ABSTRACT
Background. COVID-19 has caused over 6 million deaths worldwide. While testing was initially centered in healthcare facilities with automatic reporting to health departments, it is increasingly being performed in the home with rapid antigen testing. Many at-home tests are self-interpreted and not typically reported. In December 2021, nirmatrelvir/ritonavir and molnupiravir were authorized for the treatment of COVID-19 in high-risk patients. In New York City (NYC), these antivirals are available for free via pickup or home delivery, allowing for early expanded access. We sought to identify if prescribing of antivirals might act as an early indicator of increasing COVID-19 incidence in the setting of decreased case reporting. Methods. Confirmed and probable COVID-19 tests are reported to the NYC Health Department. All pharmacies participating in the federal COVID-19 therapeutics program are required to report daily utilization data, which are made available to jurisdictions through the Tiberius platform. From December 27, 2021 to April 18, 2022, we analyzed citywide weekly case counts, using patients 65 years and over as a proxy for high-risk eligible patients, and weekly oral therapeutic prescription fills. We calculated weekly case rates and prescribing rates per 100,000 residents. Weekly case rates and prescription fill rates were trended to assess for concordance over time. Results. During this period, 17,522 prescriptions were filled. Prescription fills and case rates were concordant until the weeks of February 28 and March 7, when an increase in fill rate was noted from the week prior (1.76 to 2.34 to 4.10), while reported case incidence continued to decrease (6.16 to 5.08 to 4.61). This discordance coincided with the emergence of the BA.2 subvariant in NYC. After these weeks, an uptick in case incidence was noted for the remainder of the study period, in concordance with prescription data. Conclusion. Increasing rates of oral therapeutic prescribing could be an early indicator of increasing COVID-19 transmission. Limitations include the unclear impact of public and prescriber education efforts on prescribing trends. Next steps include exploring the addition of prescription data into modeling to predict trends in transmission as reported cases becomes a less reliable indicator.
ABSTRACT
BACKGROUND: Since the onset of the COVID-19 pandemic, healthcare systems have faced significant barriers to providing quality primary care, particularly as practices shifted to telemedicine modalities without established technical and educational frameworks for patients, teams, and clinicians. We created an iterative quality improvement project with Unannounced Standardized Patients (USPs) to explore variation in telehealth practices across three public ambulatory care clinics. METHODS: Clinical leadership designed two USP cases reflective of local patient populations and their common clinical needs. USPs portrayed either;(1) a 40-45-year-old Black male with hypertension, or (2) a 40-45-year-old Latina with an asthma exacerbation and hypertension. Both were vaccine hesitant. USPs evaluated visit workflow and clinician's communication skills across core domains (Table 1). After each visit, the USPs completed a behaviorally anchored checklist. Domain summary scores were calculated as mean percent marked “well done.” A t-test was used to compare scores across phases and cases. RESULTS: 60 visits (48 video, 12 audio-only) were conducted in two phases (May-August 2021;September-December 2021). Of the 24 USPs (18 calls, 9 texts) contacted prior to their visit, only 4 spoke directly to a care team member. 74% of USPs recommended the clinic. There were no significant differences in domain scores between phases or cases (Table 1). Most clinicians (82% in both phases) introduced the topic of the COVID-19 vaccine appropriately. Regarding screening, most providers asked about smoking (79%) and alcohol use (72%), but few screened for vaping (22%) or depression (4%). 70% of clinicians or care teams replied to a MyChart portal message that was sent by the USP to the care team after the visit. CONCLUSIONS: Findings highlight opportunities for system-based change to optimize telehealth care (particularly the integration of team members in previsit planning, standardized screenings, and patient follow-up). Data across phases indicate sustained need for quality improvement efforts;reviewing comparative data with clinic leadership will inform further evaluation of health systems and educational methods.
ABSTRACT
SETTING AND PARTICIPANTS: Clinician trainees across our health system, including: 1) 107 internal medicine faculty and residents who participated in workplace-based learning at public, private, and federal (Veterans Affairs) ambulatory practices, 2) 16 clinicians at our student health center, and 3) upwards of 250 medical students, residents, and newly-hired general internal medicine (GIM) faculty members from medicine, neurology, and pediatrics departments in our simulation center. DESCRIPTION: While core communication skills have always been at the forefront of medical trainee assessment, information on transference of those skills and integration of the in-person clinical workflow to the virtual care environment was limited prior to COVID-19. NYU Grossman School of Medicine (NYUSOM) implemented a telehealth improvement program across medical students, residents and faculty. In order to assess and improve our systems' ongoing telehealth practices, we employed three distinct educational methodologies across our health systems since March 2020: objective structured clinical exams (OSCEs) and announced (ASPs) and unannounced standardized patient (USPs). Cases were designed to target common, site-specific issues (i.e., hearing loss, COVID-19 vaccine hesitancy, social determinants of health, and sexual and mental health concerns). In line with previous work, all SPs were trained to use a standard behaviorally-anchored checklist to assess communication and telemedicine-specific skills over video visit ( Zoom or WebEx). USPs, professional actors who conduct visits unbeknownst to the clinician, were also trained to collect data on clinic functioning. EVALUATION: Summary reports on performance were provided to both clinical and education leadership and learners to identify future training needs. Data on telemedicine skills across all projects demonstrates room for improvement (mean % marked 'well done' across learners: 46% in the OSCE, 68% at the SHC, and 48% in the public clinics, respectively). Common telemedicine challenges included prompting the SP to adjust their video frame or remove distracting background noise. Most health systems conducted fewer screenings virtually than they did inperson (e.g., at the SHC only 41% and 6% of SPs were screened for alcohol and vaping, respectively;at the public clinics, 25% and 20% were screened for depression and vaping, respectively). Participant feedback reports highlight performance across core domains and provide resources for improvement. DISCUSSION / REFLECTION / LESSONS LEARNED: Our ongoing telemedicine training program demonstrates a highly scalable educational assessment methodology that can be leveraged to optimize common care practices. Data confirm that SPs, ASPs, and USPs can be used across the health care system in simulated and real-world scenarios to identify areas for intervention.
