COVID-19 incidence and mortality in pre-dialysis chronic kidney patients during the first wave of the pandemic in Italy

BACKGROUND AND AIMS: Many studies are available that reported a higher risk of COVID-19 disease among patients on dialysis or with kidney transplantation, and the poor outcome of COVID-19 in these patients. Patients in conservative therapy for chronic kidney disease (CKD) have received lower attention, therefore little is known about how COVID-19 may affect this population. The aim of this study was to analyse the COVID-19 incidence and mortality in CKD patients followed up in an integrated healthcare program, living in a small area of Northern Italy. METHOD: The study population included CKD patients from the Emilia-Romagna Prevention of Progressive Renal Insufficiency (PIRP) project, followed up in the 4 nephrology units (Ravenna, Forlì, Cesena and Rimini) of AUSL Romagna (Italy) and alive at 1.01.2020. All patients were in conservative therapy and none of them had initiated dialysis or received kidney transplantation. The hospital discharge database was used to identify patients hospitalized with COVID-19 up to 31.07.2020, and the mortality database was used to assess mortality among patients with COVID-19 at the same date. Multivariable logistic regression was used to identify predictors of COVID- 19 disease, and Kaplan-Meier survival analysis to identify predictors of COVID-19 mortality. Excess mortality of 2020 compared to mortality in 2015-19 in the PIRP cohort was also estimated. RESULTS: COVID-19 incidence among CKD patients was 4.09% (193/4716 patients), while in the general population it was 0.46% (5,195/1,125,574). COVID-19 was more likely in CKD patients with older age (Odds Ratio=1.038), cardiovascular comorbidities (OR=2.217), COPD (OR=1.559) and less likely in patients living in the province of Ravenna (OR=0.468), that was hit later by the first wave of pandemic compared to the other areas of AUSL Romagna. Baseline eGFR was lower in CKD patients with COVID-19 (31.7 vs. 35.8 ml/min/1.73 m2), but this difference did not reach statistical significance (p=0.066). As of 31.07.2020, the crude mortality rate among CKD patients with COVID-19 was 44.6% (86/193), compared to 4.7% (215/ 4523) in CKD patients without COVID-19 and to 14.5% (4289/29670) in the general population with COVID-19 of the Emilia-Romagna region. Factors associated with mortality of CKD patients with COVID-19 were older age (p=0.034) and the period of COVID-19 onset (p=0.003). The highest crude mortality rate (71.4%) was found in CKD patients for whom COVID-19 onset occurred between 8 and 21 March. The excess mortality of January-July 2020 with respect to the average mortality of January- July 2015-19 in the PIRP cohort was +17.7%, corresponding to 77 excess deaths. March-April was the period with the highest excess mortality (+69.8%), while in January-February a 15.9% lower mortality was observed with respect to the corresponding months of the five previous years. CONCLUSION: In our study, including a cohort of regularly followed up CKD patients, the risk of COVID-19 disease and of COVID-19 related mortality was comparable, or even somewhat higher, to that observed in patients on dialysis and those who received kidney transplantation. The incidence of COVID-19 in CKD patients was higher in the areas of AUSL Romagna earlier affected by the pandemic wave, whereas mortality rates were similar across all areas. CKD patients represent a population very vulnerable to COVID-19 disease, and their protection should be highly prioritized in the models of care and prevention measures.

Transformation of Cancer Care during and after the COVID Pandemic, a point of no return. The Experience of Italy.

Policymakers everywhere struggle to introduce therapeutic innovation while controlling costs, a particular challenge for the universal Italian National Healthcare System (SSN), which spends only 8.8% of GDP to care for one of the world's oldest populations. Oncology provides a telling example, where innovation has dramatically improved care and survival, transforming cancer into a chronic condition. However, innovation has also increased therapy duration, adverse event management, and service demand. The SSN risks collapse unless centralized cancer planning changes gear, particularly with Covid-19 causing treatment delays, worsening patient prognosis and straining capacity. In view of the 750 billion Euro "Next Generation EU", released by the European Union to relieve Member States hit by the pandemic, the SSN tapped a multidisciplinary research team to identify key strategies for equitable uptake of innovations in treatment and delivery, with emphasis on data-driven technological and managerial advancements - and lessons from Covid-19.

