COVID-19 Hospitalizations in North Texas: Impact of Insurance Status

Background. Texas has one of the highest rates of uninsured populations in the US (Fig1). We hypothesized that those without insurance were more likely to be hospitalized for COVID-19 but were at higher risk for severe disease and mortality due to uncontrolled medical illness prior to hospitalization. Methods. We conducted a retrospective analysis of patients hospitalized in 81 hospitals in Dallas- Ft. Worth (DFW) area. All inpatients and outpatients with COVID-19 from 3/1/2020 to 4/1/2021 were included to examine risk for hospitalization. Subset analysis included those hospitalized with COVID-19. Data presented is comparison between Medicaid and uninsured population as they were similar in age distribution (Fig 2). Results. 198, 174 COVID-19 unique individuals were identified;7.5% had Medicaid and 25.1% were uninsured. Among Medicaid, 29.6% were hospitalized vs. 25.8% of Medicaid vs. uninsured (adjusted odds ratio (aOR) 1.26 (1.20, 1.33). Among the 71,778 (~36%) hospitalized for COVID-19, comparing Medicaid vs. uninsured: 44.9 vs. 56.3% had ICU care;51.4% vs. 80.2% had pneumonia, 41.1% vs. 67.5% had respiratory failure with higher odds of developing these outcomes in uninsured (see Table 1). Median duration of hospital stay was longer in uninsured than Medicaid ( see Table 2a) and mortality in the hospital was 7.4% vs. 7.9% among Medicaid vs. uninsured (p< 0.0001). Thirty-day readmission rates were lower for Medicaid vs. uninsured (Table 3). In the year prior to the COVID-19 hospitalizations, use of health care among the uninsured was lower compared to Medicaid patients for outpatient, inpatient, and ER visits (p< 0.0001 for all comparisons;see Table 2b). Conclusion. Uninsured in North Texas had lower odds of hospitalization vs. Medicaid patients, likely due to younger age, but once hospitalized had higher risk for COVID pneumonia, ICU care, and respiratory failure. Median number of days was higher among uninsured but in-hospital mortality was higher among Medicaid population. Prior contact with healthcare system was lower among uninsured and 30-day readmissions were also lower, suggesting barriers accessing health care. Poorer outcomes among uninsured once hospitalized may be due to untreated comorbidities (Fig 3). Expansion of Medicaid has the potential of ameliorating these disparities.

COVID-19 Hospitalization Impact of Age, Race and Ethnicity Among Medicaid and Uninsured

Background. Texas has one of the highest rates of uninsured patients in the US and is one of the few states that has not expanded Medicaid (Fig 1). We sought to examine if there were differences by age, race, and ethnicity in the risk COVID-19 outcomes among those with Medicaid coverage vs. the uninsured population. (Table Presented) Methods. We conducted a retrospective analysis of all patients hospitalized in 81 hospitals in Dallas-Fort Worth area. All inpatients with COVID-19 from 3/1/2020 to 9/30/2021 were included in the analysis. We examined the following COVID-19 outcomes: ICU care, pneumonia, and respiratory failure stratified (separate logistic models for each outcome) by race, ethnicity, and age adjusted for a multitude of sociodemographic, clinical, and co-morbid characteristics (Fig 2). Results. 71,778 individuals diagnosed with COVID-19 were hospitalized: 12.9% had Medicaid and 23% were uninsured. For all COVID-19 study outcomes (ICU care, pneumonia, and respiratory failure), White Medicaid patients had lower odds ratios vs. their White uninsured counterparts indicating worse outcomes compared to Black Medicaid patients vs. Black uninsured counterparts (Table 1). Similarly, for all outcomes, Hispanic Medicaid patients had lower (worse) odds ratios vs. Hispanic uninsured counterparts compared to the same model with non-Hispanic patients. Finally, for all three outcomes, the youngest Medicaid age cohort (18-44 years) were less likely to require ICU care, have pneumonia or respiratory failure vs. the youngest uninsured patients;while conversely there was trend (not always statistically significant) that middle aged or older Medicaid cohorts were more likely compared to their same age uninsured counterparts to experience these outcomes. Adjusted odds ratio of COVID-19 outcomes by insurance status stratified by race, ethnicity, and age group. Conclusion. We found that age modified the risk for ICU care with younger Medicaid recipients at lower odds vs. uninsured than older cohorts. For race and Hispanic ethnicity, all Medicaid groups had lower likelihood of poor COVID-19 outcomes compared to their uninsured counterparts. However, the effect was more pronounced among Whites vs. Blacks and Hispanics vs. non-Hispanics (Fig 3). Providing health insurance such as Medicaid to uninsured younger patients could significantly improve health outcomes, especially among Whites, Hispanics, and younger patients.

