publication date: May. 8, 2020

Conversation with The Cancer Letter

Lessons from COVID-19:

Leaders of six cancer centers in the DMV area tell us about caseloads, the outlook—and impact

 William-Nelson-1-900x600

William G. Nelson, MD, PhD

Director, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins;

Professor of Oncology

Mitchell Smith

Mitchell R. Smith, MD, PhD

Associate center director, clinical investigations,

Director, Division of Hematology and Oncology,

George Washington University Cancer Center

110317-GU

Louis M. Weiner, MD

Director, Georgetown Lombardi Comprehensive Cancer Center;

Director, MedStar Georgetown Cancer Institute;

Chair, Department of Oncology,

Georgetown University School of Medicine

Robert Winn 3

Robert A. Winn, MD

Director, Virginia Commonwealth University Massey Cancer Center;

Professor, Division of Pulmonary Disease and Critical Care Medicine

Michael E. Williams

Michael E. Williams, MD, ScM

Byrd S. Leavell Professor of Medicine, Chief, Division of Hematology and Oncology,

Physician lead, Cancer Service Line,

Associate director, clinical affairs,

University of Virginia Cancer Center

John Deeken

John F. Deeken, MD

President, Inova Schar Cancer Institute;

Medical director, Inova Schar Head and Neck Cancer Programv

 

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

As the District of Columbia, Maryland, and Virginia prepare to loosen pandemic restrictions and reopen economies, hospital networks and academic cancer centers brace for a potential uptick in SARS-CoV-2 infections.

While the region has avoided a cataclysmic surge of confirmed cases and deaths, because of social distancing measures, overall, the epidemic curve has neither plateaued nor taken a downward trend.

In six interviews, leaders of major cancer centers in the DMV describe cost-saving measures at their institutions, what it will take to manage the pandemic in the coming months, and how they are ramping up their clinical and research enterprises.

 

Matthew Ong, associate editor of The Cancer Letter, asked all six experts the same 14 questions.

 

Matthew Ong:

If I called you three years from now, which aspect of the COVID-19 pandemic would you say left the most lasting impression?

Nelson, Hopkins:

The medical response to the deluge of COVID-19 cases presenting for healthcare has been astonishing.

Of course, at hospitals throughout the country, specialized acute care and intensive care units have been created to serve the needs of COVID-19 patients while protecting medical care teams and other hospitalized patients against SARS-CoV-2 transmission.

This was just the beginning. For cancer care, tactics like telemedicine, pre-visit phone calls, drive-thru injection clinics, home care, and many other approaches have been rapidly deployed, and progressively perfected.

The patient response has been overwhelmingly positive. Three years from now, we will still be using many of these approaches to make cancer care, and cancer clinical trials participation, more accessible and convenient, decreasing the time spent in waiting rooms and increasing the time spent at home with loved ones.

Smith, GW:

We don’t know where we’re going to be. If it’s totally gone in three years and it was a blip in the past, we’re going to have one story. But if this was lingering, as it might, as a new disease that’s in the system and that has changed the way we live, I think then the answer’s going to be a little bit different.

I think the lesson will be adaptability, that people have been incredibly adaptable in the face of this challenge. Sometimes with the help of systems, but often having to fight entrenched systems, but people are adaptable and make things work to take care of patients. It’s quite remarkable.

Weiner, Georgetown:

First, we have learned how quickly we can act when it is necessary. I suspect that regulations regarding clinical trials, for example, may change. I also think that all manner of meetings will be conducted in the zoomiverse, or whatever replaces that technology.

Winn, VCU:

I think the most lasting impression from the COVID-19 crisis will be the astounding acts of courage and self sacrifice shown by the medical community, the grocery workers, the postal workers, and our urban underserved, rural, suburban communities throughout Virginia.

It was really impressive how our communities came together to consistently do the right thing, for example adhering to the social distancing as best they could. That’s what I’ll remember most.

Williams, UVA:

As a leader of cancer services and programs at UVA, the thing that impressed me the most has been the collaboration and coordination across the health system, which in turn reaches well into the university itself.

As with all academic centers, we’ve had to do a great deal of preparation for what was going to be an unknown number of COVID patients and what that might mean for the ongoing care of our already very busy clinical and research programs.

I think back a few weeks to the challenges of whether there was going to be enough PPE, and how we were going to staff units that may be missing personnel. This was a huge lift, as it was for any center, and it could not work without people just being willing to step up and do everything that they could, and then some.

Deeken, Inova:

I say this as a physician and a father: I think the biggest impact is actually going to be psychological, especially on young people. Certainly, our patients, our healthcare providers who’ve been on the front line—in terms of prolonged psychological impact, post-traumatic stress, and all the other psychological manifestations—I think we’re going to have to contend with this for some time.

Obviously, there’s going to be all the kids who had to be out of school who will see a lag in terms of their getting back up to grade level. But that’s a societal question. In terms of health care, I think the biggest impact is the jump-start we’ve had to telemedicine and using technology for clinic evaluations that may not be in person.

I think there’s going to be a streamlining and financial cutbacks. There are going to be health systems that don’t survive this. There’ll be practices that don’t survive this. So, there’s definitely going to be a forced efficiency that we’ve already seen, and that, I assume, is only going to continue, because it’s not like payers are going to say, “Let’s go back to the banner days of 2019,” or whatever the framework is.

So, I think you’re going to see a lot of forced efficiencies and downsizing that will persist, a heavy reliance on telemedicine and other technology. But otherwise, hopefully, in three years, after a vaccine has been developed and works, we’ll be back to more of something that looks like what we have been doing and need to do for cancer patients.

 

MO:

How many patients with COVID-19 are in your hospital right now? What’s the most you’ve had, and what’s your capacity?

Nelson, Hopkins:

As of the first week of May, the state of Maryland has some 1,700 people hospitalized for COVID-19.

The Johns Hopkins Health System operates five hospitals in the region and can distribute COVID-19 patients throughout these sites to ensure all who need acute care or intensive care can receive treatment in a setting configured for COVID-19 care and staffed with dedicated COVID-19 expertise.

In addition, in collaboration with the University of Maryland Medical System and the Maryland Department of Health, Johns Hopkins operates the Baltimore Convention Center Field Hospital, a 250-bed facility accepting COVID-19 patients from all Baltimore City Hospitals.

Smith, GW:

We’ve been running 50 to 60. It’s been pretty steady for the last three weeks, and the admission rates have been pretty steady. The patients stay for several weeks. It’s pretty intense because these are labor intensive patients.

But we haven’t seen a downtrend. I think social distancing has really worked. It did what it was supposed to do, which was smooth out the curve, so we didn’t see the surge that New York had. I can certainly see how that could have happened.

Credit goes to people and institutions managing to lower the curve. The trade-off is that I think we’re going to be at this for a while. I don’t think it’s going to magically be, “Oh, because we tamped down the curve, it’ll still be over in two more weeks.” I think we’re going to be at this level for a long period.

