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Qaseem A, Yost J, Abraham GM, Andrews RA, Jokela JA, Miller MC, Humphrey LL, Obley AJ, Dunn AS, Haeme R, Lee RA, Saini SD, Tschanz MP, Etxeandia-Ikobaltzeta I, Harrod CS, Shamliyan T. Outpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 2, Update Alert). Ann Intern Med 2024; 177:e2400128. [PMID: 38976885 DOI: 10.7326/annals-24-00128] [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: 07/10/2024] Open
Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania
| | - Jennifer Yost
- American College of Physicians, Philadelphia, and Villanova University, Villanova, Pennsylvania
| | - George M Abraham
- University of Massachusetts Medical School and Saint Vincent Hospital, Worcester, Massachusetts
| | - Rebecca A Andrews
- University of Connecticut, School of Medicine, Farmington, Connecticut
| | - Janet A Jokela
- Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
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2
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Sommer I, Dobrescu AI, Persad E, Fangmeyer M, Klerings I, Gartlehner G. Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Evidence Review for the American College of Physicians (Version 2, Update Alert). Ann Intern Med 2024; 177:e2400141. [PMID: 38976881 DOI: 10.7326/annals-24-00141] [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: 07/10/2024] Open
Affiliation(s)
- Isolde Sommer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria
| | - Andreea Iulia Dobrescu
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria
| | - Emma Persad
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria
| | - Martin Fangmeyer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria
| | - Irma Klerings
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria
| | - Gerald Gartlehner
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University of Krems, Krems, Austria, and RTI International, Research Triangle Park, North Carolina
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3
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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.
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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
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4
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Tran VT, Gartlehner G, Yaacoub S, Boutron I, Schwingshackl L, Stadelmaier J, Sommer I, Alebouyeh F, Afach S, Meerpohl J, Ravaud P. Sensitivity and Specificity of Using GPT-3.5 Turbo Models for Title and Abstract Screening in Systematic Reviews and Meta-analyses. Ann Intern Med 2024; 177:791-799. [PMID: 38768452 DOI: 10.7326/m23-3389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Systematic reviews are performed manually despite the exponential growth of scientific literature. OBJECTIVE To investigate the sensitivity and specificity of GPT-3.5 Turbo, from OpenAI, as a single reviewer, for title and abstract screening in systematic reviews. DESIGN Diagnostic test accuracy study. SETTING Unannotated bibliographic databases from 5 systematic reviews representing 22 665 citations. PARTICIPANTS None. MEASUREMENTS A generic prompt framework to instruct GPT to perform title and abstract screening was designed. The output of the model was compared with decisions from authors under 2 rules. The first rule balanced sensitivity and specificity, for example, to act as a second reviewer. The second rule optimized sensitivity, for example, to reduce the number of citations to be manually screened. RESULTS Under the balanced rule, sensitivities ranged from 81.1% to 96.5% and specificities ranged from 25.8% to 80.4%. Across all reviews, GPT identified 7 of 708 citations (1%) missed by humans that should have been included after full-text screening at the cost of 10 279 of 22 665 false-positive recommendations (45.3%) that would require reconciliation during the screening process. Under the sensitive rule, sensitivities ranged from 94.6% to 99.8% and specificities ranged from 2.2% to 46.6%. Limiting manual screening to citations not ruled out by GPT could reduce the number of citations to screen from 127 of 6334 (2%) to 1851 of 4077 (45.4%), at the cost of missing from 0 to 1 of 26 citations (3.8%) at the full-text level. LIMITATIONS Time needed to fine-tune prompt. Retrospective nature of the study, convenient sample of 5 systematic reviews, and GPT performance sensitive to prompt development and time. CONCLUSION The GPT-3.5 Turbo model may be used as a second reviewer for title and abstract screening, at the cost of additional work to reconcile added false positives. It also showed potential to reduce the number of citations before screening by humans, at the cost of missing some citations at the full-text level. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Viet-Thi Tran
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris; and Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, AP-HP, Paris, France (V.-T.T.)
| | - Gerald Gartlehner
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria; and Center for Public Health Methods, RTI International, Research Triangle Park, North Carolina (G.G.)
| | - Sally Yaacoub
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris, France (S.Y., F.A.)
| | - Isabelle Boutron
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris, France; and Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, AP-HP, Paris, France (I.B.)
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany (L.S., J.S., J.M.)
| | - Julia Stadelmaier
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany (L.S., J.S., J.M.)
| | - Isolde Sommer
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (I.S.)
| | - Farzaneh Alebouyeh
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris, France (S.Y., F.A.)
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE)-EA 7379, University Paris Est Créteil Val de Marne, Créteil, France (S.A.)
| | - Joerg Meerpohl
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany (L.S., J.S., J.M.)
| | - Philippe Ravaud
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris, France; Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, AP-HP, Paris, France; and Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York (P.R.)
