ABSTRACT
Background: Utilization of teleneurology for MS care rapidly expanded during the COVID-19 pandemic to maintain healthcare access. Disparities in telehealth use have been described in other health conditions, but not in a MS population. Objectives/Aims: To evaluate longitudinal utilization of teleneurology across age, race, geographic factors, and insurance categories to identify potential disparities in utilization at a single academic MS center (Cleveland Clinic). Method(s): MS patients attending a specialty clinic in Cleveland, a medium-sized city, who completed >=2 visits at least 24 months apart from 1/2019 to 6/2021 were studied. Patients with fully inperson care were compared to patients with <50% or >50% teleneurology care. Categories of age, race, geographic factors, and insurance were compared using Kruskal-Wallis tests and pairwise Wilcoxon rank sum tests with Bonferroni correction for multiple comparisons. Result(s): 892 patients met the inclusion criteria and completed 3710 visits during the study timeframe: mean age 49.1+/-11.7 years, 73.7% female, 85.6% white, median disease duration 11.2 years [0.15;60.3], and relapsing-remitting 62.3%. 37% patients were fully in-person, 37.2% patients had <50% teleneurology care, and 25.8% patients had >50% teleneurology care. There were no significant differences for race (white, black, other), insurance type (Medicare, Medicaid, private, non/other), area deprivation index (ADI), and residence location (rural vs metropolitan) in the use of teleneurology. Use of teleneurology care varied based by age, with older patients utilizing more in-person care. In person care was 23.4% for ages 18-39, 38.5% for ages 40-60, and 47.8% for those greater than 60 (p<0.001). Patients residing in greater Cleveland had significantly more in-person care (55.3%) compared to residents residing in Ohio outside of the greater Cleveland area (34.7%) and outside of Ohio (10.1%) (p=0.031). Conclusion(s): There were no significant differences in teleneurology utilization across race, insurance, ADI or rural vs metropolitan residence, suggesting it is a broadly accessible tool to overcome disparities in access to MS care. Utilization of teleneurology care for older and local patients was lower, which may be due to decrease demand in these groups. Future studies should assess the optimal integration of teleneurology and in-person visits in MS management.
ABSTRACT
Background: With widespread COVID-19 immunization efforts, reports of vaccine-induced thrombocytopenia and thrombosis (VITT) have emerged, particularly in association with adenoviral vector-based vaccines (ChAdOx1 nCoV-19 and Ad26.COV2.S). The incidence of VITT is considered to be extremely low, with the benefits of vaccination strongly outweighing associated risks. Despite the favorable safety profile of COVID-19 vaccines, VITT has garnered the attention of and likely contributes to vaccine hesitancy among a persistently unvaccinated portion of the United States population. Aim(s): We sought to characterize thrombotic events following COVID-19 vaccination in a large clinical enterprise where mRNA-based vaccines were mostly administered. Method(s): With institutional approval, medical records of 779,602 patients vaccinated against COVID-19 (2 mRNA-based vaccines: 61.2% BNT162b2, 36% mRNA-1273, and adenovirus-based Ad26. COV2.S, 2.7%) from 12/4/2020-6/ 6/2021 at Cleveland Clinic Enterprise locations in Ohio and Florida were queried. A baseline complete blood count was available for 223,345 patients, of which 663 (0.3%) demonstrated thrombocytopenia-defined as >=50% platelet decline 4-28 days post-vaccination- and were subject to chart review. Thrombotic events including deep vein thrombosis, pulmonary embolism, stroke/transient ischemic attack, myocardial infarction, cerebral venous sinus thrombosis, and splanchnic thrombosis were assessed. Thrombotic risk factors including medications, viruses, and malignancy, as well as platelet factor 4 antibody assays were recorded. Result(s): Of 76 patients with thrombosis, 63 (82.9%) demonstrated clear etiologies. Thirty (39.5%) had malignancies (24 treated with chemotherapy associated with thrombosis risk). Seven (9.2%) were considered hypercoagulable, six (7.9%) had catheter-related thrombosis, five (6.6%) had recent surgery, five (6.6%) had reduced mobility, five (6.6%) had cardiovascular risk factors, three (3.9%) had diagnosed/suspected immune thrombocytopenia, and two (2.6%) were septic. Of three patients with unprovoked thrombosis, one had findings concerning for VITT (Figure 1). Conclusion(s): 76/223,345 (0.03%) patients demonstrated thrombosis following COVID-19 vaccination, with one (0.0004%) case concerning for VITT. In a large clinical enterprise, VITT is exquisitely rare.
ABSTRACT
Background: The COVID-19 pandemic has resulted in disruptions to HIV prevention and care services access throughout the US. We sought to evaluate the impact of service disruption from the COVID-19 pandemic response on key Getting to Zero San Francisco (GTZSF) HIV prevention and care metrics of HIV antibody (Ab) and HIV viral load (VL) testing, Pre-exposure prophylaxis (PrEP) use, and the continuum of HIV care. Methods: Reports of positive and negative HIV Ab testing from 4 laboratories and a large community testing site (CTS), and HIV VL testing for people living with HIV reported to the San Francisco Department of Public Health were included. We compared the number of HIV Ab and VL tests, and PrEP visits at the CTS each month from January-October 2020 with the corresponding months in 2019. The continuum of HIV care was calculated for new HIV diagnoses in January-June 2020 compared to the same period in 2019. Results: From January-October 2020, the mean number of monthly laboratorybased HIV Ab tests decreased from 4,400/month in 2019 to 3,644/month in 2020 (Table);and from 1,382/month to 766/month at the CTS. April 2020 had the lowest number of HIV tests, a reduction of 54% in laboratory reporting and 88% in the CTS compared with April 2019;there was a partial rebound through October 2020. While the number of positive HIV tests was lower per month in 2020 compared with 2019, the proportion HIV positive remained stable throughout the study period (2020: Range 0.9-1.4%;2019: Range 1.1-1.6%). HIV VL testing also declined in 2020 similar to the trend of HIV testing with the largest decline (57%) in April 2020. Overall, PrEP visits at the CTS declined more than 31% in the study period;the largest decline (90%) occurred in April 2020 with partial rebound through October 2020. From January to June 2020, 75 new HIV diagnoses were identified, compared with 101 in 2019. Linkage to care within 1 month was 93% in 2020 and 97% in 2019;HIV viral suppression within 6 months was 75% in 2020 and 76% in 2019. Conclusion: We have observed substantial reductions in HIV Ab and VL testing during the COVID-19 pandemic, and likely decreased HIV case finding. PrEP care engagement also declined dramatically;however rapid linkage to care and viral suppression after HIV diagnosis remained robust. Continued monitoring of key HIV prevention and care metrics is essential to assessing the complex impact of COVID-19 on the GTZSF goals, and developing tailored mitigation responses.