ABSTRACT
Introduction: The COVID-19 pandemic has altered the delivery of all health care. In spring of 2020, efforts made to minimize disease transmission including “stay-at-home” orders and the deferral of elective outpatient encounters may have led to later, more acute disease presentations. Aim: Assess the impact of the COVID healthcare shutdown on patients presenting to hospital with gastrointestinal bleeding (GIB). Methods: We compared weekly counts of ED visits and inpatient admissions for GIB between the time periods of March 27-May 7, 2020 (COVID period) and March 27-May 7, 2019 (pre-COVID period) in a large health system comprising academic and community hospitals. We also compared the severity of GIB presentations between periods, using incident rate (IRR) and odds ratios (OR) of “severe” GIB (requiring >4 units of red blood cells, endoscopic therapy, interventional radiology or surgical procedure), ICU admission, or shock, as well as multiple secondary clinical outcomes based on automated extraction of ICD-10 diagnoses as well as manual chart review. Lastly, we looked for effect modification of demographic covariates on any association between year and GIB outcomes. Results: The number of ED visits for GIB was significantly lower in 2020 (534 ED visits) compared to 2019 (904 in 2019;IRR 0.59, 95%CI 0.53-0.66, Figure 1). A greater proportion of ED visits for GIB required an inpatient stay in 2020 (73.6% vs 67.8%, p=0.02). Although the absolute number of inpatient and ICU admissions for GIB in 2020 were fewer, the percentage of visits categorized as severe GIB was significantly higher in 2020 (19.3% vs 14.9%, p=0.03). Average transfusion requirement, the first or extreme values for hemoglobin and lactate, and the proportion diagnosed with shock were statistically worse in the 2020 group. While higher frequency variables (e.g. number of endoscopic procedures with hemostasis intervention, total units of red cells, hospital/ICU lengths of stay) were higher in 2019, those for lower frequency variables of more severe disease, including vasopressor support, intubations, renal replacement therapy and inpatient deaths, were similar. There was a significant interaction between year and race, with non-white patients experiencing greater proportions of severe GIB, and greater absolute counts of shock or ICU admission in 2020 than 2019 (Figure 3). Conclusion: A significantly lower number of ER visits and hospitalizations GIB occurred during the pandemic period compared to the same period the year prior. The severity of pandemic presentations was greater, driven by disproportionately worse outcomes in minorities. During the rest of COVID-19 and future pandemics, it is critical to maintain standards of care for non-COVID conditions, with a particularly eye to racial equity. (Figure Presented) (Figure Presented) Interactions of race/ethnicity with year of presentation for probabilities of clinical outcomes
ABSTRACT
Background: A number of factors can inform ICU escalation decisions, including the likelihood of survival and patient co-morbidities. This study examined prior liver transplant (LT) recipients and patients with chronic liver disease (CLD) diagnosed with SARS-CoV-2, and compared the rate of ICU admission and decline amongst those who were sick enough to require ICU care. Methods: Patient data from 12 March 2020 to 6 May 2021 was extracted using two international reporting registries (SECURE-Liver and COVID-Hep). Patients had a history of LT or CLD, laboratory-confirmed SARS-CoV-2, and were deemed ill enough to require ICU care. Patients were either admitted to the ICU, or declined admission due to inadequate capacity or because ICU escalation was deemed inappropriate. We compared patient characteristics by ICU decline, and compared ICU decline rates by LT and CLD categories with unadjusted and multivariable logistic regression. Results: 173 LT recipients were admitted to the hospital with SARS-CoV-2 (transplant year 1986-2020, median age 63, 74% male), and 66 (38.2%) were deemed unwell enough to require ICU care. Among those sick enough to require ICU care, 55 (83.3%) were admitted to the ICU and 11 (16.7%) were declined admission. Compared to those admitted to the ICU, patients declined ICU admission were significantly older (median 69 yrs vs 62 yrs, p=0.01) but otherwise similar in other characteristics. ICU decline rates in prior LT recipients (16.7%) were similar to patients with non-cirrhotic CLD (16.1%, p=0.96), but substantially lower than patients with Child A cirrhosis (31.8%, p=0.03), Child B cirrhosis (37.1%, p=0.006) and Child C cirrhosis (38.7%, p=0.004). Differences in ICU decline between LT recipients and Child B or C cirrhosis remained statistically significant after adjustment for age, sex and major co-morbidities. Among patients admitted to the ICU, mortality was higher in LT recipients compared to non-cirrhotic CLD (OR 0.31, 95% CI 0.14-0.71) but lower in LT recipients compared to Child C cirrhosis (OR 3.85, 95% CI 1.47-10.11) after adjustment for age, sex and co-morbidities (see Figure 1). Conclusion: ICU decline was less likely in LT recipients compared to patients with decompensated cirrhosis. LT recipients may be seen as gaining more benefit from ICU care, given the higher mortality amongst patients with decompensated cirrhosis. This is in line with prior data showing decompensated cirrhosis is a predictor of higher mortality in patients with SARS-CoV-2. Moreover, large investment of resources in LT recipients may make them more likely to be admitted to the ICU.
ABSTRACT
Background: Smartphone applications are on the rise;yet it is unclear whether liver transplant (LT) recipients would use or benefit from this technology. We aimed to understand baseline smartphone practices and identify preferences for an app-based intervention to guide the development of the LiveRightTM Transplant app among LT recipients Methods: Twenty in-depth, in-person interviews were conducted from 2019-2020 among adults 3 to 6 months after LT at the University of North Carolina We evaluated baseline use of smartphone technology, as well as acceptability of and preferences for a LT app Interviews were conducted by trained qualitative experts and analyzed in an iterative fashion using a thematic content approach to identify relevant themes Coded transcripts were analyzed using Dedoose qualitative software Results: Among 20 LT recipients, median age was 61 years (range 28-68);65% were male;60% Caucasian;40% underwent LT for non-alcoholic fatty liver disease, 20% for viral hepatitis, and 10% for alcohol-associated liver disease Patients lived 76 miles (range 14-270) from the hospital A majority (90%) of patients owned smartphones In addition to calls, text, and email, smartphone users engaged in social media including Facebook (55%), sought information through search engines (50%), and played games or watched videos (30%) on their phones Most (65%) used EPIC MyChart to communicate with the transplant team and set phone alarms for medication reminders A majority (80%) were interested in a LT app that enabled: 1) anonymous and secure ways to connect with other LT recipients, 2) logging biometric data, 3) medication reminders including real time updates of dosages, 4) virtual communication with the medical team (after hours or early in post-LT recovery when difficult to travel to clinic), and 5) vetted educational materials especially on medication side effects/symptoms, diet, and physical activity (Figure 1) Conclusion: LT recipients want a smartphone app to aid in their recovery Most important to them is connecting with other LT recipients for peer support, educational resources related to expectations, symptoms and medication side effects, and easy options to log biometric data to be shared with their transplant team With the advent of COVID-19, using smartphone interventions will be critical to improving transplant outcomes These data informed the development of the LiveRightTM app with pilot testing underway. (Table Presented).