How eConsults Are Helping PCPs Keep Pace with COVID-19

RubiconMD received its first COVID-19-related online consultation on January 27, 2020 from a primary care clinician concerned that a 42-year-old female with persistent fever and cough may have the virus. Since then, RubiconMD has been supporting PCPs at the forefront of the pandemic as they were trying to make sense of the rapidly changing information and guidelines by the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and other leading research and clinical care organizations. 

Throughout the pandemic, PCPs have been turning to RubiconMD specialists for their expertise, including infectious disease specialists, pulmonologists, and other specialists from top medical centers in the US, many of whom were overseeing Remdesivir trials at their institutions. Specialists were able to help PCPs reconcile the overwhelming amount of information from the latest experimental studies, case reports, media outlets, and various clinical guidelines, and combine this knowledge with their own clinical experience on the field. This feature highlights the learnings derived from eConsults that have supported our clinician community since January – including PPE shortages, testing protocols, decontamination guidance, medication indications, complications, and more.

At the beginning of the pandemic, most eConsults revolved around the diagnosis of COVID-19 infection due to the lack of information surrounding symptoms.  Soon after, many primary care organizations began to experience capacity and inventory constraints leading PCPs to inquire about personal protective equipment (PPE) use and COVID-19 testing.  

Meanwhile, various reports and studies began to create confusion around indications of medications, including Chloroquine in the prevention and treatment of COVID-19, while commonly used drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), were presented as playing a role in COVID-19 symptoms. These trends were reflected in the types of questions PCPs were submitting.  

The range of possible COVID-19 symptoms gradually increased over time and PCPs started to turn to RubiconMD dermatologists, cardiologists, hematologists, etc., to get the latest expert opinions on the extrapulmonary manifestations of the virus that they started to note in their patients.  As PCPs’ understanding of the presenting symptoms of COVID-19 has increased, their confusion about testing has also grown and RubiconMD specialists were able to share their knowledge on results based on specific patient presentations.  Finally, specialists are progressively learning about the long-term sequelae of COVID-19 in their specialty practices and are sharing this knowledge with PCPs to empower them in the care of their patients.

We reviewed COVID-19 related eConsults submitted on the RubiconMD platform between January and August 2020 and found some insightful trends below.

PPE shortages

• The CDC guidance (Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Patients Under Investigation for 2019-nCoV in Healthcare Settings) was recommending N95 masks for health care professionals until March 2020 when it updated the recommendations to prioritizing N95 masks for aerosol-generating procedures. Until then, PCPs who were facing shortages of N95 masks and other PPE in their facilities had difficulty reconciling the difference between what PPE was recommended and what equipment they had access to which led to confusion and anxiety.
• PCPs and clinic medical directors leveraged eConsults to get recommendations from infectious disease specialists on PPE alternatives. Infectious disease and pulmonology specialists were able to share the protocols used in their own facilities that were also facing PPE shortages.

Decontamination guidance

• The CDC website was providing guidance in April 2020 on decontamination of the filtering facepiece respirators (FFRs) that are found in respirators such as N95, with recommendations for a number of decontamination methods based on minimal concrete evidence. PCPs and clinic medical directors wanted more clarity on the most appropriate decontamination method in light of respirator shortages.
• Specialists were able to share the decontamination approaches in their practices and provide advice and support adapted to what was available for PCPs.

Extra-pulmonary manifestations

• In March 2020, case reports and anecdotal evidence began to emerge around extra-pulmonary manifestations of COVID-19. The CDC website and other clinical resources were updated months later to include these extrapulmonary symptoms in their diagnostic criteria.
• Starting in April 2020, PCPs began to submit questions about patients presenting with unusual symptoms such as urticaria and other rashes. Specialists were sharing that they started to hear about extra-pulmonary symptoms of COVID-19 infection in their clinical settings and from their colleagues. Over the next few months, cases were submitted about patients with other extrapulmonary symptoms including conjunctivitis, agnosia, anosmia, etc., and PCPs were able to receive guidance from specialists who were sharing the latest evidence on COVID-19 manifestations. Such guidance was especially helpful in the beginning of the pandemic to help diagnose COVID-19 on clinical grounds when the testing was lacking. A PCP submitted an eConsult on that topic for a 30-year-old female with a 2-week history of rash on her upper and lower extremities and suspected COVID-19 infection a month before the rash began. The PCP was interested in getting a dermatologist’s opinion about whether this rash was related to COVID-19 or something else.

Medication indications

Chloroquine, Hydroxychloroquine, and Azithromycin

• The recommendations from the CDC and other clinical resources on chloroquine and hydroxychloroquine in March through April 2020, were unclear due to poorly designed trials and did not provide direct recommendations to clinicians. Similarly, Azithromycin was also being investigated and presented without clear guidance. Chloroquine has received even more attention after the Trump Administration called it “a game changer” and the FDA issued an emergency use authorization for Chloroquine and Hydroxychloroquine to be used to treat patients hospitalized with COVID-19 before the federal COVID-19 Treatment Guidelines Panel issued recommendations against the use of these drugs to treat COVID-19.
• Starting in early March 2020, PCPs began to submit questions around indications for Chloroquine/Hydroxychloroquine and/or Azithromycin for their patients with COVID-19 and specialists were able to share their perspective and recommendations based on the quality and amount of evidence.

