The flu, RSV or COVID-19? When choosing a PCR solution, you want one that combines accuracy, speed and flexibility, while delivering more than just results.
In this webinar, Dr. Dov Shapiro, a pediatric physician managing Physician Associated Pediatric Partners SC, the oldest pediatric practice in the state of Illinois, discusses how transitioning to Cepheid's GeneXpert Systems increased his patient satisfaction scores and overall workflow and patient diagnosis in his practice. COVID has upended the seasonal viral patterns by its mitigation strategies and the ability to accurately diagnose the cause of the patient's illness is imperative.
Presented by: Dr. Dov Shapiro, managing physician, Associated Pediatric Partners
- Minute 1:55 – Intro
- Minute 7:30 – Comparison of rapid antigen COVID-19 tests
- Minute 11:00 – Viral testing for respiratory illnesses
- Minute 14:40 – Testing in clinical settings
- Minute 17:35 – PCR testing for group A Streptococcus (group A strep)
- Minute 19:10 – Effects on clinical practice
- Minute 21:05 – Current climate
- Minute 23:05 – Q&A
Brandon Martin: Good afternoon, everyone and thank you for joining us today. My name is Brandon Martin, customer engagement manager with McKesson Medical-Surgical. I'm pleased to welcome you to today's webinar, Integrating PCR Solutions into everyday practice brought to you by Cepheid.
Our speaker today is Dr. Dov Shapiro. Dr. Shapiro is a managing physician at Associated Pediatric Partners. He attended medical school at the Pritzker School of Medicine at the University of Chicago and did his pediatrics residency at Lutheran General Hospital in Park Ridge, Illinois.
He prides himself on providing top-notch care in a warm, friendly, and compassionate manner. His areas of interest are preventative health care, allergies and asthma, ADHD, behavioral and school issues, and child development. He sees children from newborn through college age and is equally comfortable in caring for newborns, adolescents and young adults. Dr. Shapiro is married and lives in West Rogers Park with his wife and five children.
Before we get started, I just want to direct your attention to the lower left-hand screen. If you have a question for Dr. Shapiro, feel free to post throughout the presentation as there will be a brief Q&A following. Simply locate the Q&A panel as I mentioned, in the lower left corner of your console, type your question in the text box, and click send.
We will do our best to answer questions as time allows at the end of the webinar. A recording of today's presentation and a copy of the slides will be sent to you within 48 hours via email. Once again, thank you so much for joining us today, and please join me in welcoming Dr. Dov Shapiro.
Dov Shapiro: Hi, everyone. As you mentioned, I'm Dr. Shapiro. I'm here to talk to you today about how my practice integrated PCR into our everyday practice and how that actually helped to transform the way my practice provides care to our patients.
This is the title slide, my journey in using Cepheid's GeneXpert Xpress how it transformed my practice. I know you already heard a wonderful bio on me. Thank you. That was actually very generous. One of the interesting things about my practice is we are the oldest practice in the entire state of Illinois.
This is our 67th year in practice. I've not been there all 67 of those years. I'm in there 22 years. But as a result, we actually not have first generation patients. We actually have second and third generation patients in our practice. We see grandparents bringing in their grandkids and the grandparents themselves were children in our practice once upon a time.
We discovered in adopting PCR in our office was not only did it achieve higher patient satisfaction, better clinical care, but it actually improved my practice's efficiency and profitability. And I wanted to share a little bit with all of you about the journey we undertook and how it affected my practice and how it could potentially affect all of your practices moving forward.
Quick disclosure, support and honorarium fees for development and delivery of this presentation have been provided by the Cepheid's Speakers Bureau.
All right. So for all of those in health care, which I assume is everybody on this presentation today, there has been no event in my career and I doubt it anyone else's career that has been as transformative and as disruptive as the COVID-19 pandemic.
It's changed the way we interact with our patients. It's changed the way we interact with our friends and family. It's changed how we go to school. It's changed how we shop. It's in many
cases changed how people celebrate family occasions. The people that pray, it's changed how they pray and sit in synagogues and churches. It's really changed almost every facet of our lives.