We were prepared for more. We had plans for converting all sorts of beds. We certainly made some wards COVID wards, so it’s definitely expanded, but we haven’t seen a situation like New York, making ICU’s in the cafeteria and those sorts of stories. So, we’ve been able to manage the numbers.

The physicians and staff are pretty stressed, because it’s intense. We have taken a few physicians out of their comfort zone to help take care of patients in ICU or backfill into the wards. We had multilevel plans for staffing, but we’ve only had to dip our toe into that plan so far. Hopefully that will continue and not see the big surge.

Not as many go into the ICU, and actually not all of them are vented. That’s a tribute to information dissemination rapidly adopted by our ICU, pulmonary and infectious disease colleagues.There’s been a steep learning curve.

The usual triggers for ventilation aren’t necessarily applicable in this disease, so that we can let people get more hypoxic as long as they’re not in distress. I think we’re allowing people to test the limits and only intubating them if we really need to. Proning helps.

So, I think that the intubation rate is actually on the order of closer to 10% to 20% of admissions of COVID patients.

Weiner, Georgetown:

All of our hospitals have significant numbers of COVID-19 patients—but the numbers are frequently changing.

Winn, VCU:

As of a week ago, I believe the Richmond area had a total of 321 cases, 61 of those where hospitalized and 14 deaths total. In the state, we have had 21,570 cases, 2,955 hospitalizations, and 769 COVID-19 deaths.

We at VCU Massey were certainly preparing for the worst. The initial surge number of cases for Virginia as calculated by the IHME were quite concerning at the beginning of the crisis. We had about 50 ICU COVID-19 cases at our peak. We are all very relieved that we were able to avoid the cataclysmic numbers that were first predicted for the Richmond area.

I think that there were two things that help us avoid a disaster. The first, was  Governor [Ralph] Northam’s quick and decisive action to adopt social distancing practices early, and the willingness of communities all over Virginia to adhere to the social distancing measures. I also certainly think it helped that our governor was a physician. These actions together really helped us to avoid many more deaths.

Williams, UVA:

We’ve certainly been impacted less than most centers thus far. We had more lead time than some of the major cities, especially in the Northeast. As of now we have 20 to 25 COVID-positive inpatients with about a third in the ICU.

A couple of weeks ago, we were running in the 30 to 35 range, but it seems to be leveling out. And the expectation is that we’re going to have a very protracted level of COVID admissions, with periodic bumps from localized outbreaks.

We serve a very large geographic area, including much of Virginia and a good bit of West Virginia. As COVID infections reach into rural areas, especially given that rural hospitals don’t necessarily have the capacity and the staffing, especially ICU-level care, we’re ready, if needed, to take patients in transfer from those areas.

The capacity that we have overall is excellent, as we were just about to open a new hospital tower. There was a great deal of effort that brought two of those floors online this past month. It’s allowed us to create COVID acute care units in those new rooms.

This adds to our existing capacity in the main hospital tower ICUs and acute floors. So, if we had to go up in response to a surge, we would be able to handle upwards of 125 ICU patients and about 250 acute care patients with COVID.

Deeken, Inova:

Inova, as a system, started preparing for this more than eight weeks ago. We’ve had sufficient capacity to take care of inpatients. Our ICUs have not become overloaded. We’ve had plenty of ventilators. We have more ventilators than are currently being used right now, as the care has moved towards not ventilating if at all possible. We’ve been successful.

I think we have had over 800 patients discharged to home. At our main hospital, we play a song over the loudspeaker every time a COVID patient goes home. So, we’re still seeing the numbers go up. We’re in the upper 300s right now, in terms of inpatients across the system, which continues to go up by the day. And I think that reflects both the new diagnoses who need to come in, and then also discharges.

So, the net numbers are slowly increasing, because I think the volumes in our catchment area are going up. We’re getting people discharged, but more than those are coming in on the front end. So we’re still seeing trend lines going up, in terms of diagnosed patients who need inpatient hospitalization.

Fortunately, we’ve got plenty of capacity to take care of that. Much of the PPE issues have been resolved, not that it’s completely resolved. Testing is still incredibly in short supply, and our staffing, our ICU physicians, nursing, respiratory tech staffing have definitely been pushed to the limit.

They are truly heroes, the ones on the front lines here, and that’s a continuing concern, I think, as we continue to see increasing cases in our area, and increasing hospitalizations from those patients.

 

MO:

Did you know what to expect? Has anything in your career prepared you for this?

Nelson, Hopkins:

Looking back, the high transmissibility of SARS-CoV-2, particularly during asymptomatic phases of COVID-19 illness, the propensity of the virus to cause serious life-threatening illness, and the degree to which COVID-19 cases seeded throughout several regions of the country, were generally underestimated.

For cancer care, previous experience with the influenza A virus subtype H1N1 epidemic in 2009 provided us with some operational preparation. Then, like now, we created screening tents at hospital and ambulatory clinic entry points, performed nasal swab testing, and adopted clinical care workflows to isolate infected patients in order to protect other patients and staff against virus transmission.

Smith, GW:

No. The simple answer is no. I was training back in the AIDS day and everyone you’ll hear will talk about, “HIV, it was scary because we didn’t understand it, and we didn’t know how it spread.” In New York at the time where I trained, it was scary, but we didn’t get the sense that the entire system was stressed to the point of breaking and being overwhelmed.

And so, this is more like a natural disaster, but not just for one day. A natural disaster that just keeps going and going and going. And that, I don’t think anyone has really seen.

Weiner, Georgetown:

I can’t say we were surprised. We saw what happened in China, Italy and Spain, and then in New York City. While it certainly is an extraordinary time, we remain ever-ready to handle emergency situations like this given the hospital’s preparations for SARS, MERS, and anthrax among others.

Winn, VCU:

No. Nothing from my training as a Pulmonary Critical Care physician prepared me for this COVID-19 crisis. I honestly don’t think that any of us could be prepared.

My disaster training included things like preparing for natural disasters—tornadoes, gun violence, etc., but I was not prepared for a pandemic. Nothing in my previous training prepared me for this COVID-19 crisis.

The stress from the COVID-19 crisis has been tremendous. Many of you probably have heard or read about one of our outstanding ER physicians who unfortunately took her own life.

There has not been a lot on the frontline to help our healthcare providers deal with their own mental health. I lived through the HIV period in the 80’s and 90’s. While this current crisis has some similarities to the HIV crisis, there have also been a number of important differences.

Williams, UVA:

Nothing on this scale, of course. We already had plans in place to deal with previous influenza outbreaks, the SARS preparation that was done a few years back, and more recently the Ebola outbreak. The work had identified how those patients would enter the system, where they would be isolated, how they would be managed. And so we had a template that we were able to build upon.

Deeken, Inova:

Being in D.C., and I’m sure in the other hospitals you talked to, D.C. has had its fair share of events, whether it be 9/11, the anthrax attack—I was an intern in the ICU here at Fairfax Hospital when the anthrax patients came in early 2002—and then we had the H1N1 epidemic, and then we had Ebola. So, just being in the D.C. area, and the risk of bio-terrorism, I think the D.C. hospitals have had to be on the higher end of being prepared for mass events like this.

