How Earlier COVID Diagnosis and Treatment Saves Lives

CHRISTIANE AMANPOUR: Now, hovering above all of this, the ongoing COVID pandemic. Here in the U.K., a harsh national lockdown continues amid pressure to perhaps impose stricter new border controls. And in the United States, 25 million cases now have been reported. The vaccines have provided the only light at the end of this tunnel, but supply is now an issue everywhere. Two E.R. doctors on the frontline tell our Hari Sreenivasan more must and can be done to save lives through earlier diagnosis. Dr. Caputo works at the Lincoln Medical Center in New York. And Dr. Richard Levitan at Littleton Regional Hospital in New Hampshire.

HARI SREENIVASAN: Thanks, Christiane. Dr. Caputo, Dr. Levitan, thanks for joining us. Dr. Caputo, I want to start with you. You are in a unique position to be able to work at public hospitals and through kind of private concierge service, break it down for me. I mean, how many of the patients that you are treating in the Bronx have negative outcomes or die versus the patients that you are treating in the concierge medical service?

DR. NICHOLAS CAPUTO, ATTENDING EMERGENCY PHYSICIAN: Right. So, we actually just published a paper in the journal of Internal Medicine on our outcomes for the time period of the pandemic surge. And depending on the co-work you fell into really dictated your risk of poor outcome. Overall, mortality for that six-week time period we covered, which is about 12,000 COVID positive patients was about 30 percent. So, you know, if you got COVID in New York City during the time of the pandemic surge in the public system, the mortality was around 30 percent for the overall population of patients that were admitted to the hospital. Now, these were highly acute, highly ill patients that came in. So, to me, that number is actually quite good. Just when you breakdown the subgroup analysis to that, if you were on renal replacement therapy or you were intubated, your risk of fatal outcome really shot up to above 80 percent, above 90 percent. So, your high-risk of having a poor outcome if you had severe illness on top of COVID as opposed to — at Solace, in the concierge service, it was less than 1 percent. Now, why was this? It really had to do with our ability to deploy things such as fingertip pulse oximetry at home, Telehealth at home, doing daily check-ins with patients. And I’m talking early, I’m not talking this was just initiated like two or three months ago. We really initiated this back in late March, early April and it really was to the credit of our leadership over at Solace. And so, I think those interventions early on really helped us to, you know, find those patients that were at highest risk earlier in their course of the disease which, you know, led to better outcomes.

SREENIVASAN: So, Dr. Levitan, we recently have he the president saying we’re looking at possibly 500,000 people dead by the end of February. Have things changed enough where we can bring the number down by doing things, intervening after people have a diagnosis of COVID but before they get to the hospital?

DR. RICHARD LEVITAN, EMERGENCY PHYSICIAN, LITTLETON REGIONAL HOSPITAL: We have learned incredible amounts of stuff about COVID over the last 10 months. We have learned that the amount of virus you get exposed to can affect your outcome. Obviously, we’re learned that comorbidities, age, diabetes, heart disease, there’s a myriad of things that we know now are associated with worse outcomes. But after 10 months, the fundamental thing we have learned about this disease is that the sooner you come in, the earlier you get diagnosed with COVID pneumonia, the earlier we can detect it and the earlier we initiate supportive care, we can modify disease outcome. So, 10 million Americans over the next few months, 10 million Americans despite the best efforts of Biden administration, which I hope they are very successful of getting out the vaccine out, but 10 million Americans are going to be infected with COVID and they cannot adjust their age, they can’t adjust their viral load, they can’t adjust their diabetes status or their race. And we know that Hispanic and black patients are at greater risk of serious outcome. But the one thing they can do which was shown by Donald Trump, which was shown by Boris Johnson and which, you know, Nick Caputo is speaking to about the Concierge Service is that earlier diagnosis, earlier treatment, supportive care can improve the outcome tremendously.

CAPUTO: Let me just jump in real quick. This is actually — we are starting to see this in the literature. You know, there’s evidence out of Italy as well as the Midwest in the United States where they are showing the patients who were discharged from the emergency department that were COVID positive, that were sent home on a home monitoring program with fingertip pulse oximetry and daily checks, had a lower revisit rate and had lower rates of intubation and poor outcome. So, the evidence is starting to come out. So, you know, it’s nice to be ahead of the game just a little bit but the evidence is starting to catchup with what we’re seeing on the frontlines.

SREENIVASAN: And, Dr. Levitan, the pulse oxis that I see at my local pharmacy, these are maybe $25 or so, maybe $30, maybe less. Is this something that hospitals and the state health agencies should start distributing?

