise: Help family physicians research and scale great ideas, quickly.

“This is a groundbreaking opportunity for family physicians on Main Street to explore the phenomenal ideas they have that will bring about change,” says Richard Smith Jr., an AAFP Foundation Board of Trustee and co-chair of the FMD RapSDI Work Group. “The healthcare system is fraught with barriers to innovation. This approach helps mitigate that.”

As a collaboration between the AAFP Foundation and the AAFP National Research Network, FMD RapSDI is open to family physicians whether they have research backgrounds or not. By providing the infrastructure and resources needed, the FMD RapSDI awards empower the physicians to explore small projects that can yield results in a 12-month timeframe.

What does Family Medicine Discovers offer to scholars?
Selected scholars are awarded a monetary grant to cover costs associated with completing their research projects and/or to offset a portion of the scholar’s salary (up to 20% FTE) to develop and complete a project in 12 months. The AAFP National Research Network will provide scholars with research infrastructure to empower scholars to successfully develop and implement their research projects and to stimulate their professional development. FMD RapSDI Scholars will begin projects on June 1, 2021.
In its inaugural year, Family Medicine Discovers received 45 research proposals from 40 different physicians and ultimately, two projects were awarded. The scholars selected for the inaugural program and their topics are:

Dr. Vijay Singh, a clinical assistant professor at the University of Michigan Medical School in Ann Arbor, will use evidence-based family medicine interventions, proven successful with adolescents, to help identify men with anger issues and provide relevant services. “I was interested in applying to be a FMD RapSDI scholar to access program resources to complete a research project, with salary support and dedicated time to adapt an evidence-based male intimate partner violence intervention to the needs of family medicine patients and providers," said Dr. Singh.

Dr. Lauren Ciszak, a family physician with the South End Community Health Center in Boston, will research the impact of providing meal kits and nutritional education to patients with chronic diseases, rather than ready to heat/eat meals, the standard approach.m“I hope we get strong enough evidence to convince insurance companies to cover this,” said Dr. Ciszak. “If this was covered, it could open so many doors for us and help our patients live better.”

This investment in building a robust family medicine research infrastructure will advance knowledge and discovery in our specialty; it will also prepare our specialty for the transformation needed to deliver upon the Quadruple Aim. FMD RapSDI has exceptional potential to advance new evidence and knowledge while fostering a culture shift of what it means to participate in family medicine research.

Do you have a patient care-inspired question, clinical problem, or clinical conundrum you'd like to investigate? Apply to be an FMD RapSDI Scholar! The application period for FMD RapSDI will open July 1st, 2020 and run through August 23rd, 2020. During the open period, the application portal will be accessible here.
Please spread the word about this program, and/or consider applying yourself!
For more information, please visit the FMD RapSDI website or contact us at

Tuesday, June 16, 2020

Using artificial intelligence in primary care: progress and challenges

- Kenny Lin, MD, MPH

As applications of artificial intelligence (AI) in health care multiply, AI-enabled clinical decision support is coming to primary care. For example, a recent article in the Journal of Family Practice discussed applications of machine learning (ML) software to screening for diabetic retinopathy (DR) and colorectal cancer, and a study in the Journal of the American Board of Family Medicine utilized ML to create a new clinical prediction tool for unhealthy drinking in adults. Although research on primary care AI remains limited in scope and diversity of authorship, Drs. Winston Liaw and Ioannis Kakadiaris argued in a Family Medicine commentary that appropriately guided, such research could help preserve the parts of primary care that physicians and patients value most:

The digital future is not a passing trend. We will not return to paper charts. The volume of information we are expected to manage will not decline. Without a strategy for our digital present and future, our specialty risks being paralyzed by data, overwhelmed by measures, and more burned out than we already are.

We can define our future, by embracing AI and using it to preserve our most precious resource—time with patients. Adaptation to this new reality is key for our continued evolution, and AI has the potential to make us better family physicians. ... For AI to elevate the practice of family medicine, family medicine needs to participate in relevant design, policy, payment, research, and delivery decisions.

Evaluation and implementation of AI-based clinical approaches is challenging. In addition to being externally validated and corrected for biases, ML models should be transparent about data sources and assumptions and quantify and communicate uncertainty. In addition, involvement of clinicians in model building and adoption into clinical decision support systems is essential.

In the Diagnostic Tests feature in the March 1 issue of AFP, Dr. Margot Savoy reviewed an application that seemingly adheres to all of the best practices for AI in primary care. IDx-DR, a software program that uses AI to analyze retinal images from an automated nonmydriatic camera, is approved by the U.S. Food and Drug Administration for DR screening in adults 22 years and older. In a prospective study of 819 adults with diabetes recruited from 10 primary care practices, IDx-DR correctly identified 173 of the 198 patients with more than minimal DR according to the reference standard.

In a separate project, Google Health researchers evaluated the implementation of a deep learning algorithm for DR detection in 11 clinics in Thailand, a country with low screening and early treatment rates due to a shortage of ophthalmologists. Unexpected issues arose, according to an article in the MIT Technology Review:

When it worked well, the AI did speed things up. But it sometimes failed to give a result at all. Like most image recognition systems, the deep-learning model had been trained on high-quality scans; to ensure accuracy, it was designed to reject images that fell below a certain threshold of quality. With nurses scanning dozens of patients an hour and often taking the photos in poor lighting conditions, more than a fifth of the images were rejected.