I think we’ve been very well prepared across the geography in D.C., because of our potential targets, and because we’ve had things to contend with. Inova as a health system, from supply chain to emergency room surging capabilities, to ICU capabilities, we’ve been incredibly well-prepared for this kind of thing.

We have had to face these events in the past, and each time succeeded, because we didn’t face worst case scenarios, and fortunately, so far, we haven’t had with COVID. Hopefully that will continue to be the case, with all the precautions in place.

So, I think D.C., like New York City, has uniquely seen a number of events in most people’s careers, over the last 10 to 20 years. While this is worse than any of those, they made us develop capabilities and processes and team approaches to contending with these things when they did happen, so that we could take care of the patients of our community when it did.

 

MO:

What is your outlook for your city or the DMV region for the next month, this summer, and later in 2020? Do you think we’ve peaked, or is there more to come?

Nelson, Hopkins:

As you know, there are several mathematical models for SARS-CoV-2 transmission, medical resource utilization, COVID-19 mortality, etc., in the Maryland, District of Columbia, and Virginia region.

Some of the best have come from Johns Hopkins. The projections of each of these predictive tools varies substantially with the effectiveness of mitigation tactics like social distancing.

I believe that if SARS-CoV-2 transmission can be suppressed in a sustained way, even after re-animating the economy of the region, then the medical systems in the region will be able to meet any challenges to come.

Smith, GW:

I am concerned that what we see right now is pretty much what we’re going to be at for weeks and probably several months. I don’t think it’s magically going to go away when the summer heat comes.

People say, “Oh, New York, 25% of the people have antibodies,” but that means 75% don’t. And here it’s probably lower. So, I think we’re going to see this rumbling along of similar numbers. And if there was a sense that it was going to go down a little, that’s going to be balanced by more people being out and more transmissibility. So, I think we’re going to be sitting at this level for some time, barring some effective antiviral medicine.

As for a vaccine, vaccines are not 100% effective. Even if you had a vaccine that tested well, the logistics of gearing up to make it, distribute it, and get it to the people who need it, and then it’s not 100% effective. So I think people are placing their bets on a vaccine, and I think in the long run, that’s where we want to be, but I don’t see that coming anytime in the near future.

I would put more hope in an antiviral, because what really made HIV manageable is effective antiretroviral medicines, which I think are more likely to come more quickly than a vaccine.

Weiner, Georgetown:

It’s still hard to know, as we don’t know what our long-term discipline will be regarding physical distancing in D.C., and whether effective testing for active infection, prior infection, antivirals or vaccines will emerge, and when. My sense is that we will experience a continuing burden of new cases, and we will gradually ramp up activities as we learn which physical distancing approaches are most effective.

Winn, VCU:

I am cautiously optimistic that we will reopen without a huge negative impact on our communities. As was apparent in Germany and Singapore, reopening does come at the risk of increasing the number of newly infected COVID-19 patients. It appears that we have gotten past the first peak. I am however, very concerned about the fall and winter.

Williams, UVA:

Depending on which models you look at, the peaks come at variable times. It’s expected that as Virginia starts to loosen statewide restrictions on usual activities, that we may see a bump in cases. We hope not to see a major surge at this point, unless something changes dramatically.

We do anticipate that, over the coming six to 12 months, before we have an effective vaccine, we’re going to see peaks and valleys of cases. As people get newly active, new populations get exposed and develop the infections that we’re going to see more of those, off and on. We’re looking ahead, right now, to understand what it’s going to look like as we get into the next influenza season and we start having overlap of patients, with flu and with COVID in the mix as well.

Deeken, Inova:

While you’ll have daily fluctuations that go up or down, from what I see, the curve still looks like it’s going up, and that’s the same in Maryland and D.C. as well. I think we flattened the curve, but we haven’t plateaued.

The curve has less of a slope, fortunately, and therefore, we’re not getting the overwhelming numbers that New York had to suffer through. And social distancing and all the things we’ve gone through have succeeded, but I don’t think we’ve seen the peak.

I don’t think we’ve seen a plateau in terms of the DMV area, if you look at just the publicly available numbers from CDC and Hopkins, and the people who are gathering these data. If you look at those trend lines, they’re continuing to go up. We haven’t plateaued.

We certainly haven’t come back on the other side of the curve, which is concerning for plans of opening things up. I think all of us who are on the front lines of this are concerned, depending on how we open up and how rapidly, we could get ourselves back into trouble that we successfully avoided over the last six to eight weeks by all the precautions and stay at home orders that have been in place.

 

MO:

What’s happening at your basic research labs?

Nelson, Hopkins:

In accordance with Governor [Larry] Hogan’s order on March 23 to close all “non-essential” businesses in the state of Maryland, laboratory research, including cancer research, has been ramped down substantially.

The exceptions have been laboratory work on SARS-CoV-2/COVID-19 aimed at improving detection, diagnosis, prevention, and treatment of the disease.

The results have been stunning. In early March, clinical microbiologists Karen Carroll, MD, and Heba Mostafa, MBBCh, PhD, developed one of the first SARS-CoV-2 tests able to secured an Emergency Use Authorization from the FDA to allow its introduction into clinical care.

Shortly thereafter, Mario Caturegli, MD, PhD, created a serologic test for antibodies to SARS-CoV-2 now also available for use in the clinic. The Good Manufacturing Practices (GMP) facility in the Cancer Center, used to produce anti-cancer vaccines and other novel treatments for cancer clinical trials, was converted to a COVID-19 testing kit factory, now well on its way to producing tens of thousands of such kits.

Currently, in addition to writing grant proposals and authoring scientific papers, our laboratory researcher leaders are working to build plans for deploying social distancing maneuvers throughout all of the laboratory facilities to ensure maximal safety for workers and for the community-at-large.

These plans will be ready for implementation when Governor Hogan permits reopening of the laboratories and return-to-work.

Smith, GW:

The cancer center here is a matrix cancer center, so we’re under the university. And the university has basically said, “All buildings are shut down. All research labs, only essential people keeping essential experiments going, cell lines, etc.” It’s put a little bit of a damper on the ability to pivot to COVID research., though we’re in the process of doing that. There are some seed grants to stimulate that, but the initial reaction was really, “Shut down the university, follow the D.C. guidelines.”

We’ve done that, and now we’re slowly saying, “Okay, these are critical investigations just ramping up.” We didn’t quite turn everyone directly to COVID research, which, in retrospect, might’ve been a little bit better plan, but we’re starting to ramp up those efforts now.

We have strengths, for instance, in cell therapy. So, can we target T cells to virally infected cells? Thinking a little outside the box from drugs and vaccines. Those are the kinds of things that we’re starting to open up.

Weiner, Georgetown:

All non-COVID-19 research remains on hold, with the exception of necessary maintenance of critical cell lines and mouse colonies.

