ABSTRACT
Introduction: Solid organ transplant recipients have 2-5 times increased mortality after coronavirus disease 2019 (COVID-19) infection as compared to general population. These patients also have lower protection after vaccination against COVID-19. Therefore, the risk of breakthrough infection and hospitalization are also significantly higher in this patient population. Studies on efficacy of COVID-19 vaccination in post liver transplant (LT) patients are limited. We aimed to investigate the rate of mortality, hospitalization, and breakthrough infection and assess possible risk factors in COVID-19 infection mortality post LT. Methods: A retrospective chart review study. All post liver transplant patients at Carolinas Medical Center (CMC) who were tested positive for respiratory syndrome coronavirus 2 (SARS-CoV- 2) PCR test from Dec. 2020 (when first COVID-19 vaccine was approved in the US for emergency use authorization) until Nov. 2021 were included in this study. Breakthrough infection was defined as COVID-19 infection ≥14 days after full vaccination. Data was analyzed using Prism (GraphPad Software, San Diego, CA) and reported as mean ± SEM. T- test and chi square tests were applied for analyzing the data. Results: Thirty-six patients were identified and 66.1±9.6 months post liver transplantation (LT). Mean age was 61.2±1.6 years-old, male (72.2%) and Caucasian (91.6%). Ten patients (27.7%) expired. Chronic kidney disease (CKD) was present in 70.0% of expired patients as compared to 53.3% of recovered (p=0.0003). Type 2 diabetes (T2DM) was present in 70.0% vs. 25.0% of expired and recovered patients, respectively (p<0.0001). Hypertension (HTN) was present in 90.0% vs. 55.0% of expired and recovered patients, respectively (p<0.0001). No statistically significant difference was observed in weight of expired vs. recovered patients (50% vs. 65% obesity;p=0.4). Only 9 patients were vaccinated. Breakthrough infection rate was 25% and 2/9 (22.2%) died vs. 29.6% of non-vaccinated patients (p=0.4). COVID-19 infection occurred 4.9±0.86 months after vaccination. Hospitalization (44.4% vs. 55.5%) and ICU admission (22.2% vs. 37.0%) was not statistically different among vaccinated and non-vaccinated patients. Conclusion: T2DM and CKD were significantly higher among COVID-19 infected patients who expired, which are similar risk factors in patients who have not had a liver transplant. However, obesity was not significantly correlated with mortality as it was shown before in non-immunocompromised population. Although COVID-19 vaccine is effective in post LT patients, larger studies are warranted to evaluate its efficacy in this population. Our study also highlights that the efficacy of current COVID-19 vaccines decreases in 4-6 months after full vaccination, which warrants evaluating the efficacy of booster dose(s) in post LT patients
ABSTRACT
Background: The COVID-19 pandemic forced an abrupt and urgent adaptation to the use of telemedicine (TM). Though the use of TM in the care of liver disease predates the pandemic, its widespread use has been hindered by regulatory and reimbursement restraints. Furthermore, there is a dearth of data directly comparing clinical outcomes between TM and face-to-face (F2F) visits in patients with cirrhosis. Accurately characterizing outcomes between these modalities may aid in determining under which circumstances TM may be most appropriately incorporated into the care of patients with cirrhosis. Methods: Utilizing ICD-10 codes, a retrospectively identified, prospectively followed cohort of patients with cirrhosis was compiled (n=407). Individual encounters were independently vetted through direct review of patient records by study personnel. Two cohorts were identified. The TM cohort (n=151) included encounters conducted via TM (audio or video) from 4/7/2020 - 6/7/2020. The F2F cohort (n=333) included in-person clinic visits from 1/1/2019 - 6/1/2019;representing the standard of care prior to implementation of TM. Each cohort was followed for a total of 6 months from their index visit to assess clinical outcomes including Emergency Room (ER) visits and hospital admissions. Guideline-based hepatocellular carcinoma (HCC) screening was used as a surrogate for preserving standard of care. This included appropriate ordering (by provider) and adherence to recommendation (by patient). Results: The two cohorts were similar in composition, without statistically significant differences between race, mean income, insurance carrier, etiology of cirrhosis, or presence of decompensation. There was a significantly higher volume of return visits in the TM cohort vs. F2F cohort (84.1% vs. 59.2%;p<0.001). There were no statistically significant differences between the cohorts in ER visits, hospital admissions, or provider ordering/patient adherence to HCC screening guidelines (Table 1). Conclusion: Telemedicine preserved access to care for patients requiring Hepatology services during the pandemic. Telemedicine did not negatively impact quality of care as determined by similar adherence to HCC surveillance compared to in-person visits. Telemedicine is a suitable alternative to in-person visits in patients who otherwise may have difficulty accessing Hepatology care.
ABSTRACT
Background: During the COVID-19 pandemic, telemedicine (TM) became an essential component of healthcare delivery to mitigate transmission of SARS-CoV-2. However, applications of TM to the field of Hepatology predate the COVID-19 pandemic, many of which were intended to increase access to care beyond subspecialized centers. We aimed to assess the impact of TM on access to Hepatology care within our healthcare network Methods: Utilizing ICD-10 codes, a retrospectively identified, prospectively followed cohort of patients with cirrhosis was compiled (n=407). Individual encounters were independently vetted through direct review of patient records by study personnel. Two cohorts were identified. The TM cohort (n=151) included encounters conducted via TM (audio or video) from 4/7/2020 - 6/7/2020. The face-to-face (F2F) cohort (n=333) included in-person clinic visits from 1/1/2019 - 6/1/2019;representing the standard of care prior to implementation of TM. Each cohort was followed for a total of 6 months from their index visit. Demographics, clinical metrics, and no-show (NS) rates were determined via chart review and use of the American Community Survey (data from the U.S. Census Bureau). NS rate was utilized as a surrogate for healthcare access. Results: The two cohorts were similar in composition, without statistically significant differences between race, mean income, insurance carrier, etiology of cirrhosis, or presence of decompensation (Table 1). NS rate was 13% in the F2F cohort vs. 4.5% in the TM cohort;a statistically significant decrease of 8.5% (p < 0.0001). The mean income estimate was significantly lower in patients with a NS in the F2F cohort (p = 0.04), but the mean income estimate was not significantly different in patients with NS in the TM cohort (p = 0.95). In the F2F cohort, Black patients were significantly more likely to NS than white patients (p = 0.001). However, black patients were less likely than white patients to NS in the TM cohort (p = 0.01). Conclusion: Overall NS rates significantly declined during the TM period, suggesting increased access to care facilitated by the implementation of TM. During the F2F period, Black patients and patients with lower income were more likely to NS to an appointment, suggesting potential barriers to attending F2F clinic visits. TM appeared to alleviate these barriers and increase access to Hepatology care in these populations.