1
|
Penrose K, Srivastava A, Shen Y, Robertson MM, Kulkarni SG, Allen KE, Porter TM, Puzniak L, McLaughlin JM, Nash D. Perceived Risk for Severe COVID-19 and Oral Antiviral Use Among Antiviral-Eligible US Adults. Infect Dis Ther 2024; 13:1743-1757. [PMID: 38909338 PMCID: PMC11266331 DOI: 10.1007/s40121-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/03/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Oral antiviral medications are important tools for preventing severe COVID-19 outcomes. However, their uptake remains low for reasons that are not entirely understood. Our study aimed to assess the association between perceived risk for severe COVID-19 outcomes and oral antiviral use among those who were eligible for treatment based on Centers for Disease Control and Prevention (CDC) guidelines. METHODS We surveyed 4034 non-institutionalized US adults in April 2023, and report findings from 934 antiviral-eligible participants with at least one confirmed SARS-CoV-2 infection since December 1, 2021 and no current long COVID symptoms. Survey weights were used to yield nationally representative estimates. The primary exposure of interest was whether participants perceived themselves to be "at high risk for severe COVID-19." The primary outcome was use of a COVID-19 oral antiviral within 5 days of suspected SARS-CoV-2 infection. RESULTS Only 18.5% of antiviral-eligible adults considered themselves to be at high risk for severe COVID-19 and 16.8% and 15.9% took oral antivirals at any time or within 5 days of SARS-CoV-2 infection, respectively. In contrast, 79.8% were aware of antiviral treatments for COVID-19. Perceived high-risk status was associated with being more likely to be aware (adjusted prevalence ratio [aPR]: 1.11 [95% confidence interval (CI) 1.03-1.20]), to be prescribed (aPR 1.47 [95% CI 1.08-2.01]), and to take oral antivirals at any time (aPR 1.61 [95% CI 1.16-2.24]) or within 5 days of infection (aPR 1.72 [95% CI 1.23-2.40]). CONCLUSIONS Despite widespread awareness of the availability of COVID-19 oral antivirals, more than 80% of eligible US adults did not receive them. Our findings suggest that differences between perceived and actual risk for severe COVID-19 (based on current CDC guidelines) may partially explain this low uptake.
Collapse
Affiliation(s)
- Kate Penrose
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA.
| | - Avantika Srivastava
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA
| | - Yanhan Shen
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA
| | - McKaylee M Robertson
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA
| | - Sarah G Kulkarni
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA
| | | | | | | | | | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), 55 W. 125 Street, 6 Floor, New York, NY, 10027, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA
| |
Collapse
|
2
|
Konetzka RT, Grabowski DC, Mor V. Four Years And More Than 200,000 Deaths Later: Lessons Learned From The COVID-19 Pandemic In US Nursing Homes. Health Aff (Millwood) 2024; 43:985-993. [PMID: 38950293 DOI: 10.1377/hlthaff.2023.01460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Nursing home residents and staff were disproportionately affected by the COVID-19 pandemic, drawing attention to long-standing challenges of poor infection control, understaffing, and substandard quality of care in many facilities. Evolving practices and policies during the pandemic often focused on these challenges, with little effect. Despite the emergence of best practices to mitigate transmission of the virus, even the highest-quality facilities experienced outbreaks, indicating a larger systemic problem, rather than a quality problem at the facility level. Here we present a narrative review and discussion of the evolution of policies and practices and their effectiveness, drawing on evidence from the United States that was published during 2020-23. The lessons learned from this experience point to the need for more fundamental and nuanced changes to avoid similar outcomes from a future pandemic: greater integration of long-term care into public health planning, and ultimately a shift in the physical structure of nursing homes. More incremental measures such as vaccination mandates, higher staffing, and balancing infection control with resident quality of life will avoid some adverse outcomes, but without more systemic change, nursing home residents and staff will remain at substantial risk for repetition of the poor outcomes from the COVID-19 pandemic.