Winn, VCU: The COVID-19 crisis has been devastating for our basic scientists. Despite the crisis, there are a number of unsung heroes that have been critical to keeping the laboratories going, even if many of our labs are only on life support.

Those people who have taken care of our animal models and various cell lines  deserve special recognition for their efforts. The sad reality is many of us are trying to simply be able to keep our bench research projects alive.

Reopening the laboratories will not be trivial. How do we do that safely? Who will be the first phase of lab workers to go back? How will we maintain the appropriate social distancing measures?

Williams, UVA:

Much of the wet lab experimental work has been on hold. That’s been true across the university. But a lot of the cancer center investigators have been working remotely. They’re doing data analysis. They’re writing new grant proposals. They’re getting manuscripts finished up.

School of Medicine research leaders are planning now to start to phase back in the research lab onsite work.

We’re in our 34th year as an NCI center, with a CCSG renewal that goes in a little less than a year from now. That work is continuing under Dr. Tom Loughran, the UVA Cancer Center director. All the program leaders within the NCI grant continue to have regular virtual meetings and reviews, and build research priorities and productivity in each of our programs.

Deeken, Inova:

We have more translational labs than basic science, because we’re not a university. But most of those have shut down their work while we survive this. We’re one of the sites for the Moonshot proteomics program, which is APOLLO.

We have some other translational lab research. Most of that has been shut down as best as possible just to keep the lab people safe, and to get them home. With our lab researchers, staff, as with our clinic staff, people that can work at home and stay at home and work remotely, we’ve done that across the board, including in those areas of  research.

Obviously, clinical lab staff are fully on board, because we’re fully busy and fully open. But our research staff that can work remotely, clinical research and translational research, we’ve gotten them home while we ride this out.

 

MO:

How have cancer care and clinical trials changed in your institution? Which of these changes are here to stay and will be carried forward as best practice?

Nelson, Hopkins:

For cancer care, I believe that there will be increased use of telemedicine, home care, and other services that improve patient access and convenience.

Clinical cancer research will exploit some of these same tools. Basic cancer research, and cancer training and education, will benefit from increased use of videoconference interactions.

Smith, GW:

Clinical trials, we basically had to shut down. Any extra visits would have exposed patients to extra risk. We have difficulty in scheduling procedures or CAT scans. There would be deviations. So, we’re still planning trials, hopefully to open them in the next few months.

For active trials, patients on trial were monitored as needed. We tried to convert, as we did cancer care, to telemedicine visits, getting labs locally, rather than coming all the way to the main campus, if that was possible. We’ve tried to limit patients’ exposure with extra visits, make sure that they’re taken care of safely. If they were on treatment, clearly we keep that treatment going. We didn’t stop any treatments, but ancillary visits, we tried to minimize.

That’s similar to what we did in cancer care. We had a little bit of a lead time warning , and we’re carefully screening patients coming to the clinic with questionnaires, and, more recently, testing. We limited visits to the clinic. We have patients get their labs closer to home. We’ve gone quite quickly into telemedicine. A vast majority of our patients, if they’re not on treatment, are not coming in for visits, they’re being visited electronically. We’ve had pretty good uptake from our providers and our patients for that, which is interesting.

We’ve made changes in our infusion room. We’ve taken out some chairs so that we have more space between patients. We then expanded hours to compensate for that, because the treatments are still ongoing.

We made staffing changes, rotated staff, so that not everyone is in every day, so that if someone did get sick, we have backups at home who aren’t sick or exposed who can come in. We did that with physicians, nurses and staff, rotating teams.

We’ve been pretty fortunate actually; so far, our health care workers have not been hit hard. I think that’s a testimony to people’s caution, and screening patients and wearing PPE. But we’ve made significant changes to reduce exposure of patients and staff to potential infection.

Fortunately, we’ve been able to make these changes work. All of these things, until there’s really a clear treatment for the virus, I think are here to stay. The idea of people sitting in a waiting room, a crowded waiting room, is just not going to happen in the foreseeable future.

I think there will be some real changes to clinical trials. European trials often beat the U.S. They simplify their trials, perhaps not getting all the lab correlatives that we would want, maybe not every endpoint we would like, but we have to go back and say, “Do our trials have to be so complex? Do we have to get every visit, every endpoint? How can we do this? Can we monitor people at home instead of a visit? What can we do locally? What can we do on the phone or telemedicine?”

There are lessons we could learn from this to simplify our trials to make them more patient-friendly, user-friendly. Some of the barriers to clinical trials are the complexity, the time and effort it takes for a patient to come for an extra visit, to arrange child care or get off work.

We can learn to simplify trials, try to make trials easier and more accessible to the broad range of patients. There are some opportunities here.

Weiner, Georgetown:

This is truly a moving target. We are exercising necessary fiscal discipline, but it’s too soon to know what changes will be temporary, as opposed to durable.

Winn, VCU:

At least for VCU Massey, there has been a silver lining. I’d like to say that the institution, as a whole, from our frontline staff to our nurses to even our community, have come to really appreciate the value of why we do clinical trials, beyond COVID-19.

There has been a particular renewed interest in ramping up our clinical cancer trials. The crisis has forced us all to work better together and to reduce the amount of red tape that had previously served as obstacles, preventing many high impact clinical trials.

Williams, UVA:

For active therapeutic clinical trials we have worked out a mechanism for clinical research staff to work remotely, with a rotating schedule for some to come in to see patients who need to be consented for a clinical trial, or to help with onsite monitoring.

We’re part of the national ORIEN network, and have put in a process to do remote consenting. As a result, we’re able to obtain tissue and other biologic samples for banking and correlative research.

Deeken, Inova:

For good or ill, as we keep telling ourselves, cancer doesn’t stop for COVID. So, we’ve seen, across the board, our volume stayed the same, as busy as it was. We’ve moved to using telemedicine for about half of our patient visits.

But otherwise, our infusion units, our radiation facilities are fully being utilized, and we haven’t seen any drop. We saw a little bit of drop in breast surgery clinic visits, because mammograms are being held off. But even those are starting to come back.

So, we haven’t seen any drop in outpatient care. And we made a conscious effort, since we were open for business and taking care of patients, including new patients, that we kept open our clinical research program fully as well. We’re doing a lot of e-consenting and a lot of video meetings of patients to discuss clinical trials.

We’re fully open for business, and we haven’t seen a big impact in our volumes. We already were heading towards things like e-consenting and things like that. Our clinical research staff has done a lot of work remotely via video for patients who have identified an interest in a clinical trial.

The sort of trials where we’re just getting bio samples and just biobanking samples, we’ve pulled back from that, just because we don’t want to expose additional risk to our patients and to the staff collecting samples. So, pure biobanking studies, we’ve put on hold, but clinical research studies are fully open here, phase I to phase III.

 

MO:

What have you learned about any deficiencies in your existing systems in a crisis model?

