ABSTRACT
Background: New York State mandates the offering of hepatitis C (HCV) testing for persons born between 1945-1965 in the outpatient primary care setting. Despite this, < 50% of HCV screening candidates are offered screening and among those found to be HCV Ab positive, not all undergo HCVRNA testing and even fewer are linked to care. We evaluated the use of nurse educators to visit 60 outpatient primary care offices to educate PCPs and their staffs about HCV screening and linkage to care. During the COVID pandemic, most primary care offices were closed to in-person visits, in-person PCP patient visits decreased significantly and tele-medicine visits increased. We evaluated the long-term effects of nurse educators on HCV screening and the effects of the COVID pandemic on HCV screening and linkage to care. Results: From April 1, 2018- August 31, 2021, 50,047 previously unscreened patients born between 1945-1965 were screened with an HCV AB with reflex testing to HCVRNA in all positive HCV ABs. The use of nurse educators increased the rates of HCV AB screening and linkage to care when compared to same office historical records. Overall, 47863 tests were negative. 1093 had a positive HCV AB (2.2%) and 245 (0.5%) were HCVRNA positive. 23% of HCVAB positive patients were HCVRNA positive. The number of patients screened in the year 1, 2 and 3 were 18969, 15309 and 15,769, respectively. The number of HCV AB positives in year 1, 2 and 3 were 334, 345 and 412, respectively. The number of HCVRNA positives in years 1,2,3 were 94, 56, and 94, respectively. In year 1, 28% of the HCV AB positives were HCVRNA positive compared with 17% and 23% in years 2 and 3. All 245 HCV RNA positive patients were referred to an HCV provider. 101 patients completed therapy, 93 are currently in treatment or follow up and 22 declined therapy. 5 are awaiting initiation of DAA therapy and 8 were transplanted prior to initiation of therapy. 10 subjects expired prior to initiating treatment and 6 were lost to follow up. In year 3, nurse educators visits were suspended due to the COVID pandemic. Despite this, the rate of screening for HCV and linkage to care was not affected by the COVID pandemic. Conclusions: Over the three-year study period, screening for HCV infection by primary care providers in patients born between 1945-1965 remained stable despite the COVID pandemic and an increase in the use of telemedicine visits. The legacy of staff education by nurse educators led to continued HCV screening despite lack of in-person staff re-education. Linkage to care for newly diagnosed HCV patients remained high throughout the study period, despite the COVID pandemic in year 3 with a high percentage of patients initiating DAA therapy. Nurse educators are a vital component in increasing HCV awareness in the community setting
ABSTRACT
Background: Liver test abnormalities are common in patient hospitalized with COVID-19 infection and correlate with adverse outcomes Predictors of liver injury in patients with COVID-19 infection have not been adequately studied Our study assessed the association of baseline covariates with severe liver injury and in-hospital mortality in a large cohort of COVID-19 patients Methods: We reviewed electronic medical records of 10,856 COVID-19 patients who were admitted to our health system from March 1 to April 30, 2020 We correlated baseline characteristics on hospital admission of these patients with degrees of liver injury (without, mild to moderate, and severe) We performed univariate and multivariate logistic regression analysis to assess predictors of severity of liver injury We analyzed in-hospital mortality based on severity of liver injury and presence of comorbidities using Kaplan-Meir analysis and Cox-Proportional Hazard model Results: There were 28 5% patients with no liver injury, 63 9% patients with mild to moderate liver injury, and 7 6% patients with severe liver injury Younger patients, Hispanic or Latino, males, patients with chronic liver disease and those without hypertension, coronary artery disease, heart failure, or diabetes mellitus were more likely to present with severe liver injury in unadjusted analysis These risks of severe liver injury remained high after adjusted for demographic and co-morbid factors The risks of in-hospital mortality were incremental with increasing severity of the liver injury Increasing severity of liver injury in older patients (>60 yrs.), male, patients with hypertension or diabetes mellitus was associated with incrementally poor survival Conclusion: Severe liver injury on hospital admission is associated with increased in-hospital mortality in COVID-19 patients Increasing severity of liver injury was associated with higher risk for poor outcome in older patients, male, and patients with hypertension or diabetes.
