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Lenhard A, Daoud M, Donahue L, Jones S, Kip PL, Zapf RL, Minnier TE. How SWAT Changed the Conversation: Implementation of a Discharge SWAT Team Improves Morale and Facilitates Communication During the COVID-19 Pandemic. Prof Case Manag 2024:01269241-990000000-00009. [PMID: 38421720 DOI: 10.1097/ncm.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF STUDY Hospital overcrowding and delays in discharge are serious issues in the modern health care landscape and can lead to poor patient outcomes and health care personnel (HCP) burnout. The goal of this project was to develop a collaborative forum where HCP representing the entire spectrum of the inpatient care team, including case management team members, could connect to discuss challenges and barriers to patient discharge. The following describes the development, implementation, and outcomes of the discharge SWAT (Solutions, Wins, Actions, and Tactics) team, which is a 30-min virtual daily meeting where discussion is primarily centered around challenges in discharging individual patients and addressing case manager needs. The primary aim of SWAT meetings is fostering a positive atmosphere to address barriers to discharge while prioritizing patient care and outcomes. PRIMARY PRACTICE SETTING This study was conducted in a 40-hospital academic health system in the United States. METHODOLOGY AND SAMPLE SWAT meetings were first implemented at a representative flagship facility in a health system. HCP at this first facility were surveyed to assess satisfaction with SWAT meetings. SWAT meetings then were implemented at the majority of facilities in a 40-hospital academic health system. During SWAT implementation, average inpatient length of stay (LOS) and patient care transitions were monitored for participating and nonparticipating service lines. RESULTS Among surveyed HCP, the majority view SWAT meetings favorably and reported that it was a valuable use of their time and positively impacted their work in the patient discharge space. Nonprovider and case management staff in particular valued the SWAT meetings and found them beneficial. LOS remained stable for patients under the care of participating providers, despite the upheaval of the ongoing COVID-19 pandemic, and the research team also observed a positive impact of SWAT meetings on appropriate inpatient care transitions.
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Affiliation(s)
- Amanda Lenhard
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Majd Daoud
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Lisa Donahue
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Sherri Jones
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Paula L Kip
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Rachel L Zapf
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
| | - Tamra E Minnier
- Amanda Lenhard, MD, is the Chief of Medicine at UPMC Shadyside, Senior Medical Director for Care Coordination and Discharge Planning at UPMC, and Associate Professor of Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, PA
- Majd Daoud, MD, MHMS, is Project Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Lisa Donahue, DNP, RN, CPPS, is the Senior Director of Patient Safety, Innovation and Quality at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at UPMC Presbyterian Shadyside in Pittsburgh, PA
- Paula L. Kip, PhD, RN, is Senior Manager, Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Rachel L. Zapf, PhD, is Research Writer at Wolff Center, UPMC, in Pittsburgh, PA
- Tamra E. Minnier, MSN, RN, FACHE, FAAN, is the Senior Vice President of UPMC Health Services Division and the Chief Quality and Operational Excellence Officer at Wolff Center, UPMC, in Pittsburgh, PA
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Schell JO, Schenker Y, Piscitello G, Belin SC, Chiu EJ, Zapf RL, Kip PL, Marroquin OC, Donahoe MP, Holder-Murray J, Arnold RM. Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation. J Pain Symptom Manage 2023; 66:603-610.e3. [PMID: 37532159 PMCID: PMC10828667 DOI: 10.1016/j.jpainsymman.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gina Piscitello
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shane C Belin
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric J Chiu
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel L Zapf
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | - Paula L Kip
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | | | - Michael P Donahoe
- Division of Pulmonary, Allergy, and Critical Care Medicine (M.P.D.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Departments of Surgery and Anesthesiology and Perioperative Medicine (J.H.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
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Lukanski A, Watters S, Bilderback AL, Buchanan D, Hodges JC, Burwell D, Triola A, Marroquin OC, Martin SC, Zapf RL, Kip PL, Minnier TE. Implementing a Discharge Follow-up Phone Call Program Reduces Readmission Rates in an Integrated Health System. J Healthc Qual 2023; 45:315-323. [PMID: 37788411 DOI: 10.1097/jhq.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
ABSTRACT In this study, we sought to determine the effect of implementing a large-scale discharge follow-up phone call program on hospital readmission rates. Previous work has shown that patients with unaddressed concerns during discharge have significantly higher rates of care complications and hospital readmissions. This study is an observational quality improvement project completed from April 17, 2020 to January 31, 2022 at 22 hospitals in a large, integrated academic health system. A nurse-led scripted discharge follow-up phone call program was implemented to contact all patients discharged from inpatient care within 72 hours of discharge. Readmission rates were tracked before and after project implementation. Over a 21-month span, 137,515 phone calls were placed, and 57.92% of patients were successfully contacted within 7 days of discharge. The 7-day readmission rate for contacted patients was 2.91% compared with 4.73% for noncontacted patients. The 30-day readmission rate for contacted patients was 11.00% compared with 12.17% for noncontacted patients. We have found that discharge follow-up phone calls targeting patients decreases risk of readmission, which improves overall patient outcomes.