Nelson, Hopkins:

The response of our cancer center to the COVID-19 crisis has revealed far more strengths amongst our personnel than weaknesses in systems.

The innovative approaches to how cancer care and cancer clinical trials had to change quickly—and will need to change for longer term—which have been proffered by our folks, have been remarkable.

Smith, GW:

We are not as nimble as we would’ve liked to be, or thought we were, in terms of opening trials. Switching our trials effort to COVID focus, outpatient trials versus hospital trials as COVID trials are largely in the hospital, which has been a barrier. Getting trials opened quickly has been a barrier.

We have to rethink our systems. I understand how much is in place because of safety and prior abuses, but the system has become very cumbersome, and we have to learn to streamline clinical trials both in terms of opening and managing them, and also designing them.

That’s a lesson I hope we will be able to learn: Streamline the number of steps, the number of committees and the number of hands in the pot that slow down getting trials open.

Weiner, Georgetown:

I have been simply awed by the coordinated and highly effective response across our partner health care system to this existential challenge. This pandemic has actually brought together clinicians from multiple disciplines in conducting research, organizing patient care and standing side by side in the trenches. It has been genuinely inspiring.

Winn, VCU:

The COVID-19 crisis has shown all of us deficiencies exist in every system, ours was no exception. Many of our regulatory and compliance units have come to recognize that they were inadvertently preventing getting patients on trials. The crisis also showed us the need for better and more effective communications between units. The crisis has forced us all to become less siloed.

Williams, UVA:

I can’t say I’ve found any particular deficiencies. We benefit from having really excellent facilities for our clinics and infusion, and just opened a new and much expanded infusion area this past December that complements our regional cancer center clinics and infusion facilities. So, the density of patients being treated and seen in the clinics has been kept at an appropriate level.

Testing for COVID, of course, has been a real challenge nationally. Under the leadership of our infectious disease experts, Dr. Amy Mathers and her team in UVA clinical labs brought online one of the first COVID tests available at any institution nationally. That’s been a huge benefit for our institution and the testing is now to a point that other centers in Virginia are now using UVA clinical labs for COVID testing.

Deeken, Inova:

At our individual institution, we certainly had to learn how to build and fly the plane at the same time. We rapidly set up working groups to look at different components of our care operation in terms of patient testing, and employee testing, and work processes to get patients tested who needed to be tested, and do that safely on the outpatient side with rapid testing.

So, we’ve had to develop processes that are new and unique to COVID, and working groups that have worked on those processes. And that’s been incredibly successful. We’ve gotten a lot of support from Inova as a health system, knowing that we were different in cancer care, since we are dealing with immunocompromised patients who had to get treatment.

When we first got the rapid Abbott testing machines, cancer got one as well as our ERs on the first pass, because we needed that to keep going in terms of taking care of patients on a day-to-day basis. So, we’ve had incredible support from Inova as a system.

The challenges that we faced in cancer are the same that the system faces, which are the same that the country faced—initially, shortages of PPE, and then still persistent shortages of testing capabilities and testing kits. So, that’s not unique to us. It’s nationwide.

In cancer in general, if you look at our societies, I think there’s been a learning curve for our societies, whether it be the American College of Surgeons, American Society of Breast Surgeons, ASCO, ASTRO—I think they’ve been trying to be helpful, in terms of issuing guidelines in how to manage patients during this.

I would say, sometimes, it’s been a little delayed, and maybe not as specific as they needed to be. Again, but we’re also learning about this at the same time that we’re trying to develop care guidelines.

This is a brand new and unique illness, whether it’s the stroke risk or everything we’re seeing.

I think a lesson learned when we come out of this is that our medical societies, ASTRO, ASCO, ACS, and ASBS will, hopefully, in the future be a little more nimble to issue guidelines, so that we’re all not trying to do this and figure it out on our own—use that collective crowdsourcing of information and recommendations to come up with guidelines that are meaningful to physicians and oncology nurses on the front lines, to know what we should do and how we should do it.

 

MO:

How have you been managing your resources and optimizing workflows with the ICU surges?

Nelson, Hopkins:

The matching of intensive care unit capacity with intensive care unit need for both COVID-19 cases and non-COVID-19 cases has been managed by the Johns Hopkins Hospital Incident Command Center, which coordinates a considerable array of resources, including Hospital Epidemiology and Infection Control, facilities, supply chain/procurement, and Command Center functions in the cancer center and in other departments.

Smith, GW:

It’s not a tidal wave. It’s a big wave, but not a tidal wave. We had a couple of weeks lead time looking at Europe and then New York, and I think one of the things we did well was a lot of active planning, having and then changing plans on the fly, thinking through the workflows. What’s our nursing staff? What’s our medical staff? How are we going to rotate people in and out?

A lot of thought went into that, and I’m sure we will, after the fact, go back and think of the things we could have done better. But I do think that we had pretty effective plans for using our resources.

Would we have liked to have a better amount and use of PPE? Absolutely. That’s a big deficit that’s not just us, but the things we could really manage in terms of our staff resources, I think we’ve done well, and largely because we didn’t see that surge, though we prepared for it.

So, getting a big wave, instead of a tidal wave, has allowed us to manage it with the plans we put in place pretty well. There are certainly stresses to the system, emergency and hospital-based docs, such as hospitalists and intensivists are stressed. But I think we were able to manage it, and I think the learning is that you can plan pretty quickly if everyone’s on board.

Weiner, Georgetown:

This has been a coordinated effort led by teams based out of our emergency medicine, infectious disease and pulmonology divisions. But, everyone has played a role.

Winn, VCU:

The issue with getting adequate PPE at the beginning of the COVID-19 crisis was a struggle.

I think we have all learned an important lesson that running a cancer hospital system too lean and too mean, in the long run may not be the best approach for the overall health of our communities. In Virginia, even with our surge, we were prepared in the context of the number of ventilators.

However, our  VCU partners were very creative in developing  3D-printed ventilators, in case we needed more last resort type ventilators. From a ventilator perspective, I think we did well as a health system.  From a PPE perspective, we struggled and continue to struggle.

Williams, UVA:

We’ve activated effective telemedicine capabilities for many patients who are routine follow ups, most not on parenteral anticancer treatment or treatment for a blood disorder. This spares them the travel to Charlottesville or our regional sites unless essential.

For patients who need to be here for assessment of acute symptoms, of course, or for their treatment, we’ve been able to do so in as safe an environment as we can provide.

Deeken, Inova:

Early on, we literally set up a central COVID command unit that would be taking care of policy issues, as well as resource allocation issues. That was a system-wide effort. We really, I think, excelled in terms of that coordination. We’re five hospitals with multiple ambulatory settings, and our vision of Inova is that we’re a unified system.

That came to be the fact, actually—I’m not just saying that because I work for Inova—but it really was system solutions and centralized command, where there were rapid decisions on key aspects that had to be agreed to as a system. If one hospital was running short on ventilators early on, we deployed ventilators between hospitals, and even deployed staff.

