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Introduction: As the U.S. population ages, gastroenterologists will provide care for an increasing number of older patients - many of whom use Medicare. In recent years there have been significant policy changes surrounding Medicare reimbursement for physicians. Understanding reimbursement trends can help reveal the financial impact of these policies on gastroenterologists. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services from 2007 to 2022. Method(s): The top 10 GI procedures and their respective CPT codes were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association. The top 5 5 CPT codes relating to office/inpatient visits provided by gastroenterologists to Medicare Part B beneficiaries was identified using data from CMS. The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022, to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were adjusted to January 2022 U.S. dollars using the U.S. Department of Labor's Bureau of Labor Statistics' consumer price index inflation calculator. Result(s): The unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% CI, 29.9% to 24.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, 235.1% to 230.9%). The mean annual growth rate in reimbursement was 22.6% (95% CI, 22.8% to 22.4%). The unadjusted physician reimbursement for inpatient and outpatient visits exhibited an average increase of 32.1% (95% CI, 4.8% to 59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.92% (Figure 1). Conclusion(s): The analysis revealed a steady decline in adjusted and non-adjusted reimbursement between 2007 and 2022. Decreasing Medicare reimbursement may impact health outcomes, healthcare access, and patient satisfaction. Reimbursement policies must be scrutinized particularly in the light of high inflation and increased costs due to additional costs associated with care during the COVID-19 pandemic, staffing shortages, and increased staffing salaries. (Figure Presented).
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Background: Due to public health regulations, many outreach programs aimed at identifying and treating disengaged populations at high risk of HCV infection were suspended. This led to a significant decrease in treatment starts and, quite likely, an increase in disease incidence among this group of core transmitters. There is an urgent need to design and evaluate novel approaches to ensure that this unmet need is addressed in concert with COVID-related programs to mitigate disease transmission, optimize COVID vaccination rates as well as timely diagnosis and treatment of COVID cases in this unique environment. Method(s): We designed a program of intervention based in single room occupancy residences in the inner city of Vancouver, Canada. Events were held in common areas and conformed to all social distancing/personal protective equipment regulations. Only residents of the building were allowed to participate, to minimize social mixing. Point of care testing for HCV was offered by finger stick rather than oral swab, to allow constant masking. Education was offered about COVID transmission, the importance of vaccination and the availability of treatment. Access to COVID rapid tests at the time of the event and beyond was facilitated, along with (more recently) an offer of antiviral treatment if eligible. In all cases, an offer of broader engagement in multidisciplinary care was made, to address HCV infection and other essential needs. Result(s): Since July 2020, 80 events have been held. We have reached 1193 individuals (71.1% male, 23.8% Aboriginal). HCV antibody positivity rate was 36.3%. Viremia testing was completed in 358 individuals, with 173 (48.3%) being positive. Of these, 97 have initiated treatment, 64 have completed treatment, with SVR12 rate of 53/54 (98.1%), and 31 patients remain in care, awaiting HCV treatment initiation. Data on COVID vaccination and disease transmission rates are being analyzed. Conclusion(s): It is still possible to design programs of intervention for inner city residents while respecting COVID regulations. Such events (conducted within a population where 1/3 are infected with HCV), conducted within the context of an offer of broader care, are highly successful and will contribute significantly towards an increase in HCV treatment starts in a group that has been particularly disadvantaged in the pandemic era.