And like I said, in no area has it affected us more than in the medical care area, where we have to be very careful about not exposing our patients to a disease, which can make them quite sick. One of the things we noticed early on is our patient's expectations and our patient's behavior changed early on in the pandemic.
Many practices saw a downturn in volume in the beginning of the pandemic. People were afraid to leave home. They didn't want to come to a doctor's office. They didn't want to get sick. If they were going to come out to see a doctor, they only wanted to be seen in a facility that could roll out or confirm COVID. Otherwise, they were going to go to a state lab. Or they were going to go to a local acute care clinic to find out because if they couldn't rule out COVID, there was no point in coming to see the doctor.
They also wanted to make sure that whatever result they got, it was accepted by their workplace and school, that way they could get back to work and their children could go back to school. The quicker the result would come back would, of course, be the better. You may recall in the beginning, sometimes it took a week or longer to get back the PCR results and people were out of work and out of school that entire time. So the quicker one could get back to their patient with an accurate result, the better for that patient, the better patient satisfaction.
Now, from the standpoint of our office, we also had to adapt. Number one, we had to be able to see patients without exposing ourselves and our other patients to COVID-19. We have immunosuppressed patients in our practice. We have newborns. I don't want to expose them to some with COVID.
At the same time, we had to see a lot more children for illnesses in the past, when a child had a mild cold or a mild cough, they stayed at home for a little while. Only if it went on for more than four or five days or they developed a fever or difficulty breathing when they come to the doctor.
But now because of COVID, these children couldn't go to school with any of those symptoms. So they're coming in on the first day of symptoms because they want to know if their child has COVID and whether or not they have to be out of work and the child has to be out of school.
So we had to find a way to accommodate all those extra sick visits while still seeing all of our regular healthy checkups and regular chronic care for our patients. And we still had to maintain an efficient workflow in doing that.
Another very important point and something I'm going to discuss several times during this presentation is that COVID has changed the way viruses present. For almost all my career, viruses had a seasonality. Flu and RSV were always wintertime viruses. The enterovirus is like hand, foot, mouth or summer viruses.
Strep, while you can see it all year round, was most predominant in the fall when school would begin, and many other bacteria and viruses had a very strong seasonality to them. Because of COVID and because of the different types of measures we've taken to keep ourselves safe, like masking and social distancing and schools being closed, they've completely upended that pattern.
I don't know about all the rest of you, but we were seeing a lot of flu in our office until just last month. Even though it's only August, we're already seeing tons of RSV, so much so that in many states we started to give infants premature birth RSV immunoglobulin already early to protect them from RSV.
So once again, all these diseases are changing. We're seeing diseases in completely wrong seasons and as a result, we have to keep our eye open not just for COVID, but for other illnesses that normally wouldn't appear in the current season. They're still in our list and they often do occur.
So that's changed how we view patients' illnesses. We no longer can rely on seasonality to inform us what our patient may or may not have. We realized early on that in order to be able to continue to see our patients and provide the care which we were used to, we had to be able to offer COVID testing in our office.
And there was all types of technologies even back in the beginning to this day, of all the rapid antigen tests which can be done at a doctor's office or at home. But as everyone on the slide knows, PCR is still by far the gold standard when it comes to testing for COVID.
So much so that the term PCR is one of those terms that everybody in the country knows now. Whereas prior to COVID-19, only doctors and medical professionals knew that term PCR. But we realized early on that all COVID tests are not created equal, and as a result, we had to make a decision in my office and what type of tests we were going to offer.
This next slide actually comes from the beginning of the pandemic, although the reality is the numbers haven't changed dramatically. The bottom line is the most popular and most well-used tests, the ones that people now do at home, you can order for free through the government are rapid antigen tests.
Rapid antigen tests have the benefit of being very quick, very easy to use. One of their big advantages, they're very specific. So what does that mean when I say a test is very specific? Specificity refers to how likely is a positive test to really be indicative of the disease.
