Short Takes on Social Distancing and Diagnostic Testing

Lapsed social distancing. Mobile phone telemetry shows that Americans are starting to move around more. That’s especially true in the southeast and central areas of the country.

A month ago, communiqués from US government and media stressed the importance of sheltering at home during the first two weeks of April, identified as the turning point in the pandemic. That sort of crisis rhetoric likely mislead large swaths of the public into believing that, if they made it past the peak unscathed, they’d be relatively safe going forward — like making it through a hurricane. That’s not the case. The hope at the time was that the extended regime of commercial shutdown and social distancing would finally begin to pay dividends in the form of a marked downward trend in new infections, leading toward an end of the first wave by the end of April. That hasn’t happened: US covid infection rates — and deaths — have plateaued, but have not yet shown a marked and persistent downward trend.

Three times over the past week the IHCE has increased its body count projections. No doubt increased public mobility will accelerate as businesses start reopening. It’s likely that infection rates will go up as well.

Diagnostic testing protocols seem inappropriate. Who should get tested? Here’s what the CDC has to say:

Most people have mild illness and can recover at home without medical care. They may not need to be tested. At this time, there is no treatment specifically approved for people who have COVID-19.

It usually takes a few days to get the test results back from the lab. Surely doctors aren’t waiting that long to treat a patient who’s already very ill. Since there are no covid-specific treatments to offer, test results won’t alter the course of medical care, which must focus on alleviating symptoms rather than curing the disease. Most people who meet the criteria for testing have already been running a fever, coughing, feeling short of breath and achy — too sick to get out of the chair, let alone get out of the house infecting others.

Why then test at such an advanced stage of disease progression, if making the differential diagnosis has no impact on medical treatment or disease transmission?

 

7 thoughts on “Short Takes on Social Distancing and Diagnostic Testing

  1. Well, there is the benefit of knowing the numbers when the cases are counted given that health care is not only about individual patients but also about the population. So while knowing the Covid-19 status of an individual won’t affect the treatment (yet), it will help caregivers to know the disease status so that data can be collected about symptoms, treatments and outcomes, as well as just knowing how many people have the illness. Right? So while I agree that the tests might be might be used more effectively to inform quarantine and tracking in order to prevent spread of the illness, it is useful to have diagnostic info on those hospitalized to learn more about treatment as well as to count for spread.

    Liked by 1 person

  2. Good point, A, and hopefully the data are being analyzed toward those ends. E.g., of people with confirmed covid dx, how do specific symptoms and their severity predict outcome? Hopefully also the docs are keeping track of outcomes other than just death: full recovery, permanently compromised lung function, new heart disease, etc. There’s been a shift in ventilator deployment, away from intubation and toward masks, presumably because the intubated patients were dying at a higher rate. Hopefully that conclusion was based on data analyses like you’ve suggested here, rather than just clinical impressions shared within the medical profession. So too with Trump’s favorite treatment, chloroquine, deemed based on data not just ineffective but downright harmful. This virus is going to be around for a while, so doing these clinical outcome studies should prove valuable.

    So these would be good uses of testing data that’s already being collected in the course of clinical treatment. But testing capacity is limited, and I continue to wonder whether the existing capacity shouldn’t be redeployed for identifying people with less severe symptoms who are out there roaming the world as active vectors of contagion. Already there have been more than a million test-positive cases and nearly 60 thousand deaths in the US: that should be more than enough data to run the sorts of analyses you’re talking about. Systematic targeted studies could be conducted using small fractions of those numbers, while also ensuring tighter experimental control over key variables.

    Say, didn’t you used to do clinical outcomes studies in the real world, A?

    Liked by 1 person

  3. By golly, J, you’re right. I did. I thought this all sounded awfully familiar. Ah, you and I could reminisce over the good old days…but let’s save that for another time. At this moment we both know it has been shown over the decades that the population/epidemiological perspective you discuss has been difficult for governmental leadership to embrace with dollars and support. Mostly in times of crisis do they even pay attention. Sad, isn’t it? But as I recall, outcomes work suffered (nay, suffers) similar inattention.

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  4. Yup, we were repeatedly dismayed by how little systematic effort had been put into evaluating treatments that had been deemed standard care for decades. Covid treatment is so urgent that systematic study might be falling by the wayside, which would be understandable. But surely in these dire circumstances there’s some money that can be set aside for clinical researchers to do their thing, benefiting the next waves of patients who are bound to come through.

    Evidence-based best practice sometimes gets a bad name, implying that people abandon their good judgment in blindly following the rules dictated to them by management. But it always seemed that validating standard care would serve as a baseline for exploring more innovative approaches, for pushing the margins of what’s possible.

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  5. What’s few $mil for clinical research in the face of a pandemic? Seems like a good deal to me. Data. Data. Data. Testing. Testing. Testing. Research. Research. Research. These would help so much!

    Liked by 1 person

  6. And no sooner than we wrote the words that a news story reports of the issues of trying to use clinical data to glean any information about managing Covid-19: https://khn.org/news/as-coronavirus-strikes-crucial-data-in-electronic-health-records-hard-to-harvest/?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=87207062&_hsenc=p2ANqtz–4Q5vaDnXgr4lABk40KYBZNjur2esgoy2iPkXcoHYd0_TWXJTfbXiC-zeMv2QQ8-KoKeuHegbDZHhqBGkCZvRkCTL6cA&_hsmi=87207062.

    Some of the quotes suggest that not much has happened in the 20-30 years since we were last immersed in the mire…
    “I’m stunned at EHR vendors’ inability to consistently pull data from their systems,”
    “This was a boondoggle from the get-go, and the promoters knew it at the time,”
    “If we had a national database, we’d get a readout quickly about responses to [COVID-19] treatments,”
    ‘Medical data has been hard to tease out because much of it resides in electronic “silos,” which government officials have not required technology companies to open up and eliminate.’
    ‘Officials said they are sometimes required to manually fill out and fax some forms, wasting valuable time. Some information must be printed out from EHRs and reentered by public health authorities because it cannot be sent electronically.’
    “COVID has demonstrated for people what we’ve known all along. You can’t leave public health at the end of the line.”

    The more things change, the more things stay the same–I recall these EXACT statements about electronic records in the 1980s and 1990s. And that last quote? Well, we just reminisced about that one yesterday. Sigh. Sigh. Sigh.

    Liked by 1 person

  7. Dreadful but not surprising. Also from your linked article:

    ‘commercial players produced ― and hospitals bought — systems that have proved more suited to billing than public health.’
    That figures.

    the industry has battled regulators seeking to adopt common standards, a practice known as interoperability. That failure to mine these oceans of invaluable data reflects the power of the vendors to prevent government requirements for data standards and interoperability’
    Proprietary systems to maximize ROI — that also figures.

    ‘”“If this were to have happened three or four years in the future when we have interoperability … we would be in a much better spot here. But unfortunately, that’s not quite the case, but we’re still keeping our work going,” Donald Rucker, national coordinator for health information technology, said’
    As you observed, that very quote could have been uttered a quarter century ago.

    Like

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