If there was a surge at one of the hospitals, a mini-surge over a day or two, we could surge up to what was needed across the system. And that was all done by great leadership at the helm and at the center who have managed all of those issues along the way.

We’ve had issues pop up here and there, but there’s rapidly been system-wide responses and support, no matter who needed what at what point.

 

MO:

Have you had to take austerity measures in oncology? Has compensation for physicians and other healthcare professionals in your hospitals been affected by the expected decrease in patient visits and delay of interventions, especially surgical procedures?

Nelson, Hopkins:

Johns Hopkins Medicine has its eye on ensuring financial stability to support its mission of clinical care, research, and teaching.

To reduce some of its costs, it announced leadership salary reductions, no merit increases for coming year, new hiring for critical positions only, limited/targeted furloughs to minimize staff reductions, suspension of employer retirement contributions for the next fiscal year, non-personnel expense reductions, suspension of capital projects and equipment purchases, and improvements in information technology infrastructure.

In addition, Johns Hopkins Medicine created a special COVID-19 workforce relief fund to provide grants-in-aid for its lowest-resourced employees.

Smith, GW:

Obviously, this is a drain on the economics of the system, and a number of places have furloughed people, cut salaries, etc. That’s above my pay grade, but we’ve not done that yet.

I don’t think we’re out of the woods. It wouldn’t shock me if the realities get to the point where we have to do it. We’ve really focused on outpatient practice telemedicine, which has eased things a little.

Our chemotherapy revenues have continued, because we need to keep treatments going. Our radiation oncology group has done a good job, actually publishing their planning model. Their volumes are down also, but so far we’ve managed without true financial austerity measures, though every dollar is looked at.

We’re not hiring anyone, we’re not expanding. People are doing extra jobs. There is some natural attrition—we had jobs that would have been filled that we’re not filling, so people are having to fill those positions with extra work.

Fortunately people who were on staff have not suffered any decrease. But as I said, I think that’s a day-by-day, week-by-week decision.

Weiner, Georgetown:

It’s a bit early to know what will happen. It is simply too soon to know exactly how hiring, furloughs, compensation changes and the like will shake out, as we are still in the fog of war.

Winn, VCU:

I’m super proud of the folks here at VCU Massey. We did have to scale back on our clinical trials. We limited our trials to the tier one trials that as a cancer center believed would have the highest and most favorable impact.

Our associate director for clinical research, Harry Bear, and with others throughout the hospital, were able to keep open a number of important clinical trials. It was not easy. We had to change the culture in which we were seeing patients.

Telehealth has become incredibly important to our clinical trials and to our care for most of our patients. In fact, we’re able to keep up our number of visits.

A big change that was difficult for us to implement, was the rule to not have family members in the examining room with our patients. This was tough, but necessary to keep everyone safe.

Williams, UVA:

Of course, COVID has had a major adverse financial impact on the university as a whole and on the health system in particular. Just in the last two weeks, financial mitigation measures have been put in place, including temporary salary reductions for faculty and senior staff.

There’s also a mechanism for staff members who are not taking a salary reduction to be furloughed for two to four weeks. It’s an additional and significant challenge in a very difficult time. However, those who are furloughed will continue to have their health and dental insurance.

Deeken, Inova:

We definitely had to take some, across Inova as a system, which is over 17,000 people. We eliminated almost 500 nonclinical positions, as a means of cost savings. Our leadership, a number of lawyers have taken pay cuts for this year, the highest pay cut was done by our CEO.

For physicians, especially the frontline physicians, we haven’t had to take any cuts in their base salary or anything like that, which has been respectful, I think, of their contribution to this.

But we have had some personnel position eliminations and some base salary reductions, again on the leadership and administrative side of the house.

 

MO:

How is COVID-19 affecting underserved communities and populations in your catchment area? How does your institution cope, and what can be done?

Nelson, Hopkins:

The state of Maryland has both rural and urban underserved populations.

A significant worry is that during this COVID-19 epidemic, minority populations, the poor, and the uninsured may be especially vulnerable to poor outcomes because of obesity, high blood pressure, cigarette smoking, and diabetes—all conditions that could be prevented or treated.

These same risk factors propel increased risks for cancer as well. As such, in addition to improving access to high-quality cancer care for all Marylanders, much of the community engagement of the cancer center has targeted these chronic disease risk factors.

Over the past few years, a community-anchored clinical trial of weight loss among cancer survivors in Baltimore City was completed with the help of support from the State of Maryland Cigarette Restitution Fund.

Further clinical studies of such interventions are planned or underway throughout the state.

Smith, GW:

We are a nascent cancer center, planning to apply for NCI designation, so we do assess our catchment area. Our patient population matches the D.C. area, which is between 40 and 45% African American, and we have a significant Hispanic population as well.

The difference is, and we see this, in the mortality among African Americans in D.C. Eighty percent of the deaths listed on the D.C. Department of Health website are African American, with over 40% of the cases.

Clearly, there’s a disparity in mortality, likely reflecting comorbidities and other health problems, but also socioeconomics. So, yes, we do see disparities in who ends up in the ICU. That’s a big concern.

Given our catchment area, we focus on community outreach in normal times. Just announced earlier this week was the new hospital in collaboration with GW in the East Side Ward 7 and 8 areas.

In the long term, we’re here to stay in that catchment area. In the short term, it’s taking care of the patients that we have and understanding that they have special needs. Our social workers have gotten Zoom accounts, just as our physicians, and they are doing telemedicine support groups to reach out. So, we’re doing what we can to reach out to the community. As this rolls on, we’re going to make additional efforts to get out into that area.

Weiner, Georgetown:

Underserved communities have felt the brunt of this pandemic in our region, just as elsewhere. MedStar Washington Hospital Center has emerged as a leading site of care for such patients, but the burden is shared across the MedStar health system.

Winn, VCU:

Unfortunately, in Richmond, 13 of the 14 COVID-19 deaths were African American. Of the 321 people who tested positive in Richmond, 61 of those were hospitalized, and of the 14 deaths, 13 of those were African Americans.

During this crisis, people have been more afraid  to visit our hospital and clinics. But the lack of testing, the lack of early intervention, the lack of effective communication in these communities have contributed greatly to the poor outcomes in Richmond and the U.S.

Since the African American church remains an anchor institution for most black and underserved communities, we have started a Facts, Faith, Friday roundtable partnership with VCU Massey and the Faith leaders of Richmond to get better information to our faith leaders.

These leaders have served as a trusted and reliable source of data for these communities. We have been working with this group along with city and state leaders to help them get through this COVID-19 crisis.

Williams, UVA:

I don’t have specifics as to our local COVID population aside from the state health department releases, which are updated every day.

Deeken, Inova:

I don’t have the breakdown in terms of our system numbers. What I do know is Virginia numbers, and the thing that is impressive are the number of patients coming from nursing homes, assisted living, and long-term care facilities. That’s sort of well-known.

