ABSTRACT
Background. The percentage of all respiratory diagnoses prescribed an antibiotic is an outpatient stewardship metric and was introduced as a HEDIS measure in 2022. Given a stable case mix, this metric is not affected by differences in coding practices between clinicians or health systems since all respiratory diagnoses are considered together. The onset of the COVID-19 pandemic introduced a high number of viral illness episodes where antibiotics are not recommended. The impact of this shift in case mix on respiratory diagnosis coding and prescribing metrics has not been explored. Methods. We examined antibiotic prescribing rates for respiratory diagnoses in a network of urgent care clinics affiliated with the University of Utah during two periods. Pre-Pandemic was Mar 2019-Feb 2020 and Pandemic was Mar 2020-Mar 2022. Respiratory diagnoses were identified using ICD10 codes and further stratified into 3 Tiers (Tier 1: antibiotics indicated;Tier 2: antibiotics sometimes indicated;Tier 3: antibiotics not indicated). We examined trends in antibiotic prescribing across these periods including the percentage of all respiratory visits prescribed antibiotics and by Tier and the distribution of diagnoses by Tier. No formalized stewardship interventions were introduced during these periods. Results. There were 146,897 urgent care visits during the study period (47,423 Pre Pandemic and 99,474 Pandemic). The respiratory prescribing rate declined from 42.3% Pre Pandemic to 26.2% during the Pandemic (Figure). The distribution of respiratory diagnoses by Tier and prescribing within Tier are shown in the Table. Tier 3 diagnoses increased from 48% to 67%, while Tier 2 diagnoses declined from 47% to 31%. Antibiotic prescribing declined for both Tier 2 and Tier 3 diagnoses. 15,429 (23%) of Tier 3 diagnoses during the Pandemic were coded as COVID-19. 50% of the reduction in prescribing is attributable to changes in Tiers alone. Figure Table Conclusion. The COVID 19 pandemic was associated with a reduction in the percentage of respiratory diagnoses prescribed antibiotics. Half was due to an increase in Tier 3 encounters although declines in prescribing occurred with Tiers in addition. Using this metric for benchmarking requires accounting for the impact of case mix differences over time or between systems and clinicians.
ABSTRACT
Background. There have been reports of COVID-19 infection characterized by prolonged viral replication [chronic active COVID-19 (CAC)] among immunocompromised patients, including those receiving B-cell depleting therapies (BCDTs). We aimed to characterize the severity and incidence of CAC among patients on BCDTs with COVID-19, and to identify associated risk factors. Methods. We retrospectively reviewed all patients who received an anti-CD20 BCDT within 1 year of a positive COVID test at University of Utah Health. Demographics, comorbidities, indications, and timing of BCDT were documented. Chart review was performed to characterize the clinical course, including need for hospitalization, COVID-specific therapies, need for ICU and ventilatory support, and mortality. We defined CAC as: (1) despite initial clinical improvement, progression of illness extending beyond 14 days, characterized by ongoing fevers or progressive respiratory failure;or (2) ongoing symptoms with demonstration of absent seroconversion ≥ 14 days into illness. In some patients the diagnosis of CAC was supported by low viral PCR crossing thresholds that occurred ≥ 14 days into illness. Logistic models were used to identify risk factors for CAC among the cohort of patients who survived through the initial period of infection. Results. We identified 66 individuals who received a BCDT within 1 year of a positive COVID test;29 (44%) were hospitalized, 4 (6%) required ventilation, and 7 (11%) died within 60 days. Among 63 patients who survived their initial COVID course, 16 (25%) had courses compatible with CAC. Nine (56%) who received a BCDT within 1 month before or 2 weeks after their COVID diagnosis developed CAC;OR 7.4 (95% CI 1.7, 31.6, p=0.002). Conclusion. We clinically observed COVID-19 infection lasting longer than the typical course and propose a definition for CAC. Incidence of CAC was highest among patients who received BCDT within 30 days before or 2 weeks after COVID-19 diagnosis. High suspicion for CAC is warranted among patients receiving these therapies. Additional study is needed to better define risk for CAC among varying immunosuppressed populations and determine whether COVID-specific treatments early in disease may benefit these patients.