Bird flu, cancer screening, drug ads, telemedicine and COVID-19 roundup

February 10, 2022

Today, I’ll discuss whether we should worry about avian influenza, research showing that cancer screening is still not back to its pre-pandemic levels, and pharmaceutical advertising for “low value” drugs. I’ll also review some data on telemedicine and discuss the current status of COVID-19 in the US.

1. Should we be worried about bird flu?

Avian influenza, H5N1, has been all over the news lately. (Here, here, and here, for instance). This strain of influenza usually causes deaths of wild and domestic birds, but this season avian influenza has caused illness and deaths in a mink farm in Spain, of a lion in a zoo in Peru, and of dolphins and sea lions off of South America.  Humans who have been infected with bird flu in the past have usually been poultry workers or those with high exposure to birds, and the mortality rate from human exposure has been high. Epidemiologists have worried for years that this type of influenza could “jump” to humans and create a worldwide pandemic.

Bird flu, though, is generally not easily transmitted from mammal to mammal, limiting the likelihood of a human epidemic. Some experts fear that the mink farm outbreak could mean the virus has mutated and could be more contagious in mammals, as minks have upper respiratory tracts similar to ferrets, which are used as models for human transmission. Most scientists interviewed by StatNews reported that they are uncertain about whether bird flu will be a threat to humans.

We have a long history of successful influenza immunizations, and there are multiple avian influenza vaccines that are already licensed, although we don’t have large stockpiles, and none are in widespread production. Messenger RNA technology could allow rapid ramp-up of vaccine production if indeed bird flu becomes a severe threat.

Implications for employers:

-        Efforts to make the workplace safer in the last few years, including better ventilation and access to hand sanitizer, can limit spread of all types of influenza

-        If there is a serious outbreak and vaccines are not yet widely available, masks and more remote work can help reduce early spread

-        Employers should continue to monitor public health advisories, but it’s not likely that bird flu will cause business disruption outside of the food processing industry in the near future.

2. Cancer screening rates remain low

Researchers from University of Texas have demonstrated that rates of cancer screening remain below pre pandemic levels. We have also not ‘caught up’ from the large number of screening tests skipped in the initial COVID-19 wave (Spring, 2020) and the Omicron wave (Winter-Spring, 2021).  This data is from Medicare, but it’s likely to be directionally similar to the experience in employer sponsored health plans as well.

Source: Doan, et al JAMA Network Open February, 2023 LINK

The researchers used a Medicare database, and projected likely future screening rates from 2017-2019 experience.  The results were similar for lung cancer screening. The bump in mammography each October to November is associated with the breast cancer awareness month campaign.

Implications for employers:

-        This decrease in cancer screening is likely to lead to more cases of cancer discovered at later stages, which can lead to lower survival and increased costs associated with treating later stage cancers

-        Public awareness campaigns work, and employers can continue to encourage cancer screening for their eligible members.

-        Meeting health plan benchmarks may underestimate the screening rates possible. Employers can use HEDIS or published literature to guide their goals for employers who aim to be leaders in this space.

-        Employers can try to influence their health plan to have better performance guarantees for immunizations to better align incentives between patients, health plans, and employers.

3. Pharmaceutical companies spend a larger portion of their marketing budget on DTC for drugs of lower value.

Only two countries, the United States and New Zealand, allow direct-to-consumer (DTC) marketing for prescription drugs, and drug company spending on such advertising increased fourfold to $6 billion from 1997 to 2016. Anyone who watches television or opens a magazine recognizes that pharma spending on DTC marketing has not slowed since then!

Researchers from Johns Hopkins have evaluated pharmaceutical company marketing spending and found that companies are likely to direct more direct-to-consumer advertising dollars to drugs which add the least amount of clinical value. They correlated formal determinations of drug value (from France and Norway) with reports on marketing spending on 134 medications which represent about 80% of total drug spending. The pharmaceutical companies spend 14.5% more on drugs with low added clinical value. They reap a 10% increase in sales for every 1.5% increase in spending.

Implications for employers:

-        Formularies can help lower spending on lower value medications, although complex and opaque rebate negotiations between pharmacy benefit managers and pharmaceutical companies do not always yield the highest value drug formulary for employers and members

-        Counter-detailing by at-risk provider systems or pharmacy benefit managers can encourage improved physician prescribing practices.

-         We are not likely to escape the continued onslaught of drug advertisements, as these substantially increase sales.

4. Relatively few telemedicine visits required in-person follow-ups

Two research teams reviewed de-identified data from providers who use the Epic electronic medical record system and found that most patients who had a telemedicine visit did not see a provider of the same specialty within 90 days. This was especially true of mental health providers, nutritionists and endocrinologists, where 15% or fewer patients were seen by the same specialty within 90 days of an initial telemedicine visit. On the other hand, there are some specialties, such as cardiology, surgery, sports medicine and obstetrics, where the majority of patients with telemedicine visits saw a provider of the same specialty within 90 days.

This is a large study, with 35 million telemedicine visits from 180 provider organizations in all 50 states. The researchers’ calculations were from telemedicine visits from March, 2020 to May, 2022. While this shows that the telemedicine visits likely did not lead to follow-up visits, we cannot tell from this data whether the telemedicine visits themselves were medically necessary. This data comes from large medical systems, and is not necessarily representative of the results from stand-alone telemedicine providers. One in eight telemedicine visits in this study was with a mental health provider.

Implications for employers:

-        This research suggests that telemedicine visits replace in-person visits in many instances.

-        Telemedicine provides a major source of access to mental health services

-        Telemedicine access through in-person providers could diminish if states begin to enforce pre-pandemic restrictions after the end of the Pandemic Emergency in May.

5. COVID-19 rates continue to decline in the US

COVID-19 rates continue to decline in the US - even though XBB.1.1 is becoming the dominant variant strain.  Cases continue to decline in most of the world, too.

Wastewater surveillance shows lower concentrations of the virus that causes COVID-19- which is usually a good “leading indicator” that predicts lower rates of community infection in the coming weeks. 

SARS CoV2 Virus Concentration (copies/ml, sewage)

Source: BioBot February 7, 2023 LINK

Hospitalization due to COVID-19, a “lagging indicator” that usually reflects the rate of community infection a few weeks earlier, is also down substantially.  Deaths in the US continue to be between 400 and 500 per day, so COVID-19 continues to cause about three times more deaths than even an exceptionally bad influenza season.

Source: Centers for Disease Control and Prevention; graphic from the New York Times February 7, 2022 LINK

Evidence continues to show that the COVID-19 vaccinations are effective at preventing both cases of and deaths from COVID-19.  A study published yesterday shows that people over 12 who have had the bivalent booster were 3 times less likely to die of COVID-19 compared to those who had only earlier vaccines, and 14 times less likely to die than those who were never vaccinated.

At this point in the pandemic, many people have ‘hybrid immunity’ from a combination of vaccinations and COVID-19 infection. Hybrid immunity provides especially good protection against severe infection or death. Immunity from both vaccinations and infections wanes over 6-8 months, pointing to the importance of periodic boosters for those already vaccinated and for those who have had previous infections.

As we head into Spring, I’m hopeful that we will continue to see a decline in community transmission.

Hope all have a great weekend! (And please tell colleagues to subscribe.)

Jeff