NSAIDs, ACE inhibitors, and ARBs

• In March 2020, a letter in The Lancet medical journal claimed that some commonly used medications including NSAIDs, ACE inhibitors, and ARBs, could aggravate COVID-19 symptoms. Later in May 2020, claims began to surface that these medications are actually protective against severe COVID-19.
• Following that letter, PCPs began to submit questions about the risks, and later on benefits, of NSAIDs, ACE inhibitors, ARBs, in their patients. Specialists were able to share their thoughts on the lack of available evidence behind the claims that were being made in the media. For example, a PCP submitted an eConsult for an 80-year-old female patient taking these 3 medications and wanted to know what the current recommendations for these patients in the setting are of COVID-19 given the amount of conflicting information.

Prednisone

• Reports started to come out in June 2020 about the benefits of corticosteroids in patients with COVID-19. However, these results were restricted to a specific patient population and were not relevant for most of the patients seen in the primary care setting.
• Early on, numerous questions were submitted by PCPs asking whether steroids should be discontinued in patients with asthma/chronic obstructive pulmonary disease, autoimmune disorders, etc., to decrease their risk of COVID-19 infection. However, starting in June 2020, PCPs began to submit questions around starting their patients on steroids. Specialists were able to explain the results of the study that showed benefits for a specific patient population (hospitalized, on supplemental oxygen) and whose characteristics were not applicable to most patients concerned in the eConsults.

Testing for COVID-19 infection

• The CDC was recommending a symptom-based and a test-based strategy to determine when an individual with a COVID-19 infection is no longer infectious until removing the test-based approach in July 2020.
• PCPs were submitting cases for patients who met CDC’s symptom-based strategy to discontinue isolation but who also continued to test positive for COVID-19. That led to PCPs’ confusion and diverse interpretation by patients and their employers. RubiconMD specialists noted the inefficiency of the test-based strategy months before the CDC discontinued its recommendation and were able to clarify further follow-up with PCPs in ambiguous cases.

Long-term complications

Recovery, and respiratory and neurological sequelae

• Early studies have suggested that recovery time from COVID-19 infection ranges between 2 to 6 weeks. However, data started to emerge in June 2020 about ongoing longer-term complications.
• As PCPs started to see patients in April 2020 with long-term sequelae including fatigue, respiratory impairment, and neurological complications, they began to submit questions about the association of these symptoms with COVID-19 due to the lack of available clear information. Specialists were able to share insights based on preliminary data and their experience in the field to support PCPs in their workup and management decisions.

Hypercoagulability

• Once hypercoagulability became a known complication of COVID-19 in April 2020, decision support tools such as Up To Date began to publish recommendations on venous thromboembolism (VTE) prophylaxis. However, these tools were not able to provide clear recommendations around indications, dosing and duration of anticoagulation therapy due to lack of available data. These recommendations were also not tailored to specific patient presentations.
• PCPs have been submitting questions about dosing and duration of VTE prophylaxis in patients who were discharged from the hospital post COVID-19 infection and some of their outpatients. RubiconMD hematologists were able to share advice on anticoagulation based on specific patient cases and context.

Myocarditis

• Evidence that COVID-19 may lead to myocardial injury began to appear in late April/early May 2020. However, there was a lack of clear guidance from the American College of Cardiology (ACC) to risk stratify competitive athletes as children and adolescents began to prepare to return to school and participate in high intensity sport activities.
• PCPs were asking about testing recommendations for pediatric patients that were preparing to return to high intensity sports. RubiconMD cardiologists were able to address the latest available evidence to provide tailored recommendations around tests and possible risks for these patients and support PCPs in their decision-making process. For example, a RubiconMD pediatric cardiologist received an eConsult from a PCP about a 14-year-old boy who has fully recovered from COVID-19 infection and was preparing to return to his quarterback position on his high-school football team. The specialist was able to help the PCP reconcile the various guidelines and reports, and share advice on a step-by-step plan for the patient based on available evidence.

As PCPs are constantly learning about the complexities of COVID-19 infection, the RubiconMD eConsult platform continues to be a tool that helps them navigate the challenges in managing patients affected by COVID-19. If you are interested in learning more about eConsults and how they can best support you, please reach out to us.

References

1. https://www.cdc.gov/coronavirus/2019-ncov/communication/guidance list.html?Sort=Date%3A%3Adesc&Page=9
2. https://www.cdc.gov/coronavirus/2019-ncov/whats-new-all.html
3. https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html
4. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html
5. https://www.covid19treatmentguidelines.nih.gov/antiviral-therapy/chloroquine-or-hydroxychloroquine-with-or-without-azithromycin/
6. https://www.aappublications.org/news/2020/03/11/coronavirus031120
7. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html
8. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/archived-decontamination-reuse-respirators.html
9. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
10. https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/
11. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
12. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19