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5
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Mesfin YM, Blais JE, Kibret KT, Tegegne TK, Cowling BJ, Wu P. Effectiveness of nirmatrelvir/ritonavir and molnupiravir in non-hospitalized adults with COVID-19: systematic review and meta-analysis of observational studies. J Antimicrob Chemother 2024:dkae163. [PMID: 38817046 DOI: 10.1093/jac/dkae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/05/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To determine the effectiveness of nirmatrelvir/ritonavir and molnupiravir among vaccinated and unvaccinated non-hospitalized adults with COVID-19. METHODS Observational studies of nirmatrelvir/ritonavir or molnupiravir compared to no antiviral drug treatment for COVID-19 in non-hospitalized adults with data on vaccination status were included. We searched MEDLINE, EMBASE, Scopus, Web of Science, WHO COVID-19 Research Database and medRxiv for reports published between 1 January 2022 and 8 November 2023. The primary outcome was a composite of hospitalization or mortality up to 35 days after COVID-19 diagnosis. Risk of bias was assessed with ROBINS-I. Risk ratios (RR), hazard ratios (HR) and risk differences (RD) were separately estimated using random-effects models. RESULTS We included 30 cohort studies on adults treated with nirmatrelvir/ritonavir (n = 462 279) and molnupiravir (n = 48 008). Nirmatrelvir/ritonavir probably reduced the composite outcome (RR 0.62, 95%CI 0.55-0.70; I2 = 0%; moderate certainty) with no evidence of effect modification by vaccination status (RR Psubgroup = 0.47). In five studies, RD estimates against the composite outcome for nirmatrelvir/ritonavir were 1.21% (95%CI 0.57% to 1.84%) in vaccinated and 1.72% (95%CI 0.59% to 2.85%) in unvaccinated subgroups.Molnupiravir may slightly reduce the composite outcome (RR 0.75, 95%CI 0.67-0.85; I2 = 32%; low certainty). Evidence of effect modification by vaccination status was inconsistent among studies reporting different effect measures (RR Psubgroup = 0.78; HR Psubgroup = 0.08). In two studies, RD against the composite outcome for molnupiravir were -0.01% (95%CI -1.13% to 1.10%) in vaccinated and 1.73% (95%CI -2.08% to 5.53%) in unvaccinated subgroups. CONCLUSIONS Among cohort studies of non-hospitalized adults with COVID-19, nirmatrelvir/ritonavir is effective against the composite outcome of severe COVID-19 independent of vaccination status. Further research and a reassessment of molnupiravir use among vaccinated adults are warranted. REGISTRATION PROSPERO CRD42023429232.
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Affiliation(s)
- Yonatan M Mesfin
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Immunity & Global Health, Murdoch Children's Research Institute (MCRI), Parkville, VIC, Australia
| | - Joseph E Blais
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
| | - Kelemu Tilahun Kibret
- Global Centre for Preventive Health and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Teketo Kassaw Tegegne
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Benjamin J Cowling
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
| | - Peng Wu
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
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6
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Qaseem A, Yost J, Abraham GM, Andrews R, Jokela JA, Miller MC, Humphrey LL, Dunn A, Haeme R, Lee R, Saini SD, Tschanz CMP, Etxeandia-Ikobaltzeta I, Harrod C, Shamliyan T, Umana K. Outpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 2). Ann Intern Med 2023; 176:1396-1404. [PMID: 37722112 PMCID: PMC10620951 DOI: 10.7326/m23-1636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
DESCRIPTION Evidence for the use of outpatient treatments in adults with confirmed COVID-19 continues to evolve with new data. This is version 2 of the American College of Physicians (ACP) living, rapid practice points focusing on 22 outpatient treatments for COVID-19, specifically addressing the dominant SARS-CoV-2 Omicron variant. METHODS The Population Health and Medical Science Committee (formerly the Scientific Medical Policy Committee) developed this version of the living, rapid practice points on the basis of a living, rapid review done by the ACP Center for Evidence Reviews at Cochrane Austria at the University for Continuing Education Krems (Danube University Krems). This topic will be maintained as living and rapid by continually monitoring and assessing the impact of new evidence. PRACTICE POINT 1 Consider molnupiravir to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease. PRACTICE POINT 2 Consider nirmatrelvir-ritonavir combination therapy to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease. PRACTICE POINT 3 Do not use ivermectin to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 4 Do not use sotrovimab to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting.
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
| | - Jennifer Yost
- American College of Physicians, Philadelphia, and Villanova University, Villanova, Pennsylvania (J.Y.)
| | - George M Abraham
- University of Massachusetts Medical School and Saint Vincent Hospital, Worcester, Massachusetts (G.M.A.)
| | | | - Janet A Jokela
- Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois (J.A.J.)
| | | | - Linda L Humphrey
- Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland, Oregon (L.L.H.)
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