LEVITAN: I absolutely believe so. These oximeters are tiny, they are small. This one is $20 from Walgreens. And what we now know is that they will show lung injury before the patients feel it. So, you know, this past week, I had a handful of patients who were being monitored with these pulse oximeters, and the only reason they came in was because their oxygen fell. One woman who went to bed at night with a normal oxygen woke up and it had gone from 95 percent, 94 percent down to 78. Now, she is morbidly obese, a cancer patient, she has stents and diabetes. She came in with a pulse ox that had dropped overnight significantly. And she was shocked when I told her that her x-rays showed a small pneumonia, the beginnings of COVID pneumonia. And she was surprised when I said, we have to hospitalize you. We can get ahead of this and we can make sure you have a good outcome. And she looked at me and said, but I feel fine, and that is exactly the challenge of COVID. The challenge of COVID is that the patients do not realize they are developing lung injury early on. And when they finally come in, because it is clear they can’t breathe, when we shoot the x-rays of those patients who come in at eight days, 10 days after the diagnosis of a COVID positive test, when they come in, their lungs are severely injured and they have a high-risk of landing on the ventilator and landing in the ICU. And so, just by comparison, this week I had a 29-year-old who fell into the category. She had been diagnosed 10 days earlier, did not get home monitoring and she came in when she was out of breath and had severe lung injury, wound up in the ICU and, you know, wound up on ECMO, which, you know, our last thing we do to try to keep these patients alive, by putting them on a heart/lung machine. So, I believe early treatment results in better outcomes, significantly better outcomes. It is important to note that this is not my idea. You know, this is now adopted universally at the Mayo Clinic. If you are diagnosed with COVID, you are monitored with pulse oximetry. The Mayo Clinic is one of the finest institutions in this country. The best institutions in this country are doing this on all of their patients. Nick can speak to the fact that New York City recently deployed 200,000 of these pulse oximeters. NHS in England also recently deployed 200,000 oximeters to high-risk patients. So, to the Biden administration, over the next two months, you know, great. Let’s get the vaccines going, but let’s help as best we can the people who will get diagnosed with COVID so that have their best chance of survival.

SREENIVASAN: So, Dr. Caputo, what is happening in New York? What are you finding with the deployment of these?

CAPUTO: You know, I think part of the problem was the messaging that we put out. So, you know, basically, what we told people was it, if you have COVID, stay home. But if you get sick, you should go to the hospital. But as Richard was saying, with this disease that causes silent hypoxia, it is difficult to navigate that situation because you don’t know when you are actually going hypoxic, right.

SREENIVASAN: Is that because our bodies are compensating in some way or I mean, am I —

CAPUTO: That’s what we believe. We believe that it is a slow progression to hypoxia. And so, it is not a sudden onset. So, you’re not all of a sudden out of breath. It’s slowly — your o2 levels are slowly dropping over time. And so, you are not really noticing it. And so, that is a major issue right there. You know, one of the spectrums, we’re saying, you have COVID, stay home, isolate, quarantine and one the other end, I’m saying, if you get sick, come to the hospital. Well, as Richard was saying, when people start to feel sick, they’re short of breath, they’re dyspneic, we’re already way behind the eight-ball, because these were the people that were showing up in March, April and May that had, you know, pulse oximetry’s in the 60s, 70s but they were sort of short of breath. At that point, it was — you know, they were on the fence. You know, so what the city basically did, because, you know — and New York City Health and Hospitals treats the population, you know, as truly diverse as the city itself, you know, not all of the patients speak English or have smart phones. And so, we needed a solution that would work for everybody. And you know, the HH Program that was developed, and, you know, I have to give credit because it is due by a good colleague and a friend of mine, Gabe Silvestre, who is an (INAUDIBLE) doc here at New York City Health and Hospitals. It’s a program that does daily checks and provides a pulse oximeter to patients who are diagnosed with COVID and discharged from the hospital to determine the early signs of deterioration, and really give them the means to have a meaningful visit by phone or FaceTime or Zoom or whatever it has to be with an emergency medicine provider to determine the proper course of action. Now, anecdotally, what I have seen is much less severity coming through the doors or the emergency department here at Lincoln and as well as in other emergency departments that I work at, but more of a volume of the COVID positive patients. So, the volume is going up but the severity is coming down and I think that is in part as to what Richard was saying due to what we have learn and how the treat the disease. And really, how to detect it early on. So, again, early detection leads to early treatment, leads to better outcomes.