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Background and aims: As a result of disengagement in addiction care during the COVID-19 pandemic, there has been a record increase in mortality associated with opioid overdoses (primarily fentanyl), particularly in North America. In the USA there were over 100, 000 overdose deaths in 2021, while over 2000 were recorded in the province of British Columbia. As we attempt to develop novel ways to increase HCV treatment following ≥30% declines during the pandemic, we evaluated publicly available adverse events (AEs) reports for opioids and DAAs to assess whether safety concerns from potential drug interactions arewarranted, particularly amongst those using fentanyl. Method: Data were downloaded from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) Public Dashboard. AEswith the DAAs glecaprevir/pibrentasvir (G/P), sofosbuvir/ velpatasvir (SOF/VEL), ledipasvir/sofosbuvir (LDV/SOF), sofosbuvir/ velpatasvir/voxilaprevir (SOF/VEL/VOX), andelbasvir/grazoprevir (EBR/ GZR) listed as the suspect product were analyzed with an initial received date from July 28, 2017-December 31, 2021, as were opioidassociated AEs for all 2017–2021. Subsequently, AEs were counted based on listed concomitant use of opioids (fentanyl, oxycodone, hydrocodone), or overdose outcomes irrespective of concomitant opioid use. Data are descriptivewithout any statistical analyses. Results: In the reporting period, 40 total AEs were recorded with concomitant DAA and fentanyl use, 14 resulting in death (G/p = 3, SOF/VEL = 11;Table 1);626 total AEs were recorded with concomitant DAA and oxycodone or hydrocodone use, 28 resulting in death. Separately, overdose events were reported 196 times, 32 resulting in death. The number of overdoses declined each year from 2018 (N = 56) to 2021 (N = 29). Fentanyl AEs showed no trend year to year. Table 1: FAERs AEs and deaths with opioids and with concomitant HCV DAAs. (Table Presented) *N represents the sum of fentanyl, oxycodone, and hydrocodone overdose AEs and deaths, whereas n’s for DAA overdose AEs and deaths are irrespective of concomitant opioids. Conclusion: With the limitations of FAERS data (under or duplicate reporting, inability to establish causation or incidence), these data showthat among ~58, 000 fentanyl, ~189, 000 oxycodone, and ~100, 000 hydrocodone AEs reported to FAERS since 2017, a small proportion (0.19%) have been reported in association with concomitant DAA therapy, with no association between recorded events and a specific DAA regimen. This should reassure HCV treaters on a lack of safety signal for concomitant opioid and DAA use.
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Introduction: Despite COVID-19 being a viral illness, antibiotic use has been more prevalent. In addition, co-infection (3.5%) and secondary infection (14.3%) were relatively low in hospitalised patients with COVID-19. A major concern is the increased risk of antimicrobial resistance (AMR) due to inappropriate antibiotic consumption (1). Aim: This review aims to evaluate antimicrobial consumption (excluding repurposed drugs such as remdesivir) in hospitals and determine the prevalence of COVID-19 patients who received antibiotic therapy using meta-analysis. Methods: The review was conducted according to PRISMA guidelines (2). The two investigators independently developed and applied eligibility criteria to examine original articles. Studies were eligible for inclusion if they met the following criteria: (i) original research studies with a minimum sample of 50 patients;(ii) focussed on antibiotic consumption (AMC);(iii) patients with COVID-19 or consumption amid COVID-19 pandemic;(iv) any age group or gender;and (v) reported in the English language. The included articles were retrieved from MEDLINE, CINAHL, WHO COVID-19 databases, including studies published in EMBASE, Scopus, WHO-COVID, and LILACS between December 2019 to July 2021. The modified version of Newcastle-Ottawa Scale (NOS) was used to measure biases in included studies after the consensus by both authors. The random-effects model was used to estimate the pooled prevalence or proportion of AMC among hospitalized COVID-19 patients. Results: A total of 34 studies conducted among hospitalised COVID-19 patients were included. The extracted studies presented AMC in defined daily doses (DDD) or frequency and percentages. Azithromycin was the most frequently prescribed antibiotic in almost all studies. The meta-analysis that examined overall AMC using data from 25 studies (17 studies from high income countries and eight from low-middle income countires) revealed 69% (95% CI:63%-74%) of hospitalized COVID-19 received at least one course of antibiotics. The sub-group analysis of studies from high income countries (HICs) revealed 59% (95% CI: 51%-66%) consumed antibiotics compared with 89% (95% CI: 82% to 94%) among hospitalised COVID-19 patients in low-middle income countries (LMICs). Conclusion: This review highlights the trend of antibiotic consumption in hospitalised COVID-19 patients. A significant rise in antibiotic consumption was observed in LMICs and increased antibiotic consumption in the first few months of the COVID-19 pandemic in HIC. The review outcomes emphasised the importance of rational and judicious use of antimicrobial therapy as well as to strenghting the antimicrobial stewardship policies and activities, particularly during a global pandemic. The limitation of the review undertaken was not identified incidence of co-infection and don't include studies on reported AMC in immunocompromised patients.