Collapse
Affiliation(s)
| | | | - Vincent Mor
- Vincent Mor, Brown University, Providence, Rhode Island
| |
Collapse
|
3
|
McGarry BE, Gandhi AD, Chughtai MA, Yin J, Barnett ML. Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities. JAMA Intern Med 2024; 184:799-808. [PMID: 38829646 PMCID: PMC11148790 DOI: 10.1001/jamainternmed.2024.1079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 06/05/2024]
Abstract
Importance During the COVID-19 pandemic, stabilized COVID-19-positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy. Objective To assess the association between the admission to SNFs of COVID-19-positive patients and subsequent COVID-19 cases and death rates among residents. Design, Setting, and Participants This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19-positive patients) were matched to control facilities (ie, without initial admission of COVID-19-positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024. Exposure The week of the first observable admission of COVID-19-positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period. Main Outcomes and Measures Weekly counts of new cases of COVID-19, COVID-19-related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages. Results A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19-related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages. Conclusion This cohort study suggests that admission of COVID-19-positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.
Collapse
Affiliation(s)
- Brian E. McGarry
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester, Rochester, New York
| | - Ashvin D. Gandhi
- Anderson School of Management, UCLA (University of California, Los Angeles)
| | - Mah Afroze Chughtai
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jiamin Yin
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
4
|
Yan L, Bui D, Li Y, Rajeevan N, Rowneki M, Berry K, Argraves S, Huang Y, Hynes DM, Cunningham F, Huang GD, Aslan M, Ioannou GN, Bajema KL. Identifying Veterans Who Benefit From Nirmatrelvir-Ritonavir: A Target Trial Emulation. Clin Infect Dis 2024:ciae202. [PMID: 38864601 DOI: 10.1093/cid/ciae202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Nirmatrelvir-ritonavir is recommended for persons at risk for severe coronavirus disease 2019 (COVID-19) but remains underutilized. Information on which eligible groups are likely to benefit from treatment is needed. METHODS We conducted a target trial emulation study in the Veterans Health Administration comparing nirmatrelvir-ritonavir treated versus matched untreated veterans at risk for severe COVID-19 who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from April 2022 through March 2023. We measured incidence of any hospitalization or all-cause mortality at 30 days. Outcomes were measured for the entire cohort, as well as among subgroups defined by 30-day risk of death or hospitalization, estimated using an ensemble risk prediction model. RESULTS Participants were 87% male with median age 66 years and 16% unvaccinated. Compared with matched untreated participants, those treated with nirmatrelvir-ritonavir (n = 24 205) had a lower 30-day risk for hospitalization (1.80% vs 2.30%; risk difference [RD], -0.50% points [95% confidence interval {CI}: -.69 to -.35]) and death (0.11% vs 0.30%; RD, -0.20 [95% CI: -.24 to -.13]). The greatest reductions in combined hospitalization or death were observed in the highest risk quartile (RD -2.85 [95% CI: -3.94 to -1.76]), immunocompromised persons (RD -1.91 [95% CI: -3.09 to -.74]), and persons aged ≥75 years (RD -1.16 [95% CI: -1.73 to -.59]). No reductions were observed in the 2 lowest risk quartiles or persons younger than 65 years. CONCLUSIONS Nirmatrelvir-ritonavir was effective in reducing 30-day hospitalization and death in older veterans, those at highest predicted risk for severe outcomes, and immunocompromised groups. Benefit was not observed in younger veterans or groups at lower predicted risk for hospitalization and death.