Remote observational research for MS: a natural experiment

Background: Prospective, deeply phenotyped research cohorts monitoring people with multiple sclerosis (MS) depend on careful participant engagement that was threatened by COVID19- related restrictions to in-clinic visits. Coincidentally, there was forced adoption of televideo-enabled care. Objective(s): To leverage a natural experiment of "going virtual" during the pandemic to evaluate two hypotheses pertaining to remote MS research: that (1) global costs of remote visits are lower, and (2) disability evaluations are non-inferior. Method(s): Between 3/2020 and 12/2021, 207 UCSF EPIC/ ORIGINS MS cohort participants underwent hybrid in-clinic and virtual research visits. Among these, 96 contributed 100 'matched visits', i.e. in-clinic (Neurostatus, NS-EDSS) and remote (televideo-, tele-EDSS;electronic patient-reported, ePR-EDSS) evaluations within 14 days. Clinical and socio/ demographic characteristics were collected. First, visit costs were compared. Then, the quality of data extracted was compared using non-inferiority design with NS-EDSS as primary outcome. Result(s): The 96 participants contributing 100 matched visits had mean age 41.4 years (SD 11.7) and MS duration 1.4 years (SD 3.4);69% were female and 72% White, 8% lived in lowincome zip codes;median driving distance was 70 miles (mean 545). The costs of remote visits to participants (travel, caregiver time), to research (facilities, personnel, parking, participant compensation), and carbon footprint were all lower than in-person visits (p<0.05 for each). Median cohort EDSS was similar, whether evaluated using NS-EDSS (2), tele-EDSS (1.5) or ePREDSS (2), with range 0-6.5. Utilizing a TOST for Non-inferiority, both remote evaluations were non-inferior to NS-EDSS within+/-0.5 EDSS point (p<0.01 for each). Year-to-year, the % of participants with worsening/stable/improved EDSS scores was similar, whether the annual evaluations both used NS-EDSS, or whether the annual evaluation switched from NS-EDSS to tele-EDSS. Discussion(s): "Going virtual" during the pandemic represented a natural experiment in which to test hypotheses about remote research visits. These visits lowered costs for investigators and participants. Further, remote assessments were non-inferior to NS-EDSS and for more precision, could be supplemented with biosensors. Together, these insights support the conduct of research that is more inclusive to participants regardless of geography, race, income, opportunity costs or ability level.

Micro-pulse Transscleral Laser Therapy and ‘Topical-plus’ Anaesthesia: Ideal for Glaucoma Management During COVID-19

Micro-pulse transscleral laser therapy (MP-TLT) is a non-invasive laser procedure for the treatment of glaucoma, and was introduced in 2015. The aim of the procedure is to achieve a reduction in intraocular pressure while minimizing collateral tissue damage. The favourable risk profile of this non-cyclodestructive procedure makes it applicable to a broad spectrum of glaucoma cases, including patients with good central vision, and does not limit its usability to late-stage refractive cases. In 2019, a revised delivery device simplified the procedure, and more recently, a ‘topical-plus’ anaesthesia protocol has been introduced. The revised delivery system and topical-plus protocol reinforce the utility of MP-TLT as a practical treatment option in an office setting or procedure room, with minimal patient discomfort during and after treatment. Additionally, with minimal follow-up requirements, MP-TLT is ideal for glaucoma management during COVID-19 social restrictions. The following article provides an overview of the use of MP-TLT under topical anaesthesia (topicalplus), the potential role of MP-TLT in the glaucoma treatment algorithm during the COVID-19 pandemic, and the advantages of the revised MicroPulse P3® probe (IRIDEX Corporation, Mountain View, CA, USA).

Home Blood Pressure Monitoring in Women with Severe Hypertension Utilizing Audio-Only and In-Person Postpartum Encounters

Objective: Prompt postpartum follow-up for women with hypertension is recommended. We hypothesized that use of home blood pressure monitoring may be beneficial to improve engagement. Our aim was to utilize home blood pressure monitoring with in-person and audio-only virtual visits in women with severe hypertension. Study Design: From March 2020 – September 2020 women with severe hypertension requiring oral antihypertensive therapy postpartum were provided a blood pressure cuff at time of hospital discharge and taught to take home measurements twice daily. Follow-up was scheduled within 10 days. Due to the COVID pandemic, audio-only virtual visits were prioritized, but left to the discretion of the discharge provider. Home blood pressure logs were reviewed at each encounter and documented in the medical record. Severe hypertension was defined as 160/110 mmHg or greater. Subsequent in-person or virtual visits were determined by the provider. Follow-up data and blood pressure values up to 6 weeks postpartum were retrospectively obtained. Statistical analysis included χ2 and McNemar’s test, with a P value <.05 considered significant. Results: Blood pressure cuffs were given to 206 women. Ten (5%) women on antihypertensive therapy represented to the hospital for hypertension. Ten women were lost to follow up after discharge from the hospital, leaving 196 women (95%) who presented for at least 1 postpartum visit. Systolic and diastolic values at the first visit were significantly lower at the last postpartum visit when compared to the first. Additionally, by the last postpartum visit, women were are on less blood pressure medications than at time of discharge from the hospital (P=.048). Composite blood pressure ranges above 140/90, 150/100, and 160/110 mmHg were significantly lower at the last visit when compared to the first, except for severe diastolic values (Figure 1). Conclusion: Use of audio-only virtual visits with in person follow-up for women with severe hypertension allowed for decreased oral antihypertensive medications and a reduction in blood pressure 140/90mmHg or greater. [Formula presented] [Formula presented]