So if a rapid antigen test says you have COVID, depending on the test, the numbers are close to 100% accurate. It is very rare to get a false positive on any COVID test, including a rapid antigen test. Unfortunately, when it comes to sensitivity, that's where they lack.
Sensitivity refers to how sensitive is a negative test. If I think I may have COVID and I test and I test negative, how likely is that test to be accurate? Maybe I still have COVID, but the test isn't sensitive enough to pick it up. And unfortunately, most rapid antigen tests, in the beginning, were around the 50% mark. The best ones in the market are best 60 to 62%.
And that's only for people that are very symptomatic. For people that have mild cases are asymptomatic, the numbers are even lower. And all of us have seen those cases of people that have done two, three, four rapid antigen tests at home, all been negative. They do a PCR and they're positive.
So once again, we realized early on that if we wanted to be able to tell our patients with confidence whether or not they had COVID, the rapid antigen tests were not going to do the trick. We do a lot of research, and we came across Cepheid's Xpert Xpress system, the Gene Xpress system, and that's the copy of picture of a machine on the right.
That's a picture of a cartridge on the left. What's beautiful about this particular system, it is by far the most sensitive one on the market. Just like the rapid antigen test, it doesn't have any false positives. You look at the right side, negative percent agreement, that's another similar term to specificity.
A positive test on this test means you have COVID. No question they detected COVID in your nose and your nostrils. But if you look on the positive percent agreement, which is another word for sensitivity, how likely is it to be accurate, how likely is it not to miss a positive, for flu A, flu B and RSV, it is actually nearly 100%.
And even for COVID, it's actually 99.2 to 100% sensitive, which means it misses less than 1% of COVID tests. This makes it actually the most sensitive PCR test that's currently available for office use. And it's extremely accurate.
As you also notice, the beauty of this test is it doesn't while you can test for COVID alone, you can also test for common other viruses all with the same swab and all in the same amount of time. So we adopted this system early on in the pandemic.
In fact, we were the first practice in the entire state of Illinois to begin in-office PCR testing and using this machine. And our patients were thrilled and our volume went up tremendously as a result and we were able to give our patients same day very, very quick results with a greater deal of accuracy.
So a question people ask me is okay, great, why are you testing for four things? Why not just test for COVID? Well, the answer is early on we did just test for COVID. But once we realized how much the seasonal viral patterns had changed, we realized the testing for COVID alone was not sufficient because many of our children had other conditions which could be treated, for example, flu.
As many of you know, if you catch flu early enough, especially the child that has some risk factors, you can initiate treatment. Whether it's Tamiflu for younger children or Xofluza for older children. You can make a real difference if you catch flu early enough. With RSV, which is very, very dangerous for little babies, knowing that a family member has RSV is really important because if they have a young child or a baby in the house, you have to be very cautious that that baby doesn't catch RSV.
And if a baby is diagnosed RSV, you are going to watch them really carefully to make sure they don't end up needing hospitalization. So knowing early on what your patient has, not just that they don't have COVID, but actually what virus they do have, can very much inform the treatment they get and result in better outcomes for the patient.
It's interesting before COVID most of my patients, you have a virus. It's not COVID, not flu, you have a virus, people accepted that. Nowadays because people are used to viral testing now, a lot of my patients, I would say the majority find it unsatisfying to simply be told they have a virus.
They often want to know what it is and whether or not there's a medical justification for this. And I would argue that there is in most of these cases, it definitely improves patient satisfaction. You can give them a definitive answer what they have, not just because you can initiate treatment, but because you can tell them what to expect.
You have the flu. It's already been two days, so it's too late to treat you. You can expect to have fever for another four or five, six days, watch for shortness of breath, so on and so forth. Being able to tell a patient early on what they have, increases their satisfaction and also lets them know when their symptoms veer from what's expected.
So in my office, we've actually used the 4-Plex testing for actually almost all our patients and we are still getting positive hours fees every single day right now. And last month we were getting positive flu is multiple times a day and I found it to be a very effective test and it's actually changed quite a bit how I practice medicine.