Collapse
Affiliation(s)
- Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - David Bui
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Stephanie Argraves
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
| | - Yuan Huang
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety-Pharmacy Benefit Management (PBM) Services, Hines, Illinois, USA
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington D.C., USA
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Office of Research and Development, Veterans Health Administration, Washington D.C., USA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Kristina L Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
5
|
Dong S, Jutkowitz E, Giardina J, Bilinski A. Screening Strategies to Reduce COVID-19 Mortality in Nursing Homes. JAMA HEALTH FORUM 2024; 5:e240688. [PMID: 38669030 PMCID: PMC11065177 DOI: 10.1001/jamahealthforum.2024.0688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 05/01/2024] Open
Abstract
Importance Nursing home residents continue to bear a disproportionate share of COVID-19 morbidity and mortality, accounting for 9% of all US COVID-19 deaths in 2023, despite comprising only 0.4% of the population. Objective To evaluate the cost-effectiveness of screening strategies in reducing COVID-19 mortality in nursing homes. Design and Setting An agent-based model was developed to simulate SARS-CoV-2 transmission in the nursing home setting. Parameters were determined using SARS-CoV-2 virus data and COVID-19 data from the Centers for Medicare & Medicaid Services and US Centers for Disease Control and Prevention that were published between 2020 and 2023, as well as data on nursing homes published between 2010 and 2023. The model used in this study simulated interactions and SARS-CoV-2 transmission between residents, staff, and visitors in a nursing home setting. The population used in the simulation model was based on the size of the average US nursing home and recommended staffing levels, with 90 residents, 90 visitors (1 per resident), and 83 nursing staff members. Exposure Screening frequency (none, weekly, and twice weekly) was varied over 30 days against varying levels of COVID-19 community incidence, booster uptake, and antiviral use. Main Outcomes and Measures The main outcomes were SARS-CoV-2 infections, detected cases per 1000 tests, and incremental cost of screening per life-year gained. Results Nursing home interactions were modeled between 90 residents, 90 visitors, and 83 nursing staff over 30 days, completing 4000 to 8000 simulations per parameter combination. The incremental cost-effectiveness ratios of weekly and twice-weekly screening were less than $150 000 per resident life-year with moderate (50 cases per 100 000) and high (100 cases per 100 000) COVID-19 community incidence across low-booster uptake and high-booster uptake levels. When COVID-19 antiviral use reached 100%, screening incremental cost-effectiveness ratios increased to more than $150 000 per life-year when booster uptake was low and community incidence was high. Conclusions and Relevance The results of this cost-effectiveness analysis suggest that screening may be effective for reducing COVID-19 mortality in nursing homes when COVID-19 community incidence is high and/or booster uptake is low. Nursing home administrators can use these findings to guide planning in the context of widely varying levels of SARS-CoV-2 transmission and intervention measures across the US.
Collapse
Affiliation(s)
- Shirley Dong
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Eric Jutkowitz
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island
| | - John Giardina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Alyssa Bilinski
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
6
|
Paules CI, Osevala N, Lehman E, Heilbrunn ES, Francis E, Hogentogler RE, Kong L, Kraschnewski JL. Underuse of SARS-CoV-2-Neutralizing Monoclonal Antibodies in Skilled Nursing Facilities. J Am Med Dir Assoc 2024; 25:290-295. [PMID: 37944905 PMCID: PMC10872363 DOI: 10.1016/j.jamda.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Little is known about deployment of SARS-CoV-2-neutralizing monoclonal antibodies (mab) in skilled nursing facilities (SNFs), a high-risk population for COVID-19-related complications. We assessed the utilization of mabs in SNFs and identified facility characteristics associated with effective use. DESIGN Retrospective cohort study assessing the correlation of SNF characteristics with increasing mab use. SETTING AND PARTICIPANTS United States SNFs participating in Project ECHO (Extensions for Community Health Outcomes). METHODS The primary outcome was percentage of total mabs per COVID-19 cases in SNFs. Facilities were divided into 3 groups based on the percentage of the administration of mabs per number of cases: 0%, >0% to 20%, >20%. Ordinal logistic regression was applied to assess whether facility characteristics-study group, state, location, type, size, rating at baseline, weekly average of residents vaccinated, weekly average of staff vaccinated, and total weeks short staffed-correlated with the primary outcome. A multivariable model was used to evaluate the independent effect of predictors. RESULTS A total of 130 facilities were included. Between the weeks ending on May 30, 2021, and on May 29, 2022, mean mab use when accounting for the number of COVID-19 cases was 12.96% (±26.71%) and >50% of facilities administered 0 doses of mabs. Facility location was associated with mab use (P value .030), with micropolitan facilities having the highest percentage of facilities administering mabs (30.4% in >0% to 20%, and 39.1% in >20%, respectively). There was a nonsignificant trend toward increased mab use in facilities reporting fewer staffing shortages. When the multivariable ordinal logistic regression model was applied, location in a micropolitan vs metropolitan area was associated with higher odds [3.29 (1.30, 8.32), P value .012] of increasing percentage total mabs per cases. CONCLUSIONS AND IMPLICATIONS COVID-19 mabs were underutilized in a high-risk population for COVID-19 hospitalization and death. Understanding the barriers to effective distribution is critical in shaping pandemic preparedness efforts for the future.