PCN224 An Italian Experience: How the COVID-19 Era HAS Modified the Radiological Activity in a Cancer Hospital

Objectives: In this dramatic global health crisis, Radiology Units underwent some crucial changes in the daily activity organization to minimize the risk of COVID-19 contamination. This study aimed to assess the impact of COVID-19 on the radiological activity of an Italian cancer hospital. Methods: Radiological procedures performed during the period of 8 weeks of Italian lockdown (9 March ̶ 3 May 2020) and the same 2019 period were retrospectively collected and compared. Results: During the lockdown period 4053 patients (for a total of 17793 accesses) attended our institution for diagnostic or therapeutic purposes, 942 out of total patients (1110 accesses) underwent at least one radiological procedure. The Radiology Unit reviewed 1438 outpatients scheduled for radiological examinations, of these 456 patients were postponed (-31,7%): 91.7% because not-urgent, 5.6% declined the appointment, and 1.3% for presence of flu-like symptoms. The maximum reduction of patient’s access, referred in particular to the second and third weeks of March. Conversely, in the following weeks a gradually progressive growth of patient’s access was observed week after week, probably as a consequence of progressive rearrangement of the activities. Compared to the same 2019 period, the number of procedures decreased respectively of: 26.0% in CT, 34,7% in MRI, 34,8% in X-Ray and 58,5% in US. CT scans were subject to the least decrease compared to the other techniques due to their pivotal role in oncology. In the first month of lockdown the number of CT exams dropped by 29% compared to the average of 2019, while in April and May the reduction was of 23% and 18%, respectively. Conclusions: The COVID-19 outbreak has posed a great challenge to radiology, changing its activity with an overall reduction in the number of procedures performed with consequences still unknown in screening, early diagnosis and management of follow up that have been postponed.

PCN216 An Innovative Organization MODEL to Face Risks Reduction Challenges in an Italian Cancer Center during the COVID-19 Pandemic: A Risk Reduction Estimation Study

Objectives: In this Covid-19 pandemic, onco-hematological patients are at higher risk of severe infection because of both their immunosuppressive state caused by malignancy and treatments and their recurrent hospital accesses. At our cancer centre (IRST), following national authorities and scientific societies recommendations, we set up a model for reduction of risk of Covid-19 positive accesses through sequential actions on patients, caregivers and workers. In this work we give an estimate of reduction of risk of Covid-19 positive accesses. Methods: Covid-19 positive accesses baseline Absolute Risk (AR, ratio between the number of infected subjects accesses and the total number of accesses) for patients, caregivers and workers was estimated in the period from March, 11 to March, 31. Five risk reduction actions were implemented: (1) all procedures judged as deferrable by physicians have been postponed, (2) by-phone triage and (3) on-site triage have been activated to avoid accesses of suspected cases patients and caregivers. For workers (4) special leaves and (5) smartwork were encouraged. For each of these actions we estimated Absolute Risk Reduction (ARR) and Relative Risk Reduction (RRR). Results: In the analysis period we estimated 50 Covid-19 positive accesses: 14 for patients, 7 for caregivers, 29 for workers (AR 0.129%, 0.087%, 0.316% respectively). We measured 9 avoided accesses for patients (ARR: 0.084%, RRR: 65.4%), 5 for caregivers (ARR: 0.061%, RRR: 69.5%), 17 for workers (ARR: 0.184, RRR: 58.0%);for a total of 31 accesses potentially avoided thanks to the 5 actions. Conclusions: During the pandemic IRST never stopped providing care to the patients, the implemented actions allowed a risk reduction that can be an example of how to face this pandemia maintaining both continuity of care and safety for patients and staff in a context of frailty such as a cancer centre.

Mitigating strategies and nursing response for cancer care management during the COVID-19 pandemic: an Italian experience.

AIM: To describe our response to the COVID-19 emergency in a cancer centre to enable other nursing organizations to determine which elements could be useful to manage a surge of patients in their own setting. BACKGROUND: The COVID-19 pandemic represents one of the most challenging healthcare scenarios faced to date. Managing cancer care in such a complex situation requires a coordinated emergency action plan to guarantee the continuity of cancer treatments for patients by providing healthcare procedures for patients, caregivers and healthcare professionals in a safe environment. PROCEDURES: We describe the main strategies and role of nurses in implementating such procedures. RESULTS: Nurses at our hospital were actively involved in COVID-19 response defined by the emergency action plan that positively contributed to correct social distancing and to the prevention of the spread of the virus. IMPLICATIONS FOR NURSING AND HEALTH POLICIES: Lessons learned from the response to phase I of COVID-19 have several implications for future nursing and health policies in which nurses play an active role through their involvement in the frontline of such events. Key policies include a coordinated emergency action plan permitting duty of care within the context of a pandemic, and care pathway revision. This requires the rapid implementation of strategies and policies for a nursing response to the new care scenarios: personnel redistribution, nursing workflow revision, acquisition of new skills and knowledge, effective communication strategies, infection control policies, risk assessment and surveillance programmes, and continuous supplying of personal protective equipment. Finally, within a pandemic context, clear nursing policies reinforcing the role of nurses as patient and caregiver educators are needed to promote infection prevention behaviour in the general population.