One of the beautiful things about this machine, if you look at the picture in the upper right-hand corner, is depending on the size of machine you get, whether you get a two-slot machine or a four-module machine or an eight-module machine, each one of these little modules, each one of
those little doors you see on the bottom can run a test independently, and they can also run independent of one another.
So for example in slot one, you can be running a strap test, slot two you're running a COVID test and slot three, you can be running a 4-Plex test testing for COVID flu and RSV. Then slot four is to be running flu alone and each one runs on its own time frame independently of the rest.
It's almost like having four machines or two machines or eight machines in one. So that works really well with the workflow in the office because the staff doesn't have to line up the tests and put them in simultaneously. They put them in as they obtain them.
It really is an incredibly easy system to use. Training for my staff took less than an hour. You scan the barcodes in for the test. You scan to the patient's name and number and information. It's literally almost impossible to make an error. If you do anything wrong, the machine doesn't let you proceed to the next step.
It's also really a walk-away system. Once you obtain the specimen, you add it to the medium, shake it up, but a few drops in the cartridge, put it in, push the button and leave, and you go on to your next patient. And it results depending on the test, anywhere from 20 minutes to 35 minutes.
So as a result, it's really worked very well for my office. And once again, one swab can test for one virus, two viruses, three or all four viruses, including COVID, flu A, flu B and RSV. So how do we adopt this in our office? And this is something I've seen different offices manage different ways.
This machine has gotten very popular in my area. All the local hospitals, the local acute care clinics, the emergency rooms and doctor's offices have become to adopt this system over the
past six months to a year. We were first, but it's become probably the most popular system in my area.
In acute care clinics, I've seen the first model used. Where patients are triaged right when they arrive, the nurse or PAs or whoever is putting the patient in, if they meet certain criteria, already starts the swab and by the time they see the provider we already have results and those are given to the patient.
The second model also works in acute care clinics and also works in private physician offices, whereas you don't actually do the test until you see the patient because you're not sure if they need it or not. And then you get the results in an hour or less, and then you call the patient back or you email them with the results within the hour.
The last model is one my office has done, and while it does take a little more time upfront, it's allowed my office to see a large number of patients in a shorter period of time. So why have we done that? To this day, my office still does not allow sick patients and well patients in together at the same time.
We started that with the beginning of COVID. So during the morning for an hour and a half and during the evening for an hour and a half, we have sick hours. That's when all of our people with sick symptoms, whether it's cold, cough, fever or shortness of breath, that's when they come in. And during the middle of the day, we see all our healthy patients.
Our newborns are our healthy children. That way we never expose healthy and sick children to one another. And that has removed our patients' concern about coming to the doctor's office. It's also prevented us from sharing COVID among our patients, which is something we obviously don't want our patients to leave, but then they didn't come in with.
So in our case, after lunch, the doctor is given a certain period of time where they call back all the patients that have called that morning asking to be seen. The doctor gets the history, they enter it in the system including some orders. Then when the patient arrives later that afternoon, the tests are already ordered. The nurse goes ahead and obtains the tests.
The patient gets seen by the doctor and then they're discharged depending on when they came in, we have a result by the time the doctor sees them, or in many cases, the result comes in 30 minutes later, they're then called and the results are put in our portal.
This allowed us to see a large number of patients in a shorter period of time. I can often say 15, 16 patients in an hour in six hours now. So I've already gotten the entire history. I already know the plan. So it's really just a question of examining them and talking to the patients and their parents about the next steps.
And this allowed us once again to keep our healthy and sick kids separate. So any of these models work for any practice? It's really a question of the size of your facility, whether you have space to keep sick and well separate and also where you schedule your sick.
But once again, these have worked really well and made my practice able to see many, many more patients in an hour and accommodate as many sick patients as we need to. Now, that's all for viral testing for a respiratory illness. But that's not all that the Xpert Xpress system does.
