Correspondence

African American men and women are up to two times more likely to develop diabetes over their lifetimes than white Americans. Diabetes occurs when your blood glucose (also called blood sugar) is too high. Over time, high levels of blood glucose can cause heart disease, nerve damage, eye problems, and kidney disease.

Previous studies in white and Asian populations have linked disturbances in sleep to increased blood glucose levels. These disturbances may be caused by sleep apnea, a condition where breathing stops or gets very shallow for periods during the sleep cycle. Sleep apnea reduces the amount of oxygen that reaches the organs of the body, potentially leading to many health problems.

To see if links between disrupted sleep and high blood glucose levels also exist in African Americans, researchers led by Dr. Yuichiro Yano from Duke University looked at data collected between 2012 and 2016 by the Jackson Heart Study. This community-based study looked at risk factors for heart disease among African American men and women living in the Jackson, Mississippi metropolitan area.

The analysis included about 800 participants who underwent home sleep apnea testing. They also wore a wrist actigraph (a device that measures wakefulness and sleep) for a week, and kept a sleep diary. This information was used to calculate how long people slept, how often they woke up during the night, and variability in these sleep patterns. to determine if treating sleep apnea Measurements of blood glucose and encouraging better sleep patwere taken in the clinic. terns can improve blood glucose levels and prevent diabetes in African The participants were mostly womAmericans. 1 en, and about 25% had diabetes. Around a third were found to have sleep apnea, most of whom were not receiving treatment for the condi1References: Sleep Characteristics and Measures of Glucose Metabolism in Blacks: The Jackson Heart tion. The study was funded in part Study. Yano Y, Gao Y, Johnson DA, Carnethon M, by NIH’s National Heart, Lung, and Blood Institute (NHLBI) and NationCorrea A, Mittleman MA, Sims M, Mostofsky E, Wilson JG, Redline S. J Am Heart Assoc. 2020 Apr 28:e013209. doi: 10.1161/JAHA.119.013209. [Epub ahead of print]. al Institute for Minority Health and PMID: 32342760. Health Disparities (NIMHD). Results were published on April 28, 2020, in the Journal of the American Heart Association.

Both sleep apnea and fragmented sleep patterns recorded during the study were associated with higher blood glucose levels. These associations remained after the researchers adjusted for other factors including age, sex, weight, smoking and alcohol use, and history of diabetes and heart disease.

People with the most severe sleep apnea had 14% higher fasting blood glucose levels than those without sleep apnea. In people who already had diabetes, greater disturbances in sleep were associated with lower sensitivity to insulin, the hormone that signals cells to take up sugar from the blood.

“Our results reaffirm the need to improve the screening and diagnosis of sleep apnea, both in African Americans and other groups,” Yano says. Past studies have found that many people with sleep apnea don’t know they have the condition.

Treatments for sleep apnea include lifestyle changes and use of a continuous positive air pressure (CPAP) machine. More research is needed

The rule change was part of a broad The American Medical Association “ACP has repeatedly requested this package of waivers and rules shifts that called the pay parity “a major vicchange from CMS as the country has were brought forward Thursday by CMS tory for medicine that will enable been dealing with the COVID-19 in to facilitate COVID-19 testing and physicians to care for their patients, national emergency and we are heartexpand access to telehealth. especially their elderly patients with ened that they have heard our conThe Centers for Medicare & Medicaid Services on Thursday said it will bump up payments for audio-only chronic conditions who may not have access to audio-visual techcerns,” she said. “ACP has repeatedly requested this change from CMS as the country has been dealing with the COVID-19 Fincher said the increased payments are coming at a critical time for both telephone consultations to match payments made for office and outpatients visits. nology or high-speed Internet. This providers and their patients. “Right now, due to a drastic decrease in in-office patient visits, many practices are struggling to national emergency and we are heartened that they have heard our concerns.” The new rule would increase payments change will help patients address remain open and continue providing for audio-only telephone consultations their health challenges that existed needed care,” she said. “Many seniors from $14-$41 to about $46-$110, CMS before COVID-19.” and other vulnerable patients lack the said in a media release. capability to conduct video visits with Jacqueline Fincher, MD, president of their physicians, so those patients are The rule change was part of a broad the American College of Physicians, being cared for with telephone-only package of waivers and rules shifts that were brought forward Thursday by CMS in to facilitate testing and expand access to telehealth. said the “change in payment policy addresses one of the biggest issues facing physicians as they struggle to make up for lost revenue and provide visits that were reimbursed at a much lower rate.” 1 Physician associations cheered the news. appropriate care to patients.” 1HealthLeaders, By John Commins | April 30, 2020 12 AMPNATION