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BACKGROUND: The objective of this study was to determine the associations between heart disease, obesity, and demographic factors and increased COVID-19 mortality. METHODS: We extracted deidentified patient-level data from the Froedtert Health System and Children's Hospital of Wisconsin and used descriptive statistics and multivariable logistic regression to characterize relationships between heart disease, obesity, age group, sex, race and ethnicity and mortality following COVID-19 diagnosis. RESULTS: We found heart disease (adjusted odds ratio [AOR] 2.85;95% CI, 2.11-8.83) and other demographic factors are significant predictors of increased mortality in COVID-19 patients. However, obesity was not a significant predictor of mortality (AOR 1.04;95% CI, 0.53- 3.10). DISCUSSION: These unique results indicate some comorbid conditions and patient demographics contribute more strongly to mortality in COVID-19 patients.
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Background: The treatment of high priority populations, including patients actively using intravenous drugs (active PWID), must be prioritized to accomplish the WHO HCV elimination goals by 2030. Simplification of the treatment cascade is key to reaching this goal, even more so in the COVID-19 era Sofosbuvir/velpatasvir (SOF/VEL) is a protease inhibitor-free, pangenotypic, panfibrotic, single duration, single tablet regimen, to be taken without regards to food and with limited drug-drug interactions This real-world analysis evaluates SOF/VEL as a simple strategy to implement a testand- treat approach in HCV-infected active PWID Methods: Adult active PWID treated for HCV with 12 weeks SOF/VEL in different clinical settings were included from 25 cohorts in 6 countries Patients with a history of decompensation or prior NS5A-inhibitor exposure were excluded The endpoints were HCV cure (undetectable HCV RNA ≥12 after the end of therapy, SVR12) and time-to-treatment (TT) between most recent HCV RNA measurement and SOF/VEL treatment start Results: Analysis included 340 patients, mean age 44±10years, 84% male, 15% compensated cirrhotic (CC) and 8% treatment-experienced, with 43% genotype (GT) 1 and 41% GT3 73% of patients were diagnosed with a mental disorder, 27% were homeless and 21% incarcerated Of patients with TT available (n=334), 10% were treated the same day of diagnosis, 16% within 1 week, 39% within 1 month, and 69% within 3 months Treatment adherence below 90% was observed in 24 patients (8%) SVR12 is available for 254 patients (75%), as non-virological or unknown cause of failure was documented in 86 patients (25%), 79% due to lost-to-follow-up (LTFU) SVR12 was 98% overall (249/254), 98% (80/82) in non-cirrhotic and 95% (20/21) in CC patients Active PWID with mental disorders showed 97% SVR12 (181/186) Of active PWID with GT3 infection, 96% (104/180) were cured, including 95% (20/21) of those with CC Of 31 patients starting treatment within 1 week of diagnosis, all achieved SVR12 compared to 126/129 (98%) starting within 3 months of diagnosis Conclusion: SOF/VEL is a simple HCV treatment resulting in high cure rates in active PWID, including patients with multiple complicating factors LTFU remains a challenge in this population The simplicity of the SOF/VEL approach allowing for shortening of the patient care cascade and rapid treatment starts with high cure rates may help address this important issue.
