Primary Care Visits With NPs, PAs on the Rise; C. Diff in the Intensive Care Unit

Derick Alison
Derick Alison
18 Min Read

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include estimates of long COVID, who is providing care, C. difficile in the ICU, and suicidality in healthcare workers.

Program notes:

0:45 Suicide risk in healthcare workers

1:45 Registered nurses, healthcare technicians

2:45 Also increased mental health problems

3:00 Methodological pitfalls in long COVID estimates

4:01 Define long COVID

5:01 No good objective studies

6:02 Need a control group without COVID

6:45 Who might you see at your next outpatient visit?

7:45 Greatest among lower income

8:45 Involved in telehealth

9:03 Genomic surveillance of Clostridium difficile subspecies and transmission

10:01 Whole genome sequencing

11:15 Asymptomatic carriers

12:33 End

Transcript:

Elizabeth: Has science itself created an overestimation of long COVID?

Rick: Who are you likely to see in your next outpatient visit?

Elizabeth: Can we take a look at the genome of Clostridium difficile to find out where transmission is occurring when people are in the ICU?

Rick: Which healthcare workers are at increased risk of suicide?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, it’s rather sobering, this notion of who is at risk for suicide among healthcare workers. Why don’t we turn first to JAMA and look at that?

Rick: This was a study very simply to estimate the risk of death by suicide among U.S. healthcare workers. They actually had a very large database. Over 1.8 million individuals had participated in 2008, and it was called the American Community Survey. Then they were able to estimate from those individuals the healthcare workers and their risk for suicide compared to non-health care workers.

They included physicians, registered nurses, other healthcare diagnosing or treating physicians, dentists, chiropractors, optometrists, and physician assistants. They also looked at healthcare technicians, healthcare support workers, and then finally social behavioral health workers. They annualized the standardized suicide risk per 100,000 persons in each of these groups. They adjusted for any confounding factors and compared it to the general population.

What they realized was relative to non-healthcare workers, the following healthcare workers had a significantly increased risk of suicide. They were registered nurses, health technicians, and healthcare support workers.

Elizabeth: Clearly pointing to a need for awareness of this issue and strategies to intervene.

Rick: It is. This just allows us to have kind of a 30,000-foot view, but it really doesn’t dig down to why these individuals have an increased risk. Are those individuals just by virtue of their personality at an increased risk? Or are they experiencing some work-related things like burnout, lack of empathy, or work stress?

Elizabeth: Of course, I’m going to ask you to rely on your experience and to speculate for me on both what you consider to be the root causes of this issue, and also, if you were the king of the forest, how you would address it.

Rick: Very tough. You would expect if it’s just related to the job, physicians would have just as increased risk as nurses that are caring for patients. There are clearly some job-related stresses, but I think it goes a little bit deeper than that. Healthcare workers have an increased risk for mental health problems. They have higher rates of mood disorders and that’s been known for a long period of time. We need to figure out what are the specific work-related factors that contribute to this occupational risk and then how to address them.

Elizabeth: Why don’t we move to the BMJ. This is a look at methodological pitfalls that have created widespread misunderstanding about long COVID. We really do not know what is the true rate of long COVID or PASC. I noticed this morning there was a look at, well, what is this rate?

Once again, it’s saying that in data released by the National Center for Health Statistics, some almost 7% of the adults in the U.S. are estimated to have experienced this syndrome since 2022. It’s more prevalent among women (8.5%) versus 5.2% among the men. There is a lot of statistics that are still being promulgated out there that are ostensibly informative that may or may not be. What this paper did was take a look at that. What’s the literature out there and what did it do? How can we poke holes into it and methodological problems that may have overestimated the number of people who have this particular syndrome?

They define long COVID as something that was the direct sequelae of the viral infection SARS-CoV-2 and lasted at least 12 weeks. Let’s just call it PASC, which they ultimately transcend to. They said that existing PASC case definitions from four international health organizations show that none of them requires a causal link between the infection and the development of the syndrome. While these definitions did say, “You’ve got to historically say that you’ve been infected,” only 54% required a laboratory-confirmed infection.

They also say, “What about how long you’ve got these symptoms?,” once again citing good evidence that post-infectious syndromes after COVID-19 improve over time, while some symptoms may take longer to improve than others. Ultimately they say, “We really just don’t know.” We don’t have any really good objective studies to define this using controls who did not become infected with COVID-19, which, of course, would be the standard.

Rick: The term that you used, PASC, for our listeners who may not be familiar is “post-acute sequelae of COVID-19.” The first thing is you’d have to prove that someone had COVID-19, and many studies didn’t do that. Furthermore, you’re talking about symptoms that last for at least 12 weeks. Some of the studies, 40% of the symptoms that people report occurred more than 3 months after the infection attributed to COVID. Actually, when you compare it to the general population, many of us that don’t have COVID develop symptoms. As you noted, this paper indicates that many of the studies have overestimated the prevalence.

When you actually look at it more critically, there are some studies that suggest it occurs in less than 5% of individuals. This study says, “Listen, let’s get some clear definitions. Let’s all use the same definition. Let’s prove people had COVID. Let’s have a comparison group that is equivalent and let’s see if the COVID infection actually causes long-term symptoms that aren’t present in the control group, which never had COVID.”