In Virginia, I think what’s also interesting is the number that have come from the Hispanic community. I think I heard on the news this morning that up to half the patients in Virginia have been of Hispanic origin.

That definitely comports, I think, to what we’ve seen in terms of our inpatient census, that it does seem to be a high predilection to people of color, both Hispanics and African Americans. And that’s something that I could probably confirm anecdotally here in our cancer center.

We’ve done a significant number of COVID testing in our cancer center, patients who meet CDC requirements, or ASH guidelines. So, we’ve tested a large number of cancer patients, and some of them have certainly tested positive. We’ve had a few that have died, unfortunately, of COVID.

Our numbers are consistent with the percentage that you’re seeing nationally. It’s not the 40 to 50% that they initially saw in Wuhan, but it’s probably closer to 10% that we’ve seen in some of the reports so far in the U.S. of COVID-positive patients who also have cancer, or a recent treatment for cancer, in terms of their mortality risk.

But in terms of the Virginia demographics, it seems like people of color are especially at risk for the significant complications from the infection. Since we don’t have widespread screening, we don’t know what the actual rate of infection is, unfortunately.

But in terms of the patients seeking care, being diagnosed, needing testing, and therefore being diagnosed, there seems to be a high prevalence in those populations.

 

MO:

Has the pandemic affected your ability to carry out your mission that comes with having an NCI designation, or your plans to seek NCI designation?

Nelson, Hopkins:

Our Cancer Center Support Grant competitive renewal submission is due in May of 2021.

Clearly, for the calendar year 2020, we expect to have fewer clinical trials completed than we had planned, and there has been a government-ordered gap in laboratory research activity.

Nonetheless, the output of high-impact publications that change clinical practice, lead to new paradigms, and drive policy decisions has continued at nearly full speed.

Smith, GW:

Certainly things have been delayed. Our external advisory board was due late June, we’ve put that back a couple of months. As for investment in new programs, it wouldn’t surprise me if that’s delayed somewhat.

It’ll be interesting to see how the NCI and NIH react to these things, as you put in grants that might’ve required institutional support, as that institutional support may not be as strong as it would have been pre-pandemic, I think it’ll be interesting to see how the agencies deal with that.

Yes, we want to be a cancer center, yes we have institutional commitment, but they may not have the resources that they used to have to support  that. How do we deal with that in a larger NCI-designating programmatic way? I think that’s an open question.

I think we will get some financial support from [new CARES Act funds for NCI] and that will be helpful, but I think what the institute is realistically going to be able to say is not, “We’re giving you $100 million to support your cancer center.”

They might say, “You know what? We can’t commit to that because we don’t know what finances we have.” What does that do to your grant application? Hopefully, the reviewers will take that into consideration.

Weiner, Georgetown:

It is difficult to maintain momentum in the face of this pandemic. We have numerous video meetings to assure we can sustain our research momentum, though actual wet bench experimentation is largely inactive at this point. After a brief contraction we are ramping up our clinical trials efforts, even as a large proportion of our patients are being seen through the MedStar telehealth platform.

Winn, VCU:

Absolutely. Having an NCI designation has helped tremendously in our ability to have a positive impact on our communities. The resources available to our center has gone a long way to bring groups of scientists together and has really served to benefit our community outreach and engagement efforts.

Williams, UVA:

I would say no in terms of our research operations, and in terms of getting patients in and getting them seen. If we get a call from an outside facility or provider, we get those patients transferred in as soon as need be.

Deeken, Inova:

We’re not NCI-designated nor seeking that designation at this time, but we are a major regional cancer center. At our main cancer center, which is across the street from Fairfax Hospital, we have over 400 patients coming in a day to get treatment. And that, again, that really hasn’t changed.

We’ve put in a whole lot of procedures in place at our center, and did so early on, from masking patients, allowing only one visitor, having visitors masked, having all people coming in the buildings temperature-wanded, all staff have masks, all staff have temperature checked every day.

We pre-screen patients a day before they come to see if they’ve had any symptoms. And we’ve been expanding that list of questions they’re asked as we learned more about the epidemic. Early on it was, “Have you traveled to China?” Now it’s, “Have you been in contact with,” and really not those geographic questions that we had early on.

So, our screening of patients the day before, the screening at our entrance doors, and our protections in terms of masking and temperature checking have slowed things a little bit, but not significantly.

Again, we have moved to probably about half of our patients being seen, little over half being seen via telemedicine, mainly video. So that’s impacted our care delivery. But in terms of active treatments, radiation, surgery, and chemotherapy, it actually hasn’t been impacted at all.

 

MO:

Is there a need for a more robust system for managing public health crises at the federal level?

Nelson, Hopkins:

Yes. And this system should finally tackle the underlying public health challenge of obesity, high blood pressure, cigarette smoking, and diabetes, especially in poor and underserved populations, as if it were a crisis.

Smith, GW:

Yes. The clear answer to that is, yes. We were clearly, as a society, not truly prepared for this. And we can argue, without getting into politics, about whose fault it was, but clearly, we were not prepared. And frankly, when you look at our CDC response compared to other countries, it fell short. Our testing, even now, is not where we would like it to be.

So, there’s no question that we need better planning and facilities. And as people have pointed out, this is not sexy stuff. When things are going well and you don’t have a pandemic, no one wants to invest in some of these basic planning-for-disaster scenarios.

And we got away with SARS and MERS, which we sort of escaped. And it wasn’t the wake-up call, it was like, “Oh, we got away with that. I guess we don’t need to worry about it anymore.”

Hopefully, this is a true wake-up call and we will be ready next time. One can only hope, but it has to be at the federal level.

Meanwhile, regionally, with individual institutions, my hope would be that we would get together public and private institutions, even the VA, and have a plan among ourselves, so that we’re not competing for the limited resources, and that we move patients and staff around as necessary—so that we have sort of a local-regional pandemic disaster plan, whether it’s for a pandemic or an acute natural disaster.

I think the lesson is that we can rely on the federal government, and that’s fine, but maybe we should be doing more ourselves to plan to be independent of that, as a backup.

Weiner, Georgetown:

Yes. Our country needs more rapid and better coordinated early responses to emerging pandemics. These responses are needed to accelerate drug development, expand distribution networks and develop/implement testing for active and prior infections.

Had we done this with COVID-19, it would have blunted the devastating impact of this virus.

Winn, VCU:

Oh my God, yes. There has been a complete failure of leadership from the very top. However, I thank the high heavens for our governor and state and local leaders. They have served Virginia well.

I also must thank Drs. Fauci and Birx for their courage to lead under extraordinary circumstances. Their ability to tell the truth about the crisis, and to give us honest advice, despite being pressured, has been remarkable. They have set the example for all to emulate.

I also have to give credit to the various health systems in Virginia that decided to work together for the greater good. It was tough, and probably strange, for many of these systems to have to work together in the manner in which they did.

I think that there should have been more clarity and thoughtfulness, and consistency from the highest office of the land—it would have helped out a lot.

