key: cord-0962601-t51dn8nw
authors: Smith, David A.; Nazir, Arif; Katz, Paul R.
title: What Should We be Studying Regarding COVID-19?
date: 2020-06-26
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.06.044
sha: fb967ef3ea0c2843c0d35bb3cfb78cf5c0a9b13b
doc_id: 962601
cord_uid: t51dn8nw

nan

Similar to other journals representing professional organizations dedicated to the care of older adults, JAMDA -the Journal of Post-Acute and Long-Term Care Medicine -has strived to publish approaches to care that are both scientifically valid and timely. The ease at which false or misleading information on COVID-19 care has permeated the media reinforces the need to report studies that meet the minimum threshold of scientific rigor.

JAMDA has walked this narrow line through its "Pragmatic Innovations" papers. The Journal has clearly been successful toward this end as evidenced by several recently published new and highly relevant approaches to COVID-19 diagnosis and treatment. The fact that these articles include international experience speaks to their relevance given the worldwide pandemic. And, while pragmatic innovations refer to unique approaches to care for both COVID-19 positive and negative patients, at this point in time we can only speculate on the value of each organizational tactic, care process, prophylaxis or treatment to achieve quality. In fact, what goals are desirable and achievable in these innovations largely remains to be determined.

From the "front lines" in Italy, Landi and colleagues descriptively support the concept that a geriatrician should be involved in the evaluation and management of older COVID-19 patients.(1) Elaborating on this concept, Archbald-Pannone et al. report on a collaborative model whereby the intellectual resources of an academic hospital can provide structured support to long-term care facilities coping with the pandemic.(2) On a different topic, Gaur and colleagues propose a structured communication tool to assist residents/surrogates in making advanced care planning specific to the expected prognosis in the event of SARS-CoV-2 infection and severe COVID-19 disease.(3) This effort can be projected to offer patient-centered care in addition to avoiding non-efficacious use of hospital, ICU and ventilator resources for those with an expected poor prognosis. Office et al. report on a program connecting medical students by telephone with socially isolated seniors in order to reduce the psychological consequences of sheltering.(4) Mills et al. describe their home-based primary care practice's interventions to prevent or contain the spread of COVID-19 in the assisted living communities they serve, and advocate the suppression of COVID-19 through polymerase chain reaction (PCR) testing of acutely symptomatic residents, visitor management and asymptomatic employee IgM and IgG antibody testing.(5) From Barcelona, Inzitari and colleagues provide a comprehensive view of how they transformed an existing post-acute care facility into a specialized COVID-19 care site in order to meet the extraordinary challenges with which they were presented. (6) In addition to these Pragmatic Innovations papers, other recent JAMDA publications have illuminated a number of issues highly relevant to the COVID pandemic. In January 2020, a Special Article on behalf of the Infection Advisory Subcommittee of AMDA, The Society for Post-Acute and Long-Term Care Medicine, recommended that all LTC healthcare workers (direct caregiving or otherwise) be immunized for influenza in order to protect our vulnerable patients because greater than 70% of influenza deaths occur in older adults (7) . If/when a vaccine is developed for the Coronavirus SARS-CoV-2, this recommendation is well positioned to extend to cover this new threat.

In that same issue, a Special Article by Checovich et al. reported on the evaluation of acute respiratory infections in nursing facilities. (8) Highlighting the declining immunocompetence with advancing age of vulnerable patients, these authors advocated for a simple but broad approach to the diagnosis of acute respiratory infections including viral pathogens. Interestingly, they found no evidence that increasing age or time from symptom onset negatively affects the rate of virus detection by nasal swab testing.

In the May issue of JAMDA, three editorials highlighted a range of issues, many with health policy implications. Zimmerman and colleagues remind us of the need to consider the unique characteristics of assisted living communities and their residents (9), while Dosa et al. offer practical guidelines for frail individuals at high risk from COVID-19 infection.(10) Cesari and Proietti offer a startling account of the earliest experiences with quarantining and threatened overwhelming of medical resources from Italy and make an impassioned appeal to eschew rationing based on age. (11) The topic of ageism is again raised in an August editorial by the editors-in-chief of JAMDA in collaboration with the editors of several other journals in aging. (12) As we look to the future, with the realization that COVID-19 will be with us for some time to come, a number of issues will require the attention of future JAMDA contributors, some of which are enumerated below. Our hope and expectation is that contributors continue to share their unique expertise and insights regarding the care of our frail and susceptible population.