Image credit: Adobe Stock

The hidden epidemic of prediabetes You could have prediabetes and not even know it. More than Certain factors can make you more likely to develop predione in three adult Americans—approximately 88 million— abetes. You are more at risk if you have a parent or sibling have the condition, but 90% don’t realize it. with diabetes and are age 45 or older. Race and ethnicity are also factors: African Americans, Recent research by the Centers for Disease Control and PreEating healthier food Hispanic/Latino Americans, Native Americans, and some vention also reports that nearly one in four young adults (ages 19 to 34) and half of people over the age of 65 are living with prediabetes. and becoming more physically active can Asian Americans are at higher risk for type 2 diabetes. Additionally, you’re more at risk if you are overweight or obese and are physically inactive. This is just What is prediabetes? And if so help you lose weight, a short list of risk factors. To see more and to take a test to learn many people don’t realize they have it, what can you do—esfeel better, and lower about your own risk factors, visit the National Institute of Diabetes pecially if diabetes runs in your family? your risk of developand Digestive and Kidney Diseases website. Prediabetes means your blood ing type 2 diabetes. Getting more exercise and losing sugar levels are higher than a small amount of weight can help normal. The levels are not high prevent diabetes if you are at risk. enough to be diagnosed as type Eating healthier food and becom2 diabetes, but it’s a warning ing more physically active—taksign that, over time, you could develop the disease. That’s ing a brisk walk for 30 minutes a day, five times a week, for why learning about risk factors is so important. example—can help you lose weight, feel better, and lower your risk of developing type 2 diabetes. Even small steps—losing Prediabetes indicates a problem with the cells in your body. just 5% to 7% of your body weight (10 to 14 pounds for a It means that those cells are not responding in a normal 200-pound person)—can make a big difference in preventing way to insulin, an important hormone that helps sugar in type 2 diabetes. 1 the blood get into cells and be used for energy. If a person’s body can’t make or respond to insulin, blood sugar levels rise. 1 National Institute of Diabetes and Digestive and Kidney Diseases; Centers for Disease Control and Prevention

& Vascular Orthopaedics T he United States will eventually get through the acute coronavirus disease 2019 (COVID-19) crisis but not without fundamental changes to the The Business of Medicine in the Era of COVID-19 medical care system. Since the epidemic began, payment policy has stretched to remedy the bias concern even in this scenario. Will Small primary care and specialty of the health care system for in-person treatment patients have concluded that some offices are also vulnerable because provided by physicians. In response to the need services are not so essential and thus they are, in the end, small businesses: for social distancing, new policies include broader not return for them? Will the rush a significant share of primary care payment for telemedicine, expanded scope-ofof patients who do seek services physicians work in practices with 1 practice ability for non-physician practitioners, lead to delays in scheduling and the or 2 physicians.3 If primary care or and increased ability of physicians and nurses rationing of capacity, both of which specialty visits are either deferred or to practice across state lines. While these policy may lead patients to abandon valuforegone, the reduction in physician reforms address some of the immediate needs of able treatment out of frustration? practice income could shutter some this crisis, such as getting personnel to where they practices. It is unclear how effective are most needed, they are not a complete solution If the COVID-19 shutdown lasts the small-business loans that have to the COVID-19 crisis. How the aftermath of the for months or the normal business been made available to many of these current COVID-19 wave is handled will be just as of health care does not resume until practices will be in ensuring they beimportant for the business of health care as what the fall, the implications for physicome operational again when social is happening now. cians and hospitals would be much distancing ends. more severe. In the past month, the Two issues about the medical system after the response of many health care orgaThis fall, and certainly into 2021, current wave are particularly important: What nizations to the reduction in primary there could be additional consolitype of organizations will be available to treat and elective care has been to redation of practices, both large and patients a few months from now? And how will duce staff providing those services. small. Smaller hospitals will look those patients be most effectively served? Employment in health care declined for capital infusions by merging by an estimated 43 000 people from with bigger hospitals, and physicians What Will the Health Care Landscape Look mid-February through mid-March1 may find more security in larger Like? and has undoubtedly declined further groups. Several factors hasten these Hospitals and physicians treating most patients since then. Approximately half the trends. Hospitals have started to with COVID-19 have 2 financial challenges. The cost of primary care practices is work together to care for patients direct costs of caring for patients with COVID-19 attributable to salaries, so furloughs with COVID-19; merging may be are clear; many such patients are uninsured or help ensure solvency.2 But bills will a natural extension of that activity. require care that costs more than insurance pays. have to be paid, and remaining costs Further, hospital personnel will be Likely much larger, however, is the financial cannot be reduced as much. The bank exhausted by caring for patients with effect of having postponed nonemergency care, accounts of many practices are not COVID-19. Some clinicians will ranging from office visits to elective surgery. large enough to absorb a long-term have become ill while caring for These are the cases from which physicians and shutdown. patients or will, in the worst circumhospitals derive most of their profits. Elective care stances, have succumbed to the virus. has declined across the country, with reductions in Some organizations are more vulAdditional physicians and nurses some services of 50% or more. nerable than others. In the hospital may thus be necessary. For services industry, rural institutions have lower that do not come back, physicians in The good scenario for population health is also margins than urban hospitals. This is specialties that provide those services the good scenario for the business of medicine. particularly true in the South, where may need immediate job security. It is possible that COVID-19 will be contained governors have been slow to enact sooner than expected and that the economy will stay-at-home measures and many The benefit of consolidation will recover earlier rather than later. In that case, states have not undertaken Medicaid be facilities that do not close and physicians and hospitals will fare well; indeed, expansion. Nearly 100 hospitals have communities that maintain sources there could be excess demand for services still closed in the South over the past of care. But there are likely to be deemed essential. But there could be pockets of decade. costs as well. Consolidation among hospitals and between hospitals and