Collapse
Affiliation(s)
- Catharine I Paules
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Nicole Osevala
- Division of Geriatric Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| | - Emily S Heilbrunn
- Department of Medicine, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| | - Erica Francis
- Department of Medicine, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| | - R Ellen Hogentogler
- Department of Medicine, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| | - Lan Kong
- Department of Public Health Sciences, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| | - Jennifer L Kraschnewski
- Department of Public Health Sciences, Penn State College of Medicine, Penn State University, Hershey, PA, USA; Department of Medicine, Penn State College of Medicine, Penn State University, Hershey, PA, USA; Department of Pediatrics, Penn State College of Medicine, Penn State University, Hershey, PA, USA
| |
Collapse
|
7
|
Appaneal HJ, LaPlante KL, Lopes VV, Martin C, Puzniak L, Wiemken TL, Zasowski EJ, McLaughlin JM, Caffrey AR. Nirmatrelvir/Ritonavir Utilization for the Treatment of Non-hospitalized Adults with COVID-19 in the National Veterans Affairs (VA) Healthcare System. Infect Dis Ther 2024; 13:155-172. [PMID: 38217842 PMCID: PMC10828173 DOI: 10.1007/s40121-023-00910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/15/2023] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION Limited data exist regarding real-world utilization of nirmatrelvir/ritonavir. We identified predictors of nirmatrelvir/ritonavir use among Veterans Affairs (VA) outpatients nationally. METHODS We conducted a retrospective cohort study among outpatients with coronavirus disease 2019 (COVID-19) who were eligible to receive nirmatrelvir/ritonavir between January and December of 2022, to identify factors associated with nirmatrelvir/ritonavir use (i.e., demographics, medical history, prior medication and healthcare exposures, frailty, and other clinical characteristics) using multivariable logistic regression. RESULTS We included 309,755 outpatients with COVID-19 who were eligible for nirmatrelvir/ritonavir, of whom 12.2% received nirmatrelvir/ritonavir. Nirmatrelvir/ritonavir uptake increased from 1.1% to 23.2% over the study period. Factors associated with nirmatrelvir/ritonavir receipt included receiving a COVID-19 booster vs. none (adjusted odds ratio [aOR] 2.19 [95% confidence interval [CI] 2.12-2.26]), age ≥ 50 vs. 18-49 years (aORs > 1.5 for all age groups ≥ 50 years), having HIV (aOR 1.36 [1.22-1.51]), being non-frail vs. severely frail (aOR 1.22 [1.13-1.33]), and having rheumatoid arthritis (aOR 1.12 [1.04-1.21). Those with concomitant use of potentially interacting antiarrhythmics (aOR 0.35 [0.28-0.45]), anticoagulants/antiplatelets (aOR 0.42 [0.40-0.45]), and/or psychiatric/sedatives (aOR 0.84 [0.81-0.87]) were less likely to receive nirmatrelvir/ritonavir. CONCLUSIONS Despite increases over time, overall utilization of nirmatrelvir/ritonavir was low. Predictors of nirmatrelvir/ritonavir utilization were consistent with known risk factors for progression to severe COVID-19, including older age and underlying medical conditions. Unvaccinated and undervaccinated patients and those receiving potentially interacting medications for cardiovascular or mental health conditions (antiarrhythmic, alpha-1 antagonist, anticoagulant/antiplatelet, sedative/hypnotic/psychiatric) were less likely to receive nirmatrelvir/ritonavir. Further education of prescribers and patients about nirmatrelvir/ritonavir treatment guidelines is needed to improve overall uptake and utilization in certain high-risk subpopulations.
Collapse
Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | | | | | | | | | | | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA.
- School of Public Health, Brown University, Providence, RI, USA.
| |
Collapse
|
8
|
McGarry BE, Sommers BD, Barnett ML. Treatment of SARS-CoV-2 Infection in US Nursing Homes-Reply. JAMA 2023; 330:2022. [PMID: 38015222 DOI: 10.1001/jama.2023.20018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Brian E McGarry
- Department of Medicine, University of Rochester, Rochester, New York
| | - Benjamin D Sommers
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
9
|
Bergman C. Treatment of SARS-CoV-2 Infection in US Nursing Homes. JAMA 2023; 330:2021-2022. [PMID: 38015226 DOI: 10.1001/jama.2023.20015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Christian Bergman
- Division of Geriatric Medicine, Virginia Commonwealth University, Richmond
| |
Collapse
|
10
|
Chew KW, Malani PN, Gandhi RT. COVID-19 Therapeutics for Nonhospitalized Patients-Updates and Future Directions. JAMA 2023; 330:1519-1520. [PMID: 37773595 DOI: 10.1001/jama.2023.19542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
In this Viewpoint, the authors summarize the therapeutic landscape for COVID-19, discuss who is most likely to benefit from treatment, provide an update on managing illness in immunocompromised individuals, and highlight how to improve COVID-19 treatment.