COVID-19 issues relevant to post-acute and long-term care medicine include the following: 1) "flattening of the curve" to avoid overwhelming existing medical resources (the stated goal of US policymakers who orchestrated the "lockdown" of American commerce and group social interaction) 2) husbandry of scarce medical resources including emergency room availability, hospital beds, ventilators, personal protective equipment (PPE's), and other resources, including the protection of caregivers and medical support staff who are themselves a scarce medical resource 3) sheltering and protecting, as possible, vulnerable patients from transmission of the coronavirus 4) reducing morbidity and mortality due to COVID-19 without disproportionate negative impact on the quality of care for non-COVID-19 pathology, and without creating excessive morbidity and mortality, social disruption or wealth destruction (with known disastrous effect on health and wellbeing) as a consequence of pandemic response policy 5) improving communication and satisfaction with care among various stakeholders, including vulnerable patients, families, staff, government, and the general public; communication that facilitates dialog that elicits informed advanced directives is a high priority 6) ensuring the accuracy and integrity of statistical data collection and analysis to provide the raw material for clinical decision-making and policymaking not adulterated by political or financial agendas 7) mitigating or eliminating vulnerable patients' social isolation during sheltering and quarantine 8) effective cohorting and possible roles of PCR and antibody testing to mitigate social isolation. Related to this point, the use of antibody testing for decision making to deploy or not deploy an employee as described by Mills et al. is not currently recommended. (5, 13, 14) . The current delay in obtaining a result from PCR testing and its sometimes lackluster sensitivity -related to poor technique and source of testing, and with positive predictive value depending greatly on virus prevalence in the test location --makes frequent testing of staff returning to work an imperfect solution. 9) exploring, seeking to understand and leveraging a science of delivery to close the gap between known best practices and actual healthcare/prevention offered by providers and accepted by patients. This suggestion includes better understanding of the advantages, pitfalls and contraindications of telemedicine. Also, it is anticipated that the science of delivery will vary in different nations, cultures and ethnicities making our international contributors even more valued. 10) further investigating and policy making regarding the appropriate roles of the public and private sectors (partnerships and shared decision making) in epidemic/pandemic management 11) ascertaining the most effective use of medical teams in the delivery of care to COVID-19 patients including the impact of enhanced scope of care for nurse practitioners and physician assistants on quality 12) understanding the structural and organizational factors within nursing homes and assisted living communities that contribute to quality and efficiency of COVID-19 related care The goals articulated above represent but a few of the many challenges --and hopefully opportunities -for discovery around a host of COVID-19 related issues. While daunting, we are confident that AMDA--The Society for Post-Acute and Long-Term Care Medicine will continue to take a leading role in crafting a successful response to the pandemic through advocacy, education and the promotion of innovation.

The geriatrician: The frontline specialist in the treatment of COVID-19 patients

COVID-19 collaborative model for an academic hospital and long-term care facilities

A structured tool for communication and care planning in the era of the COVID-19 pandemic

Reducing social isolation of seniors through medical student telephone contact

Home-based primary care led-outbreak mitigation in assisted living facilities in the first 100 days of COVID-19

Comprehensive management of older adults with COVID-19 in post-acute care: lessons from Barcelona

Recommendations for mandatory influenza vaccinations for health care personnel from AMDA's Infection Advisory Subcommittee

Evaluation of viruses associated with acute respiratory infections and long-term care facilities using a novel method: Wisconsin 2016-2019

Long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk

The need to include assisted living in responding to the COVID-19 pandemic

COVID-19 in Italy: Ageism and decision-making in a pandemic

The COVID-19 pandemic and ageism: a call for humanitarian care

Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19

Interpreting diagnostic tests for SARS-CoV-2