Side-Effects of COVID-19 on Patient Care: An INR Story

Longitudinal impact of COVID-19 pandemic on the utilization of hemoglobin A1c testing in outpatients

BACKGROUND

During the COVID-19 pandemic, concerns arose about disparate access to health care and laboratory testing. There is limited information about the pandemic's impact on the frequency of diabetic laboratory testing across demographic subgroups (e.g., sex, age over 65 y, and race).

METHODS

This retrospective study examined outpatient hemoglobin A1c (HbA1c) testing in a large academic medical center in Upstate New York between March 2019 and March 2021. Multivariate Poisson regression models were used to evaluate the pandemic's effects on HbA1c utilization.

RESULTS

Over 190,000 HbA1c results from predominately white (76.1 %) and older (mean age, 60.6 y) outpatients were analyzed. Compared to pre-pandemic time period, the average number of HbA1c tests per patient during COVID time period experienced a small, though significant, drop (1.3 to 1.2; p < 0.001) on aggregate and in outpatients, males, females, and seniors. The modest reduction was not significant by race except for the white seniors (p < 0.001). However, the testing frequency remained within recommendations from the American Diabetes Association for monitoring prediabetic patients and patients with stable glycemic control.

CONCLUSION

Given the propensity for healthcare disruptions to widen disparities, it is reassuring that we did not observe a worsening of disparities in rates of HbA1c testing during the COVID-19 pandemic.

Proportion of Patients on Warfarin Therapy Who Are Eligible for Conversion to a Direct Oral Anticoagulant in the Setting of COVID-19

Background:

Warfarin, a commonly prescribed anticoagulant, requires frequent lab monitoring. Lab monitoring puts patients at risk of COVID-19 exposure and diverts medical resources away from health care systems. Direct oral anticoagulants (DOACs) do not require routine therapeutic monitoring and are indicated first line for nonvalvular atrial fibrillation (NVAF) stroke prevention and venous thromboembolism (VTE) prevention/treatment.

Objective:

The purpose of the study was to determine the proportion of patients who qualify for DOACs and assess for predictors of qualification.

Methods:

This cross-sectional study investigated patients on warfarin managed by Michigan Medicine Anticoagulation Service. Direct oral anticoagulant eligibility criteria were established using apixaban, dabigatran, and rivaroxaban package inserts. Patient eligibility was determined through chart review. The primary outcome was the proportion of patients who qualify for DOACs based on clinical factors. Predictors of DOAC qualification were assessed.

Results:

This study included 3205 patients and found 51.8% (n = 1661) of patients qualified for DOACs. Qualifying patients were older (71.9 vs 59.4 years, P < 0.0001) with a higher CHA₂DS₂ VASc (3.7 vs 3.4, P < 0.0007). The primary disqualifying factor was extreme weight, high and low. Accounting for a patient’s sex and referral source, age > 65 (odds ratio [OR] = 1.9, P < 0.0001) and NVAF indication (OR = 5.6, P < 0.0001) were significant predictors for DOAC qualification.

Conclusion and Relevance:

Approximately 52% of patients on warfarin were eligible for DOACs. This presents an opportunity to reduce patient exposure to health care settings and health care utilization in the setting of COVID-19. Increased costs of DOACs need to be assessed.

The Impact of COVID-19 on Laboratory Test Utilization at a Pediatric Medical Center

Background

The epidemiology and clinical manifestation of coronavirus disease 2019 (COVID-19) in the pediatric population is different from the adult population. The purpose of this study is to identify effects of the COVID-19 pandemic on laboratory test utilization in a pediatric hospital.

Methods

We performed retrospective analysis on test utilization data from Ann & Robert H. Lurie Children’s Hospital of Chicago, an academic pediatric medical center. Data between two 100-day periods prior to (prepandemic) and during the pandemic (mid-pandemic) were analyzed to evaluate changes in test volume, lab utilization, and test positivity rate. We also evaluated these metrics based on in- vs outpatient testing and performed modeling to determine what variables significantly impact the test positivity rate.

Results

During the pandemic period, there was an expected surge in COVID-19 testing, while over 84% of lab tests studied decreased in ordering volume. The average number of tests ordered per patient was not significantly different during the pandemic for any of the laboratories (adjusted P value &gt; 0.05). Thirty-three studied tests showed significant change in positivity rate during the pandemic. Linear modeling revealed test volume and inpatient status as the key variables associated with change in test positivity rate.

Conclusions

Excluding severe acute respiratory syndrome coronavirus 2 tests, the COVID-19 pandemic has generally led to decreased test ordering volume and laboratory utilization. However, at this pediatric hospital, the average number of tests performed per patient and test positivity rates were comparable between pre- and mid-pandemic periods. These results suggest that, overall, clinical test utilization at this site remained consistent during the pandemic.

Efficacy and safety of app-based remote warfarin management during COVID-19-related lockdown: a retrospective cohort study

This study aimed to explore the effectiveness, and safety of internet-based warfarin management during the pandemic. In this single-center retrospective cohort study, we compared the safety and efficacy of online warfarin management using a smartphone app (the Alfalfa app) versus conventional outpatient clinic management from January 1, 2020 to March 31, 2020. Patients in the online management group used the Alfalfa app to communicate coagulation test results and other relevant information to a doctor or clinical pharmacist, who then responded with the dose adjustment plan and the date of the next blood test. The outcomes examined were the time in therapeutic range (TTR), incidence of clinical events (i.e., bleeding events, thrombotic events, warfarin-related emergency department visits, and warfarin-related hospital admissions), and the distribution of international normalized ratio (INR) values. Data from 117 patients were analyzed in this study. TTR was significantly higher in the online group than in the offline group (61.0% vs. 39.6%, P < 0.01). Incidence of major bleeding events, thrombotic events, and warfarin-related hospital admissions were comparable between the online and offline groups. However, minor bleeds (5.3% vs. 28.3%, P < 0.01) and warfarin-related emergency department visits (1.8% vs. 23.3%, P = 0.02) were significantly fewer in the online group than in the offline group. The proportion of INR values in the therapeutic range (53.8% vs. 40.1%, P < 0.01) was significantly higher in the online group. Warfarin management using the Alfalfa app appears to be a safe and effective method for warfarin management when patients cannot physically visit hospitals for follow-up.