Postpartum Audio-Only Virtual Visits Versus In-Person Follow-up in Women with Severe Hypertension

Objective: Postpartum follow-up within 10 days is currently recommended for women with hypertension, though many women do not complete this visit. Methods beyond in-person visits may be necessary to achieve this. Our goal was to explore the use of home blood pressure monitoring with audio-only virtual visits and in-person postpartum visits for women with severe hypertension. Study Design: From March 2020 – September 2020 women with severe hypertension requiring oral antihypertensive therapy postpartum were provided a blood pressure cuff at time of hospital discharge and taught to take home measurements twice daily. Follow-up was scheduled within 10 days. Due to the COVID pandemic, audio-only virtual visits were prioritized, but left to the discretion of the discharge provider. Demographic and follow-up data up to six weeks postpartum were compiled retrospectively from the medical record. Severe hypertension was defined as blood pressure 160/110 mmHg or greater. Statistical analysis included χ2 and Student-t test, with P value <.05 considered significant. Results: Blood pressure cuffs were given to 206 women: 181 women with severe hypertension in the immediate postpartum period, and 25 who were re-admitted to the hospital with delayed-onset hypertension. Table 1 shows their demographics. Sixty-seven (32%) had pre-existing hypertension. There were 196 (95%) who had one postpartum visit, 165 (80%) had two visits. Average number of days to completion of follow-up appointment was 9 ± 6 days, with 146 (71%) following up at 10 days or less. Ten (5%) women did not return after discharge. Sixty-nine women had their first visit in-person, and 137 women had a virtual encounter. Virtual visits were more likely to be completed within 10 days (118/137 (86%) v 28/69 (41%), p<.001), and had less loss to follow-up after discharge (2/137 (1%) v 8/69 (12%), p<.001). Conclusion: In women with severe hypertension, follow-up within 10 days was more likely with audio-only virtual visits compared to clinic visits, offering an appropriate point of access to postpartum care. [Formula presented] [Formula presented]

Using real-world data from a large, multi-specialty health care system to longitudinally phenotype multiple sclerosis

Background: Real-world data (RWD) are an important complement to randomized, controlled and registry datasets in defining a disease course longitudinally. There is growing interest in understanding the insidious progression in multiple sclerosis (MS) that can occur despite aggressive relapse prevention, as well as how diversity and comorbidities impact multiple sclerosis (MS) patients, particularly in the era of the coronavirus (COVID19) pandemic. Objectives: We aim to derive RWD from a diverse cohort of approximately 4,000 MS patients in Northern California to pair with biomarkers from the Sutter-wide Precision Medicine Biobank - a longitudinal biorepository with a healthy aging comparator cohort. This pilot of 34 patients evaluates the integration of several data sources to extract key information about disease course. From the EHR, we use a combination of text processing, automated data element extraction, manual chart curation, and patientand physician-targeted questionnaires to form a real-world dataset of interpretable outcome metrics. Methods: This is an ambidirectional cohort study of subjects at least 18 years old, with a defining diagnosis of MS from at least one hospitalization or two outpatient encounters. Data elements including demographics, medication orders and comorbidities were directly extracted from the EHR. MRI reports in text format were stored in an Epic Clarity database, and neurology notes were mined for terms indicating stability versus worsening. Manual curation was used to transform prose clinician notes into tabularformat outcome scores. Results: We curated 9930 total encounters, 136 brain MRI reports and 137 spine MRI reports. We found 7.5 years (+/- 3.3) of data per patient in this pilot of 34 patients. 79% of patients were female, 21% male;68% white, 26% black and 6% other/not disclosed. The most common disease-modifying therapies used were natalizumab, dimethyl fumarate and glatiramer acetate. 68% of patients had at least one comorbidity, 35% specifically had hypertension. Using automated and manual data methods, we were able to compile metrics of clinical and radiographic worsening versus stability from information in the EHR. Conclusions: Our methods may be used to generate interpretable data on a system-wide scale from the comprehensive, longitudinal data of an EHR. These RWD can be paired with biospecimens, research assessments, and other datasets to add to the diversity of data on MS natural history and medication response.