Patients whose images were kicked out of the system were told they would have to visit a specialist at another clinic on another day. If they found it hard to take time off work or did not have a car, this was obviously inconvenient. Nurses felt frustrated, especially when they believed the rejected scans showed no signs of disease and the follow-up appointments were unnecessary.

Like all primary care tools, the way that AI-enabled decision support is implemented in real life will contribute as much to its success or failure as test results under optimal conditions.

Monday, June 8, 2020

Week in review: unethical research, hydroxychloroquine RCT, & structural racism

- Jennifer Middleton, MD, MPH

Hydroxychloroquine remains in the news. The Lancet retracted the study I wrote about 2 weeks ago, a large, multinational review of hydroxychloroquine's effectiveness for COVID-19, due to serious concerns about data integrity. After the study's publication, Australian journalists noticed that the study's Australian mortality data did not align with Johns Hopkins University data collected during the same period.  The study data was collected by a company called Surgisphere, and further journalistic digging revealed that "several of Surgisphere’s employees have little or no data or scientific background:"
“Surgisphere came out of nowhere to conduct perhaps the most influential global study in this pandemic in the matter of a few weeks....It doesn’t make sense...It would require many more researchers than it claims to have for this expedient and [size] of multinational study to be possible.” 
Some of the study authors then requested that Surgisphere submit its data to independent peer reviewers. When Surgisphere reportedly refused to do so, they requested retraction of the study. It's disheartening at any time to uncover unethical research practices only after publication, let alone during a global pandemic, when clinicians and patients are desperate for data to guide decisions.

Meanwhile, a more reputable RCT in the United Kingdom (the RECOVERY trialhalted its hydroxychloroquine arm this past week. In just the last 3 months, researchers have enrolled over 11,000 patients in the UK into this trial, which also includes lopinavir-ritonavir, dexamethasone, azithromycin, tocilizumab, convalescent plasma, and "usual care" arms. The study's independent data review monitoring committee notified the researchers that there was no difference in 28-day mortality rates between participants taking hydroxychloroquine and participants receiving usual care (25.7% hydroxychloroquine vs. 23.5% usual care; hazard ratio 1.11 [95% confidence interval 0.98-1.26]), leading the research team to discontinue randomizing patients to receive hydroxychloroquine. It seems far less likely that peer review will uncover any scruples with this rigorously conducted trial, and perhaps the question of hydroxychloroquine's benefit will finally be put to rest despite the Surgisphere fiasco.

A final word for this week: The American Academy of Family Physicians released a statement this week strongly condemning racism. As family physicians, we see daily that structural racism continues to result in profound health inequities in the US, and thousands of physicians across the US participated in White Coats for Black Lives rallies this past week. If you're looking for steps to take toward dismantling this legacy, you can find data about cultural competence training in this AFP Cochrane for Clinicians article, learn about implicit bias in this FPM article, and take practical steps toward "Achieving a More Minority-Friendly Office" here. #BlackLivesMatter.

Monday, June 1, 2020

Facing COVID-19 in the long run: a resident's view

- Enkhee Tuvshintogs, MD, AFP Resident Representative

“The county has been cleared to open up restaurants and stores this week.”

We are three months into adjusting to life with COVID-19. Our day-to-day routine for the foreseeable future has drastically changed. As much as I held out hope, like everyone else, for a return to normalcy, I have accepted that the virus will be a part of life, as ubiquitous as the flu but more deadly. We will continue to take extra precautions to protect our families and work in clinics and hospitals to keep COVID-19 at bay.

I don’t deny sometimes feeling apathetic, but just when I do, I hear cases like this: “A friend came to visit me; we hung at my house, and a week later I received a phone call that I really didn’t want to get. My friend tested positive. I am here to get tested because I am concerned I was exposed. I have no symptoms. What should I do? Should I tell others I might have it? Should I tell them to get tested too? How long should I wait?”

Variations of this conversation occur again and again as counties and states open up. Patients come to us after isolating for months at home, only to be exposed by a single visit. I understand the angst, loneliness, and frustration that they overcame to reach this point. Their adherence to “stay-at-home orders” was evident in the slowed rate of rise of COVID-19 across the country.

By staying at home and taking precautions, people gave businesses and health systems time to better prepare and restructure operations to limit in-person contact. Now, as more places open up and people come into contact, questions and concerns regarding cases of COVID-19 and non-COVID-19 related medical issues will rise. I see people trying their best to balance their mental health needs with the reality of the risks of COVID-19. Most keep their masks on. When people meet, they stay outdoors and try to keep away from enclosed spaces.

How can we manage the built-up demand for health care while the threat of COVID-19 still stalks clinics and hospitals? Telemedicine will likely be at the forefront. At our residency clinic, video visits outnumber in-person visits now. Other clinics, like the one where Dr. Erika Roshanravan works, have added telephone visits. “People love it! It makes sense. It is more convenient for people. There are still visits that we have to do in-person” but there are now more options and avenues for patients to reach us, she says.

As the weather warms, we will all be called outdoors to barbeque pits, lush grass fields, glistening waters, and a longing to feel “normal” again. I want people to enjoy themselves, but I also want everyone to stay safe. When you need care, whether for a routine medical problem or COVID-19 related concern, I will still be here: ready with my face shield, mask, gown and gloves to help and serve you. I can’t promise that we have all the answers yet, but we will try our best. As we move forward into in a brave new COVID world, I hope that my friends, family, and neighbors will continue to act in ways that do not increase the risks to the most vulnerable among us. As Dr. Roshanravan says, “this is not a sprint, it’s a marathon.”