ABSTRACT
Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic caused a rapid shift in outpatient pharmacy services from in-person (IP) to telehealth (TH) visits. The impact of this on glycemic and blood pressure control in uninsured, low socioeconomic populations is not well described. Research is needed on the impact of clinical service visit modalities changes, spurred by the COVID-19 pandemic, on clinical outcomes. Research Question or Hypothesis: To ensure therapy goals for uninsured patients at an urban free clinic were maintained during the pandemic, we compared the proportion at blood pressure (BP) goal (<130/80 mmHg), at A1C goal (<7%), and visit trends 1 year before and after the Declaration of National Emergency (DNE) on March 13, 2020. Study Design: Retrospective chart review. Methods: This retrospective chart review collected the number of missed or canceled visits, IP and TH visits, and average days between visits. Data from visits between March 13-September 13, 2019 (pre-pandemic), January 31-April 24, 2020 (during pandemic), September 13, 2020-March 13, 2021 (post-pandemic) to assess hypertension (HTN) and diabetes (DM) control were also collected. Descriptive statistics, paired t-tests, and Cochran's Q tests were used to analyze the data. Results: Seventy eight patients were included. Visit modality changed from all IP visits before to mostly TH visits after the DNE. Missed appointments decreased (2.63+2.5 v 1.69+1.8 visits per patient, p 0.011) while completed appointments remained consistent (5.31+2.1 v 5.81+2.4, p 0.058). 30% patients had controlled HTN at each time interval with no change between time intervals (p 1.00). 40-64% patients had controlled DM over the time intervals with no overall change in DM control (p 0.061). Conclusion: Visit modality shifts due to the COVID-19 pandemic reduced missed appointments but did not impact clinical patient outcomes related to HTN and DM control.
ABSTRACT
RATIONALE: In the absence of effective therapies at the start of the Coronavirus disease of 2019 (COVID-19) pandemic, anti-viral and antiinflammatory medications were used for management of COVID-19 without robust evidence of their benefit. The patterns of use, implementation, and de-implementation of these medications is unclear. METHODS: We performed a retrospective, observational study on an international cohort of adult patients hospitalized from March 2020 to November 2020 with laboratory confirmed COVID-19 infection, receiving supplemental oxygen, and enrolled in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Registry. The primary outcome of interest was to describe the hospital-level variation in the most commonly used medications repurposed for empiric management of patients hospitalized with COVID-19 (hydroxychloroquine, remdesivir, corticosteroids, and anti-IL-6 therapies). Secondary outcomes included geographic and temporal variation in medication use. RESULTS: Among 6,621 patients with COVID-19 across 86 hospitals (predominantly USbased [88%]), 1,373 (20.7%, hospital usage rates range 0%-96.4%) received corticosteroids, 1,302 (19.7%, range 0%-100%) received hydroxychloroquine, 602 (9.1%, range: 0%-65.7%) received remdesivir, and 405 (6.1%, range 0%-87.5%) received an anti-IL6 medication. USbased hospitals vs non-US hospitals showed differences in medication use with 9.9% vs. 0.8% use of remdesivir, 19.5% vs 33.2% use of corticosteroids, 18.7% vs 29.6% use of hydroxychloroquine and 6.3% vs. 3.9% use of anti-IL6 medications. Comparing use prior to July 2020 with use after July 2020, prescription of remdesivir increased from 6.5% to 20.5%, corticosteroid use increased from 17.5% to 35.0%, hydroxychloroquine use decreased from 23.9% to 1.1% and anti-IL6 use decreased from 7.0% to 2.4%. CONCLUSIONS: Hospital-level variation and geographic variation in use of repurposed anti-viral and anti-inflammatory medications for the management of COVID-19 infection was large. Coinciding with accrual of scientific evidence, the use of remdesivir and corticosteroids increased over time, while the use of hydroxychloroquine and anti-IL6 medications decreased over time. Further studies are needed to evaluate the drivers of hospital variation and impact on clinical outcomes.
ABSTRACT
RATIONALE: Critical care guidelines have supported use of non-invasive respiratory support modalities in patients with acute respiratory failure from COVID-19 since the beginning of the pandemic. However, concerns surrounding viral particle aerosolization, nosocomial spread, and patient self-induced lung injury have likely influenced choice of respiratory support strategies. To date, high flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) practice patterns have not been characterized for patients with COVID-19. METHODS: We enrolled hospitalized patients aged 18 years or older with laboratory confirmed COVID-19 infection who received supplemental oxygen, using the Society of Critical Care Medicine Discovery VIRUS Registry. The primary outcome was hospital-level variation in use of HFNC and NIPPV, summarized using the intraclass correlation coefficient and median odds ratio. Hierarchical random effects models were used to estimate patient and hospital factors associated with HFNC and NIPPV use. Risk-adjusted estimation of the association between hospital HFNC/NIPPV use and patient risk of receiving invasive mechanical ventilation (IMV) was assessed as a secondary outcome. RESULTS: Among 8,532 patients with COVID-19 receiving oxygen support across 73 hospitals, the majority were treated in the US (92.3%) and were older (median age 63 years, IQR 52-74), white (49.1%), men (56.8%) with median SOFA score of 4 (IQR 1-6) and admission PaO2:FiO2 below 300 (49.4%). Of these, 5,298 (62.1%) received low flow oxygen (nasal cannula or face mask), while 1,768 (20.7%) received HFNC, 773 (9.1%) received NIPPV and 693 (8.1%) received both HFNC/NIPPV. Patient SOFA score (OR 0.92, 95% CI 0.90, 0.95), treatment for COVID-19 after July versus March-June (OR 1.3, 95% CI 1.0, 1.6) and ICU versus floor admission (OR 10.3, 95% CI 8.2, 12.8) were associated with HFNC/NIPPV use. After adjusting for patient and hospital characteristics, the hospital of admission contributed to 27% of the variation in use of HFNC and/or NIPPV. Odds of receiving either modality at a randomly selected high vs. low HFNC/NIPPV utilization hospital was 2.9. Hospital rates of HFNC/NIPPV use were not associated with patient receipt of IMV (OR 0.87, 95% CI 0.7, 1.1). CONCLUSION: Throughout the course of the COVID-19 pandemic, use of HFNC and NIPPV varied widely across hospitals, though use of non-invasive respiratory support modalities was not associated with patient risk for invasive mechanical ventilation. Further evaluation of HFNC and NIPPV exposure, progression to IMV and subsequent mortality within these subgroups may provide additional insights regarding optimal oxygenation and ventilation strategies of patients with COVID-19.