Williams, UVA:

At the local, regional, and at the state levels, I’ve been impressed with the quality of response.

At the federal level, my opinion is that the coordination has been less organized and effective and less measured in terms of emergency management and in setting priorities.

Deeken, Inova:

Yes. I think we’ve all seen the challenges with not having a robust public health system and rapid response from the federal level, and states being left to do many initiatives on their own.

I think we’ve all seen the opportunities that maybe have been missed over the last couple of months. Hopefully, those will be lessons that we learn and keep in mind in the years ahead,  if any kind of thing like this ever happens again.

 

MO:

Is funding for infectious disease epidemiology and pandemic preparedness—including the stimulus from the CARES Act—sufficient? Has it been helpful to your institution?

Nelson, Hopkins:

Support for public health and pandemics is not enough. Significant funding will be needed through the National Institutes of Health to fuel the broader biomedical research enterprise.

The final conquest of SARS-CoV-2, and future pandemic threats, will almost certainly include contributions from researchers otherwise focused on cancers, immunity, cardiovascular diseases, basic molecular biology, etc.

Smith, GW:

I’m not sure, in the broader term. I think in the real world, at our level, we haven’t seen it. I think when you read about small businesses, etc., that some of the dollars are out there, but there’s lots of confusion as to how it’s going to be distributed and what you can use it for and not use it for.

My hope is that over the next couple of months that will be clear, and some of the big deficits we appear to be running will be less severe, as some of this money comes in to fill those spots. But I think honestly, right now, it’s too early to know how beneficial that’s going to be at different levels.

Weiner, Georgetown:

Funding to support the work we are doing is important. It is difficult to say if it is enough.

Winn, VCU:

We certainly appreciate the CARES Act, but the CARES Act, in and of itself, is not enough to sustain most health systems. However, it certainly has been appreciated and a welcome relief. At this point, every little bit will help.

I think from a preparedness perspective, we have learned a ton about being prepared for the next COVID-19 wave. It turns out that the dismantling of the pandemic preparedness team that President Obama assembled was likely a mistake. I think that if we have learned one post-pandemic lesson, it is that we must reestablish the principle that effective public health matters.

Williams, UVA:

The CARES Act has provided much needed support to UVA Health, although I don’t have the dollar amounts.

There’s a well-recognized need for COVID testing. If we want to start opening things up more, socially and economically, we need to know who’s infected, do tracing of cases, and have sharper instruments to decide who needs to be staying home and quarantining. I’m hopeful that federal funding will be able to catalyze these technologies and strategies.

Deeken, Inova:

I think there’s a fair question about that, and hopefully, the after-action reports that Congress will do will tell us whether the investment was sufficient enough, and what we might need  in terms of pandemic preparations and public health and epidemiology. I think in terms of the CARES Act, I think it was very generous from the federal government.

Inova and some of our private practice partners in the community have benefited from a part of that support, and helped to partially offset the losses that we’ve all seen. The emphasis there is on partial, and I think we’re all still struggling operationally, but also financially, and we’re all hoping that we’ll come through this intact.

Certainly, Inova came in financially very strong, so we’re not worried about our long-term soundness as a health system. Other systems in the state or in the country certainly might be at risk, but the CARES Act, so far, has provided some help for us, which we’re grateful for.

 

MO:

Do you have any other health care policy lessons that you’d like to impart?

Nelson, Hopkins:

Older people, particularly those with comorbid conditions or frailty, have proven extraordinarily susceptible to serious consequence SARS-CoV-2 infection. The aging also bears a significant burden of cancer and other chronic diseases. New approaches to caring for older populations and new research on the basic biology of aging should be explored.

Smith, GW:

I was not a boy scout, but boy, be prepared. I think the health policy lesson really is that we can’t really operate on the edge, where we have no fluff in the system, which is the way we’ve been doing it. On the other hand, you can’t afford to have excess capacity.

So, we have to be creative, I think, to figure out what we did in an emergent situation. Okay, we want to maximize efficiency day to day, but how do we build in expansion capacity? Not that it’s sitting there unused all the time, but how can we have expansion capacity for such an event like this, so we’re not scrambling quite the way we were? How do we be prepared, but in a cost-effective way? I think that’s the question.

I just can’t imagine what people in New York were facing. The ethical, moral questions, the pain of the stories of those people, even staff who were exposed and died, or staff who can’t go home to see their kids, because they’re afraid of infecting them.

The horror stories that come out of there, we are just very thankful we have not seen here. It’s been stressful, but I just sympathize and empathize with the people in Italy, the people in New York. I just can’t imagine what they’ve gone through.

Winn, VCU:

I think the most important health care policy lesson is that we must stop studying our most vulnerable populations, and actually get up off our butts and address the issues in these communities with information and approaches that we already know work.

It has not been the lack of knowledge, but the lack of political and social will that continues to plague these communities. We already know that good housing, having a great education, and having access to excellent health care will improve the health of these communities. The real question is, will we really address these issues in a post-COVID-19 world?

The second thing that this crisis has actually taught me is that you can be wealthy or poor, but if we don’t all take care of one another, the COVID virus will continue to win. So, this is the one time where we all are in the same boat, literally.

Williams, UVA:

From the local level, I think we’ve done the best we can, and are fortunate to have very committed and dedicated staff at every facet of the organization. Hopefully, we’ve got enough of a handle on the crisis that, at least for our own part of the world, we’ll be able to manage it and minimize the impact on our patients and our local and regional populations.

Deeken, Inova:

I think the move that CMS made rapidly to allow telemedicine visits, allow reimbursement for those visits, and even the decision, either earlier this week or last week to reimburse telemedicine, even telephonic visits, at the same rates as in-person visits are fantastic. And again, it will jump-start this telemedicine revolution that’s probably going to start now.

So, those policies and the technology for video connections, hopefully will stay in place and continue even after this. CMS has been, I think, incredible on the forefront of allowing those innovations.

 

MO:

Did we miss anything?

Smith, GW:

I think the lesson is, we’re not out of the woods. And people think, “Oh yeah, we’re going to open up over the next few weeks and everything’s going to be fine.” I think we have to do that, and we have to be smart and we have to do social distancing, but we recognize what we do know, and listen to that.

We have to know what we don’t know and recognize that we’re going to get a second wave and a third wave. We can’t let down our guard. Life has to go on, but we have to do it and we have to be very alert to, if we make a change and two weeks later, we see a big bump in infections and people in the ICU, we’re going to have to go back and say, “That wasn’t such a good idea. Let’s figure out another way to do this.”

It’s going to be an ongoing learning experience. This is not, “It’s gone away and we’re done.” It’s going to be a constant learning experience, and we have to adapt to that and we have to use it to learn, and hopefully have research that teaches us, so that we’re not just using anecdotes. We actually need to learn from our experience.

Weiner, Georgetown:

Our physicians and nurses on the front lines are true heroes. Scientists who have repurposed their work to attack coronavirus should inspire us all.

Copyright (c) 2020 The Cancer Letter Inc.