ABSTRACT
Background: Liver test abnormalities are frequently seen in patients hospitalized with COVID-19 infection Several inflammatory markers have been used to predict the outcome in these patients The association of liver injury with inflammatory markers, however, has not been well studied. Our study assessed the association of different degrees of liver injury with inflammatory markers in a large cohort of COVID-19 patients Methods: We reviewed electronic medical records of 10,856 COVID-19 patients who were admitted to our health system from March 1 to April 30, 2020 We collected the laboratory result, including inflammatory markers (procalcitonin, LDH, d-dimer, ferritin, lactate, CRP, and CPK) on hospital admission of these patients We categorized the liver injury into three groups based on severity (no, mild to moderate, and severe liver injury) We assess the correlation of inflammatory markers with different degree of AST and ALT elevation using Pearson's correlation coefficients. Results: A moderate correlation was observed for AST and LDH at all degrees of liver injury Lactate showed a moderate correlation with AST in the subjects with severe liver injury but a relatively weak correlation in mild to moderate liver injury. Ferritin showed statistically significant but weak correlation with AST in all degrees of liver injury Overall correlations for CRP and Procalcitonin with AST were weak D-Dimer had weakest correlation with AST compared with other inflammatory markers. A moderate correlation was noted for CPK and AST in mild to moderate liver injury, and weak correlation was observed in no liver injury and severe liver injury groups No correlation was found for LDH, CRP, procalcitonin, lactate, and d-dimer with ALT levels Ferritin showed increasing correlation with higher ALT level, however, the correlation remained weak Conclusion: AST appears to have stronger correlation with the inflammatory markers compared with ALT Stronger correlation of several inflammatory markers was found with higher degree of liver injury While these were overall weak to moderate, this suggests that systemic inflammation contributes to liver injury in patients with COVID-19 infection.
ABSTRACT
Background: Abnormalities in liver chemistries in COVID-19 infection are common, but their effects on outcomes are unclear Our study assessed the prevalence and prognostic value of initial liver chemistries in a large cohort of COVID-19 patients without known chronic liver disease Methods: We reviewed electronic medical records of 10,614 COVID-19 patients without known chronic liver disease who were admitted to our health system from March 1 to April 30, 2020 We analyzed baseline demographics and liver chemistries The primary outcome was in-hospital mortality, and the secondary outcome was a composite of in-hospital mortality or the need for mechanical ventilation Results: Elevated levels of aspartate aminotransferase (AST) appeared in 59% of patients, alanine aminotransferase (ALT) in 54% of patients, alkaline phosphatase in 13% of patients, and bilirubin in 5% of patients The majority of patients had AST and ALT within >1 to ≤4x the ULN (49% and 54%, respectively). The majority of patients had AST and ALT within >1 to ≤4x the ULN (49% and 54%, respectively) Extreme elevations of AST and ALT were uncommon, with 4.6% of patients having AST >4 to ≤10x ULN, 0.8% having AST >10x ULN, 4.1% of patients having ALT >4 to ≤10x ULN, and 0.8% having ALT >10x ULN. Most patients (76%) had AST higher than ALT on presentation Based on our a priori definitions of severe liver injury, there were 936 patients (8 9%) with a hepatocellular pattern, 133 patients (1 3%) with a cholestatic pattern, and 91 patients (0 9%) with a mixed pattern The prevalence of liver chemistry elevations differed based on sex, ethnicity, race, and presence of comorbidities (Table 2) Compared to females, males were more likely to have elevations in AST (64 8% vs 50 1%, p <0 001) and bilirubin (5 9% vs 2 8%, p <0 001) but less likely to have elevations in alkaline phosphatase (12 0% vs 14 2%, p =0 001) Elevations in ALT did not differ by sex (p = 0 34) In Kaplan-Meier survival analyses, patients with elevations in AST, ALT, alkaline phosphatase, or bilirubin had increased mortality (Figure 1A-D) and increased mortality or need for mechanical ventilation when compared to patients with measurements within the normal range These higher risks remained significant for elevations in AST, ALT, and alkaline phosphatase after adjustment for demographic factors Increasing severity of AST was associated with incrementally poor survival Patients with a cholestatic liver injury and those with AST predominant elevation (AST/ALT >1) had higher risks of in-patient mortality and the composite outcome of in-hospital mortality or the need for mechanical ventilation Conclusion: Liver test abnormalities are common upon initial presentation in COVID-19 infection and are associated with increased mortality and the need for mechanical ventilation in patients without underlying chronic liver disease Those with a cholestatic pattern of liver injury are at the highest risk for poor outcomes (Figure Presented)(Table Presented).