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Introduction: The Covid-19 pandemic has highlighted vaccination challenges with MS disease modifying treatments (DMTs). B cell depleting agents and sphingosine-1-phosphate receptor modulators have been proposed to have the most significant effect on vaccine efficacy. Objectives/Aims: To provide an overview of the humoral response of our treated adult MS patients to a completed COVID- 19 vaccination series. Methods: This is a retrospective study of patients of the Holy Name MS Center. We introduced, as part of standard of care, SARS-Covid Spike Antibody IgG semi-quantitative testing for patients who completed vaccination and were interested in this testing. It was conducted between March 25 and May 14, 2021 with most labs performed by Quest. We extracted information regarding patient age, vaccine type, date of vaccination completion and DMT / last treatment date. Data were quantitatively analyzed. IRB approval was obtained for this study. Results: There were a total of N=114 patients, age (mean & plusmn;SD) 50.9 y & plusmn;13, of whom 49 (43%) did not make a positive antibody result;this included 42 patients on infusion anti-CD20 therapy, 3 on fingolimod, 2 on natalizumab, 1 on glatiramer acetate (GA) and one following high dose solumedrol. Of 54 patients treated with infusion anti-CD20 medication who had antibodies checked, only 12 (22%) were positive;there was no statistical difference in immunity by vaccine type, Chi sq (1, N=54) = 1.38 p-value .24. The earliest post-infusion vaccination completion that yielded a positive result was day 73. Fingolimod treated patients (5) all received Moderna mRNA vaccines with 40% developing a humoral response with lowest absolute lymphocyte count at time of positive result, 274. 91% of natalizumab treated patients (20/22) did develop a humoral response, with the two negative tests in a 51- and 53-year-old who received the Janssen vaccine. 88% (7/8) of GA patients were antibody positive (negative result in 66-year-old). All teriflunomide (n=11), dimethyl fumarate/ diroximel fumarate (n=4), interferon (n=5), and remote alemtuzumab (n=2) patients made positive responses. Conclusions: We confirmed that MS patients receiving anti- CD20 infusion therapies are likely at a humoral immunity disadvantage following vaccination. This study is limited in retrospective design, small un-balanced groups, and lack of longitudinal data. We cannot exclude the possibility of a more robust delayed humoral response.
ABSTRACT
Background: The COVID-19 pandemic has raised novel questions for people with multiple sclerosis (pwMS), which worldwide registries will help answer. One question is - how will disease modifying treatment (DMT) use affect the efficacy of a future vaccine against SARS-CoV2 (the virus that causes COVID- 19) in pwMS? To begin to address this question, we evaluated our patients who were clinically diagnosed with Covid-19 for antibodies (Ab). Objectives: To determine the frequency of SARS-CoV-2 Ab in our patients with Covid-19 and co-morbid MS, and describe their clincal characteristics. Methods: This is a case series of pwMS who are patients of the Holy Name MS Center and were either proven by PCR or highly suspected of active COVID-19 infection as of July 15, 2020. Results: Of the 11 patients included, 91% (n=10) were female, average age 50.5 years (range 34-64 years);7 patients treated with an anti-CD 20 monoclonal Ab (6 ocrelizumab (OCR), 1 rituximab (RTX)), 1 teriflunomide, 1 interferon beta-1a, and 2 patients not on DMT. Nine tested positive for SARS-CoV2 Ag by nasopharyngeal PCR;1 was not tested but had a household exposure who tested positive and herself had clinical symptoms of cough, dyspnea, myalgia, weakness, fatigue and headache;and 1 patient tested negative for SARS-CoV2 PCR but was febrile with cough, fatigue and headache during the pandemic. Of this series, 5 tested positive for SARS-CoV2 Ab (Abbott test);of which only 1 was on treatment with OCR (with absent CD19 cells). In terms of clinical outcome - 4 patients (all OCR/RTX treated) required hospital admission for supplemental non-invasive oxygen. All patients survived infection. Conclusions: This case series suggests that MS treatment with monoclonal anti-CD20 drugs may be associated with some increased risk of developing COVID-19. All of our patients who required hospitalization for this infection were treated with anti- CD20 threapy. Patients with MS who are on OCR/RTX may be less likely to mount an antibody response to this infection, whereas patients treated with interferons and teriflunomide can. Lack of seroconversion following OCR treatment was also noted in another case series of pwMS (Thornton 2020). Although it is reassuring that B-cells are not required to recover from COVID-19 infection, as evidenced by a case series of X-linked agammaglobulinemia patients (Soresina et al. 2020), our findings raise further questions for the health and safety of our patients with respect to this pandemic. Will OCR treated patients be at a unique risk to suffering reinfection from COVID-19 given they are less likely to seroconvert? And, how effective will a future vaccine be in patients treated with OCR (and similar monoclonal antibodies).