physicians significantly increases health care prices.4 This trend will further increase health care spending at a time when the lingering effects of the virus will already be raising private insurance premiums.

For physicians, COVID-19 may affect how they practice in even more fundamental ways. In response to the need to maintain social distance, many physicians have turned to telemedicine. In March, the federal government substantially eased restrictions it had previously placed on Medicare reimbursement for care provided via telemedicine. To support this move, federal and state governments also provided physicians with greater latitude to practice across state lines. In addition, nurse practitioners and other non-physician clinicians were allowed greater ability to treat patients without direct supervision from physicians.

The substantial increase in the use of telemedicine during the crisis has been pervasive across health care systems. For instance, the Cleveland Clinic based in Cleveland, Ohio, reported being on track to complete more than 60000 telemedicine for visits for the month of March compared with its prior average of about 3400 visits per month.5 Similarly, Jefferson Health in Philadelphia, Pennsylvania, has seen an increase in virtual visits on its JeffConnect telemedicine platform, from 60 visits per day before the pandemic to a recent figure of 2000 visits per day.6 These are but 2 examples of a much broader phenomenon.

The rapid growth of telemedicine and the broadening of clinician license raise the question of what becomes of these new approaches to treatment once the immediate COVID-19 crisis has passed. At this point, most of the easing of regulation has been temporary. What is not clear is whether, when, and to what extent these regulations will be re-established. There are many arguments for making these regulatory changes permanent. Just as telemedicine and the expansion of clinician capacity may help patients needing certain types of urgent system for delivering care. 1 care during this crisis, it may be a useful outlet to serve the wave of elective visits that is currently welling up. Further, it 1David M. Cutler, PhD1; Sayeh Nikpay, PhD2; Robert S. may also be helpful once the system returns to something approaching a Huckman, PhD3, JAMA. Published online May 1, 2020. doi:10.1001/jama.2020.7242 “normal” level of volume. If keeping older patients and those with chronic disease home is necessary in an epidemic, it also could be beneficial outside of an epidemic. Many long-standing efforts to reform the health care system have suggested that this may well be the case.

But the push for mergers and remote practice could go much farther, changing in a fundamental way what it means to be a physician and to practice medicine. Hospitals and medical practices have already reduced benefits and decreased hours for clinical staff.7 Might organizations decide that it is better to hire physicians on an as-needed basis rather than through employment? Emergency department care in the last decade offers a fitting analogy. Many hospitals, especially those with small volumes, found it difficult to staff a full-time emergency department. As a result, they turned to outside staffing companies. Having less to manage was good for hospitals, but the outsourcing of emergency care was identified as a key driver of the surprise billing phenomenon the nation is still addressing.8 To the extent that such practices become more widespread, new forms of regulation may be needed just as others are being relaxed.

Everyone hopes that medical care will return to normal in the coming months. But the new normal may be not as recognizable as some think. Some changes may be good, but the road is fraught with risk. It is possible, perhaps likely, that the painful process of reaching a new health care equilibrium will last well into 2021. Ideally, this time will allow for thoughtful discussion of how the intertwined forces currently affecting clinicians and other health care personnel, as well as hospitals, health care centers, and practices, can lead to sustained improvement of the overall