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Background: Stigma and poor linkage to care, amplified in the setting of the COVID-19 pandemic, are significant barriers for treating hepatitis C (HCV) in vulnerable patients, reducing our ability to implement a rapid test and treat (TnT) strategy with minimal monitoring within a simple patient cascade, as currently available HCV therapies would allow us to do This real-world analysis evaluates our ability to implement this approach in both general (GP) and vulnerable (VP) populations Methods: HCV-infected patients from 32 clinical cohorts in 8 countries treated with sofosbuvir/ velpatasvir without a history of decompensation or prior NS5A-inhibitor exposure were included in this analysis The VP included prisoners, homeless patients and patients with mental disorders Time to treatment (TT) between the most recent HCV RNA measurement and treatment initiation was estimated based on available data Results: A total of 2449 patients were included, 937 in GP (58% males), 1512 (72% males) in VP (59% with mental disorders, 31% homeless, 10% imprisoned) Mean age [standard deviation] was 55 [14] and 50 [14] years in GP and VP respectively Genotype 3 was observed in 35% and 33% respectively, compensated cirrhosis confirmed in 20% and 18% of GP versus VP. The median TT [MTT, interquartile range] was 55 days [23- 107] in GP and 60 days [27-132] in VP The longest MTT of 66 days [32-134] was observed in patients with mental disorders MTT was 63 days [29-149] in prisoners and 27 days [13-71] among the homeless Only 13% of GP and 8% of VP were treated the same day of diagnosis, and 70% of GP and 63% of VP were treated within 3 months In patients with mental disorders only 4% were treated the same day of diagnosis Cure rates were high and consistent with previously reported cure rates Conclusion: MTT varies across HCV patient groups, from over 6 months to 1 day This analysis shows that a quick treatment start is possible, both in general population and in vulnerable populations, supporting the feasibility of a TnT approach in all populations New strategies should be considered to engage patients with mental disorders in this model of care more effectively.
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Background: To achieve the World Health Organization's goal to eliminate hepatitis C (HCV) as a public health concern by 2030, treatment starts will have to be maintained, especially among vulnerable inner-city populations With the advent of the SARS-CoV-2 pandemic, treatment starts were reduced due to diversion of resources away from HCV programs The inner-city population was further marginalized by essential public health measures designed to control the pandemic It is important to document the impact on HCV programs and the measures that may have already been taken to address them in the context of the evolving measures to address the SARS-CoV-2 pandemic Methods: Within our multidisciplinary program of care to address HCV among vulnerable populations (most of whom reside in the inner city), we calculated our usual rate of monthly treatment starts from 01/19 to 02/20 We then calculated treatment starts in 03/20 to 05/20, when programs to identify HCV-infected patients and engage them in care were suspended This was further compared to starts from 06/1/20 to 07/15/20 when outreach programs were slowly re-initiated in conjunction with TeleHealth initiatives to provide enhanced support to patients Results: In the 14 months from 01/19 - 02/20, there was an average of 10 treatment starts/month at our centre Key demographics of the treated population were mean age 50 (25-76) years, 79% male, 93% drug users, 89% on opioid substitution therapy (OST), 27% homeless, and 38% with psychiatric co-morbidities From 03/1/20 - 07/15/20 there were 23 treatment starts: mean age 47 (22-75) years, 83% male, 70% drug users, 65% on OST, 22% with psychiatric co-morbidities, and 17% homeless In the 3 months from 03/20 - 05/20, there were only 9 starts and in 06/20, there were 6 starts. In the first half of 07/20, there were 8 starts. This represents a 60% increase in treatment starts/month compared to our long-term average, and likely represents a partial 'warehouse' effect Conclusion: Among established programs such as ours, the advent of the SARS-CoV-2 pandemic led to a virtual suspension of HCV treatment starts for a period of 3 months As the pandemic came under control in our jurisdiction, we were able to resume our programming in a way that is consistent with the public health measures needed to control the pandemic while still optimizing HCV care delivery In order to stay on track to achieve HCV elimination goals, we must control SARS-CoV-2 transmission to allow treatment programs to resume optimal function within the framework of the 'better normal' of the evolving pandemic response.