Even before COVID, they were very popular in the use of their strep A testing. Now, this we adopted actually at the beginning of COVID epidemic as well and it's really changed how my office treats strep. Like many people on this call, up until COVID, the way we did strep testing was we did a rapid strep test. Get a result in about five minutes.
It's not terribly perfect. It does have some false positives. It does have some false negatives. Probably as much as five to 10% of strep cases are missed, which is why all of us know that if you have a negative strep rapid test, you still got to send out our overnight culture.
The beauty of the strep PCR is it's so sensitive. In fact, in this case, 99.4% sensitive. It actually does not require overnight culture. A negative strep test on the Xpert Xpress strep A PCR test means they don't have strep. No overnight cultures necessary. You can give that patient a definitive answer within 18 minutes whether it's strep or not.
Not only does that give the patient the satisfaction of knowing they do or don't have strep enough to wait two days to find out, it also avoids needless use of antibiotics prematurely. It also saves my staff and myself a lot of time having to track down those cultures and to track down the patient when they're positive.
This has changed how we treat strep no longer be writing antibiotics, which we always try to avoid because we're suspicious they have strep despite a negative rapid strep test, and no longer are we having to track down patients two days later to tell them they got strep the past two days, they have infected all their friends and family. Now we find out that same day definitively whether they have strep or not.
So how has the using the system transformed my practice? As I mentioned in the beginning, while other practices were suffering from reduced visits, we were busier than ever and we were able to accommodate all our patients, both healthy and sick. I also mentioned this is really true.
The opportunity to see many, many, many more sick visits has only increased due to COVID. Now patients need to come in at the onset of symptoms to prove they don't have COVID so they can return to school and their parents can return to work.
Being able to accommodate our patients and prove they do or don't have COVID and then get the parents back to work and the kids back to school the next day, has resulted in a very high patient satisfaction among our patient population. My office has always tracked our satisfaction scores really, really carefully.
We've always done really well in the mid-80s, which I've been very proud of, but since the beginning of the pandemic, and I would attribute a lot of this based on the comments to our ability to test kids in the office and see them same day and give them same-day results. It's increased to the upper 90s, as of last quarter it was 97% satisfaction, which is fantastic.
And our patients can't stop singing our praises to all their friends saying that, oh, I'm sorry, you had to wait a few days, we saw our doctor the same day and got an answer and my child is back in school today. As I mentioned, this is a very key point for me.
The ability to quickly and accurately diagnose what our patient have, not just they don't have COVID, but what they actually do have, whether it be flu or RSV, has resulted in better, earlier and more efficient care for our patients.
And while this was not the reason we set out to do this, I was surprised and pleased to find out that in the 20 years that I've been managing physician of my practice, we've actually had the most profitable couple of years in all the years I've been running the practice.
And the main reason for that is more sick visits and better reimbursement for PCR testing compared to other tests. And this is really changed how my practice has practice medicine and made a huge difference to our practice now during the pandemic but I'm hoping moving forward.
Current climate. COVID's changing. It's becoming more of a chronic illness now. It's still serious and people that are high risk still can get sick. But we've come to learn to live with COVID now.
But here in Illinois, during times of high COVID transmission, many cities and counties are only accepting PCR tests return to school or work.
They don't mind you testing at home, but if you have really classic symptoms in many schools and many workplaces, still want a PCR test to allow someone to come back to work. It's been interesting to watch it over the last two years.
Almost all large hospitals and all of the local children's hospitals in my area have all started using the same Cepheid system for their own inpatient and outpatient clinics. Because it's the best on the market. It's become the standard of care; it's become the gold standard.
And like I mentioned, almost all the practice and pediatricians I know in the area have also now switched or are switching to Cepheid from the other systems, and that's because it actually is the most sensitive test they've added more genetic sequences and test for than any other test.
And as a result, they pick up not only traditional COVID but all the new strains as well. And this has made it a very popular machine and one that seems to become have test taken over the market as the gold standard, as the most popular and best and easy-to-use system on the market.