Collapse
Affiliation(s)
- Kara W Chew
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles
| | - Preeti N Malani
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
- Deputy Editor, JAMA
| | - Rajesh T Gandhi
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
11
|
Ramirez GA, Gerosa M, Bellocchi C, Arroyo-Sánchez D, Asperti C, Argolini LM, Gallina G, Cornalba M, Scotti I, Suardi I, Moroni L, Beretta L, Bozzolo EP, Caporali R, Dagna L. Efficacy and Safety of Anti-SARS-CoV-2 Antiviral Agents and Monoclonal Antibodies in Patients with SLE: A Case-Control Study. Biomolecules 2023; 13:1273. [PMID: 37759674 PMCID: PMC10527378 DOI: 10.3390/biom13091273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related disease (COVID-19) has spread pandemically with high rates of morbidity and mortality. COVID-19 has also posed unprecedented challenges in terms of rapid development of pharmacological countermeasures to prevent or contrast SARS-CoV-2 pathogenicity. Anti-SARS-CoV-2 antiviral agents and monoclonal antibodies have been specifically designed to attenuate COVID-19 morbidity and prevent mortality in vulnerable subjects, such as patients with immune-mediated diseases, but evidence for the safe and effective use of these drugs in this latter population group is scarce. Therefore, we designed a retrospective, multicentre, observational, case-control study to analyse the impact of these treatments in COVID-19 patients with systemic lupus erythematosus (SLE), a paradigmatic, multi-organ autoimmune disease. We identified 21 subjects treated with antivirals and/or monoclonal antibodies who were matched with 42 untreated patients by age, sex, SLE extension and duration. Treated patients had higher baseline SLE disease activity index 2000 scores [SLEDAI-2K median (interquartile range) = 4 (1-5) vs. 0 (0-2); p = 0.009], higher prednisone doses [5 (0-10) mg vs. 0 (0-3) mg; p = 0.002], and more severe COVID-19 symptoms by a five-point World Health Organisation-endorsed analogue scale [1 (0-1) vs. 0 (0-1); p < 0.010] compared to untreated patients. There was no difference between groups in terms of COVID-19 outcomes and sequelae, nor in terms of post-COVID-19 SLE exacerbations. Three subjects reported mild adverse events (two with monoclonal antibodies, one with nirmatrelvir/ritonavir). These data suggest that anti-SARS-CoV-2 antivirals and monoclonal antibodies might be safely and effectively used in patients with SLE, especially with active disease and more severe COVID-19 symptoms at presentation.
Collapse
Affiliation(s)
- Giuseppe A. Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Maria Gerosa
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Chiara Bellocchi
- Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza 35, 20122 Milan, Italy; (C.B.); (L.B.)
- Department of Clinical Science of Community Health, Section of Internal Medicine, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Daniel Arroyo-Sánchez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Department of Immunology, Hospital Universitario 12 de Octubre, Av de Córdoba, 28041 Madrid, Spain
- Department of Immunology, Instituto de Investigación Biomédica, Hospital Universitario 12 de Octubre, Av de Córdoba, 28041 Madrid, Spain
| | - Chiara Asperti
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Lorenza M. Argolini
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Gabriele Gallina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Martina Cornalba
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Isabella Scotti
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Ilaria Suardi
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Luca Moroni
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Lorenzo Beretta
- Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza 35, 20122 Milan, Italy; (C.B.); (L.B.)
- Department of Clinical Science of Community Health, Section of Internal Medicine, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Enrica P. Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
| | - Roberto Caporali
- Department of Clinical Science of Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy; (M.G.); (L.M.A.); (M.C.); (I.S.); (I.S.); (R.C.)
- Unit of Rheumatology, ASST Gaetano Pini-CTO, Piazza Cardinale Andrea Ferrari 1, 20122 Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy; (D.A.-S.); (C.A.); (G.G.); (L.M.); (E.P.B.); (L.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| |
Collapse
|