SREENIVASAN: Dr. Levitan, someone listening to this and say, well, at what cost, right? But I am assuming that even if you paid the retail price for every one of those 200,000 pulse oximeters and you had, I don’t know how many dollars spent on the people that were on the phone, checking up on those patients, that is still less money, I am imagining than what the hospital system is spending per patient when they get in or, of course, the loss of life which is kind of incalculable?

LEVITAN: Absolutely. So, let me just give you a sense of the significance of this in terms of the system impact. Currently in Southern California, as you are well aware, ICUs are overwhelmed. What many people don’t realize about COVID patients who develop what we call the critical illness, ICU level care intubation, ECMO, these patients are in the hospital for not, you know, three days, five days, they’re in the hospital for 2, 3, 4, 5, 6, weeks if they live. We’re talking patients who land in the hospital and they don’t move through the system. Now, the patients who I have seen, and I we’ve had much experience with this now since we started doing pulse oximetry back in early April, the patients that I have seen who come in the moment their oxygen dropped, they’re in and out of the hospital in a floor bed, not an ICU bed, on a floor bed in four to five days, just like our former president. They get some steroids, they get oxygen, they get put on a proning cushion, it’s a way to make them more comfortable so they can breathe. But the things we’re doing, simple early things, have led to them to going in and out of the hospital quickly. And so, you know, even in this past week, I had a dialysis patient, diabetic, getting treated for cancer and he came in with early, you know, oxygen that had just dropped overnight, and he was only 88 percent, but he was high-risk patient. And we gave him Dexamethasone, we gave him Remdesivir, he wound up in the hospital. He was out of the hospital in four days, even though he had every risk factor you can imagine for a bad outcome. So, while there are increases in work that Nick talks about, proving Telehealth, providing, you know, access to these oximeters, getting, you know, the dollars and putting this into place, what we are saving on the backend in terms of patient days in ICU is extraordinary. And every one of those critical illness cases, I mean, just think about this for a moment, every critical illness case of COVID is in excess of $1 million. Easily. It is staggering to think about the resource utilization that is happening because of the delayed care and severe presentation that we could avoid.

SREENIVASAN: So, Dr. Caputo, if the data is coming back from places like Italy, if cities like New York are rolling out this plan, what’s to stop the rest of the country? Why is there still such a gap? I mean, because for me, what’s odd is being a New Yorker, it wasn’t like we didn’t let the world know what we were going through, right? I mean, we — everybody knew what was happening in New York. Yet, here we are 10 months later, and it is happening again in Los Angeles. So, my question is what is it going to take for other hospital systems, other health care systems, insurance companies to try this?

CAPUTO: This is the million-dollar question. You know, I don’t have an answer as to why the response in the rest of the country hasn’t been, you know, more optimal knowing that the lessons of New York were not — you know, they weren’t sealed in a vault, we didn’t work in a silo. You know, I took part in many webinars and WhatsApp groups and Facebook groups just imparting information on what we were seeing in the frontlines during the surge, during the pandemic, what was working, what wasn’t working. Now, I do have to say on the other end of that is that the mortality rate is not like what it was in March, April and May. So, obviously, people were listening, those interventions that Rich was talking about are being applied. And so, though the volume is up ticking, the mortality is not. And so, you know, that gives me comfort that, you know, the lessons of New York and the tragedy that happened in March, April and May, the really tough lessons were taken to heart in terms of individual patient outcome, but the overall lessons in terms of preparation and prevention seems like, I don’t know if they were glossed over or, you know, there were other bureaucratic issues involved that prevented optimal logistical preparation for it, but it’s a hard question to answer.

LEVITAN: Let me just give you my two cents on this. This past week, when I had this critically ill person who was not given monitoring, who was not given a pulse oximeter and who came in 10 days later, I actually reached out to the testing center where she had her COVID test. And I asked them, I said, why don’t you guys do the pulse oximetry monitoring. And the person who was familiar with her care, who was familiar with me said to me, I’ve been reading your stuff, Rich, but the CDC does not recommend it yet. There’s no recommendation from the CDC on this. So, we don’t do it. I think, you know, Biden administration is looking at what it can do to prevent deaths over the next few months and obviously as fast as they can deliver the vaccine, let’s do it. But for the 10 million Americans facing down a COVID diagnosis over the next few months, for the 100 to maybe 200,000 who may die, this is short-term reduction in resource utilization, but also improvement of the patient outcome. And the one thing that I think can make the most traction to reduce mortality in the short-term.

SREENIVASAN: All right. Dr. Richard Levitan and Dr. Nicholas Caputo, thank you both.

CAPUTO: Thank you.