A couple of resources here. The Cepheid [inaudible] team can help you to get a machine and to work with any questions you have. There's also a website that talks about applicable codes and reimbursements, which all I'll say are very, very generous and definitely help practices financially, and they can help you with that kind information as well.
And then of course most inpatient, it helps our patients because we're able to provide them better care and give them real, meaningful results in a very, very rapid amount of time. So once again, delivering a better way to improve patient outcomes by enabling access to PCR testing
everywhere. In this case, by offering it in my office, we've been able to improve patient satisfaction and patient outcomes.
I'll now open for any questions anyone might have.
Brandon Martin: Excellent. Thank you so much, Dr. Shapiro. The first question that's come to us, could you speak a little bit about adopting this technology in your practice as far as like the ease of bringing this in and any sort of anecdotes about training around using?
Dov Shapiro: I was pleasantly surprised. I always assumed that a PCR system would take a lot of training and be hard to put together. It was really simple to put together. I think that took us about 20 minutes and we downloaded some of the software updates online.
But the part that really, really impressed me was how quick we been teaching people to use a system. We in fact hired – at the outset, it never took anyone more than an hour and most people less than 30 minutes to learn how to use. We just hired two new nurses in the past and they both trained on the new system within less than a day.
They practiced with us for half an hour, by the next day they were already doing it themselves. It is really, really easy to use. It's all scan and go. It really walks you through the steps. It is an incredibly user-friendly system and requires almost no training to run and it won't let you make a mistake.
If you don't do it right, it won't let you go to the next step. So training has been as simple as I can imagine of any other system. Literally, you don't need a medical degree to run the system. You could have a high school student if you want to run the system it doesn't require any advanced training and it's been very easy to adopt in my office.
Brandon Martin: Excellent. Thank you so much. We'll leave a couple of minutes here in case any other questions come through. While we're doing that, if I could just direct everyone's attention to our product information disclaimer. And I would also like for you to review our McKesson webinar disclaimer.
Excellent. Well, thank you so much, Dr. Shapiro. I really appreciate your time today. I appreciate you joining us and walking through this system. As we come to a close, I do want to take this opportunity to thank all of our attendees for joining us today. As a reminder, you can find a list of our upcoming webinars on our website at mms.mckesson.com/educational-webinars.
Dov Shapiro: Well, thank you all very much. If there are no more questions, I want to give them another minute to see if anyone has any questions.
Brandon Martin: Sure.
Dov Shapiro: Over the years, my office has always liked adopting new technology, something we're known for. I really enjoy technology and seeing how it can improve the care I provide. And I've made some bad moves and some good moves over the years. Some systems I thought were to be incredible ended up being expensive and really did not work out well.
This particular system is by far the best decision I've ever made. It's made me look brilliant in my partner's eyes because it's worked so well for our office not just from a patient care, but from financial perspective. And it's nice to pick a piece of technology that's so necessary.
As a result of this pandemic, we've come to realize how important the flexibility and efficiencies of PCR testing in the office and now it's become our standard of care, which is going to continue long after this pandemic and into the future. Cepheid is working in many new kinds of tests that can be run in the office and I really think it's changed how we think about testing.
Being able to get a same-day result and in most cases less than 45 minutes, in many cases less than a half an hour, really changes how you treat your patients and it's been a huge, huge success for my office, which is why I'm so passionate about it and why I like giving these talks.
Brandon Martin: Well, that is excellent. And I certainly do appreciate your time and insight today. And we've also gotten a few messages of thanks come into our Q&A as well. So, Dr. Shapiro, I really appreciate it. Just to remind our audience, we will send a copy of the presentation and a recording of today's event.
So watch your inbox for that. If you do have any questions that come up later for Dr. Shapiro, please feel free to reach out to us, and we will be sure to relay that message. Dr. Shapiro once again, just thank you so much for your time today.
Dov Shapiro: You're welcome. Everybody, have a wonderful afternoon.
Brandon Martin: Thank you.
Webinar originally aired on August 17, 2022
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