Elizabeth: I would also note that they said that their most well-designed studies that they examined did provide some reassurance when a control group was included and there was also matching with age, sex, health, and sociodemographic controls. The prevalence of any of 12 common symptoms was 5% at 12 to 16 weeks after infection compared with 3.4% in a control group without a positive COVID-19 test.

Rick: In fact, they say if you look at the carefully controlled studies, there really was no difference in the prevalence of reported persistent symptoms in children or in adults younger than age 50.

Elizabeth: More definition needed. Let’s turn to your next one in the BMJ.

Rick: I titled it “Who are you likely to see at your next outpatient visit?” You might see a doctor, but you might see a healthcare extender. Those are the nurse practitioners or physician assistants that oftentimes are seeing patients in the outpatient setting and they look over a 6-year period from 2013 to 2019. They looked at over 276 million visits of Medicare individuals. If you go back to 2013, only about 1 in 7 visits were delivered by nurse practitioners or physician assistants. That has risen now [in] 2019 to 1 in 4.

Which types of visits are the nurse practitioners or physicians more likely to be involved in? It’s unusual for them to see people with eye disorders. It’s more likely they see people with hypertension, anxiety disorders, and most for respiratory infections. Among all patients with at least one visit in 2019, 42% had one or more nurse practitioner or physician assistant visits. The likelihood of receiving care from an NP or PA was greatest among individuals who were lower-income, rural residents, and those who were disabled.

Elizabeth: Anything surprising here? It sure doesn’t sound surprising to me.

Rick: I think most people would say, “I’m sorry. 42% of individuals that had a visit in 2019 saw a nurse practitioner or a PA?” I think most people would have said that number isn’t that high. Oftentimes, when people go to the outpatient clinic to have a visit, they have a hard time discerning who they are seeing.

Some of the nurse practitioners have a PhD and in some states are referring to themselves as doctors. Technically, they are a doctor. But when they represent themselves as a doctor in the healthcare setting, you think they’re an MD.

I do think it’s nice to know that they’re primarily seeing individuals within their field of expertise, things like respiratory disease and hypertension, and less likely to see people that need subspecialty care like, again, ophthalmology or cardiology.

Elizabeth: Or, cardiology — had to add that one. I also just would note again in today’s medical news about the predominance of telehealth and my suspicion is that a lot more of these care extenders are going to get involved in that arena also.

Rick: This will allow them to increase their scope of practice. The use of telemedicine will allow them to get in touch with experts. We’re doing that out here in Far West Texas, Elizabeth. That is, we’re providing telemedicine specialty services to both general practitioners and to healthcare providers.

Elizabeth: Finally, let’s turn to Nature Medicine. This is a look at this longitudinal, genomic surveillance of carriage and transmission of Clostridioides, so writ large the whole family of Clostridium species, difficile or subspecies, in an intensive care unit. This is of interest to me, of course, in my work in the MICU. The author site that C. diff remains the leading cause of healthcare-associated infections in the United States. We know that there are a lot of potential outcomes relative to C. diff infection. One of them, of course, is death.

Current prevention strategies, they say, are limited because they don’t account for patients who carry C. diff asymptomatically. The question is, are they acting as hidden reservoirs who ultimately end up transmitting infections to other patients?

They decided that they were going to do genomic analysis of all these C. diff subspecies that they were finding among intensive care unit patients. They did this over 9 months and did whole genome sequencing on all recovered isolates.

They found that despite a high burden of carriage — so lots of people carrying this around, with 9.3% of admissions having C. diff subspecies that are toxigenic detected in at least one sample — only 1% of patients who cultured negative on admission to the unit acquired C. diff via this cross-transmission mechanism. Those who came in carrying one of these particular strains of C. diff had a 24 times greater risk for developing a healthcare onset infection than non-carriers. What we really need to do is say, “Wow, how do we prevent that particular thing from happening versus worrying about asymptomatic transmission to other patients on the unit?”

Rick: Elizabeth, I’m glad you picked this particular paper. As you mentioned, C. diff is a real problem. The individuals that are predisposed are those that are older and get multiple antibiotics, so the C. diff overgrows in the GI tract. It becomes the predominant species in the microbiome of the GI tract. They develop diarrhea. They can develop systemic infection and die.

I always thought, gosh, for people that were asymptomatic carriers — you don’t know they have it — they would be the reservoir to spreading to other individuals in the ICU. But from this study, they tested everybody that was admitted, whether they had symptoms or not, and they determined that 9% were asymptomatic carriers, but they weren’t the ones that were likely to pass it on to individuals in the ICU. But they were, as you said, more likely to develop significant C. diff infection and probably as a result of being on antibiotics.

The implication is you don’t need to screen individuals. It’s that the routine stuff we’re doing now in the hospital — isolating individuals that are infected, using a hand-washing technique, using gowns and stuff like that — are sufficient to prevent spread in the hospital.

Elizabeth: That’s really good news because as you’re aware, and so am I, donning all of these gowns, gloves, and all these ostensible prevention efforts, if they aren’t going to actually have an impact we shouldn’t be doing it because that’s a generation of an enormous amount of medical waste.

Rick: Not only that, Elizabeth. It means we don’t have to screen everybody that comes into the ICU and then put them on antibiotics if we determine they have C. diff and they’re asymptomatic. A number of wonderful outcomes or implications from this particular study.

Elizabeth: On that up note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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