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Perpetua Z, Lennon J, Shovel JA, Appell KE, Patterson L, Martin SC, Minnier TE, Sackrowitz R, Zapf RL, Kip PL, McLaughlin M. A Current State Assessment on Nursing Work Activities: An Observational Study. J Nurs Care Qual 2023; 38:381-387. [PMID: 37276498 DOI: 10.1097/ncq.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Nationwide nursing shortages have led to higher patient-to-nurse ratios, nursing burnout, and decreased quality of care. LOCAL PROBLEM Staffing challenges and nursing burnout were becoming growing concerns and success was contingent upon efficient use of existing resources. METHODS Direct observation current state assessment was completed on medical-surgical specialty units to better understand work activities of registered nurses (RNs) and unlicensed assistive personnel (UAPs). RESULTS RNs spent more time performing indirect care (eg, documentation) than direct patient care. Interruptions and problems consumed 17.4% and 5.6% of their time, respectively. UAPs performed more direct patient care but had a higher proportion of downtime. RNs underdelegated nonclinical tasks. CONCLUSIONS Direct observation current state assessment offers a better understanding of workflow and workload inefficiencies. This information is critical to provide informed, evidence-based recommendations to develop future patient care models with more capacity to deliver high-quality care with greater efficiency and lessen nursing burden and burnout during the nursing shortage crisis.
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Affiliation(s)
- Zachary Perpetua
- Health Services Division (Ms Minnier), Center for Quality Improvement and Innovation, Wolff Center (Mss Lennon, Shovel, Appell, Patterson, and Martin and Drs Zapf and Kip); ICU Service Center (Dr Sackrowitz); Department of Critical Care Medicine (Dr Sackrowitz); and Department of Nursing (Ms McLaughlin), University of Pittsburgh Medical Center; Department of Acute and Tertiary Care (Dr Perpetua), University of Pittsburgh, Pittsburgh, Pennsylvania
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Seheult JN, Stram MN, Contis L, Pontzer RE, Hardy S, Wertz W, Baxter CM, Ondras M, Kip PL, Snyder GM, Pasculle AW. Development, Evaluation, and Multisite Deployment of a Machine Learning Decision Tree Algorithm To Optimize Urinalysis Parameters for Predicting Urine Culture Positivity. J Clin Microbiol 2023; 61:e0029123. [PMID: 37227272 PMCID: PMC10281150 DOI: 10.1128/jcm.00291-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/21/2023] [Indexed: 05/26/2023] Open
Abstract
PittUDT, a recursive partitioning decision tree algorithm for predicting urine culture (UC) positivity based on macroscopic and microscopic urinalysis (UA) parameters, was developed in support of a broader system-wide diagnostic stewardship initiative to increase appropriateness of UC testing. Reflex algorithm training utilized results from 19,511 paired UA and UC cases (26.8% UC positive); the average patient age was 57.4 years, and 70% of samples were from female patients. Receiver operating characteristic (ROC) analysis identified urine white blood cells (WBCs), leukocyte esterase, and bacteria as the best predictors of UC positivity, with areas under the ROC curve of 0.79, 0.78, and 0.77, respectively. Using the held-out test data set (9,773 cases; 26.3% UC positive), the PittUDT algorithm met the prespecified target of a negative predictive value above 90% and resulted in a 30 to 60% total negative proportion (true-negative plus false-negative predictions). These data show that a supervised rule-based machine learning algorithm trained on paired UA and UC data has adequate predictive ability for triaging urine specimens by identifying low-risk urine specimens, which are unlikely to grow pathogenic organisms, with a false-negative proportion under 5%. The decision tree approach also generates human-readable rules that can be easily implemented across multiple hospital sites and settings. Our work demonstrates how a data-driven approach can be used to optimize UA parameters for predicting UC positivity in a reflex protocol, with the intent of improving antimicrobial stewardship and UC utilization, a potential avenue for cost savings.
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Affiliation(s)
- Jansen N. Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle N. Stram
- Department of Forensic Medicine, NYU Langone Health, New York, New York, USA
| | - Lydia Contis
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raymond E. Pontzer
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
| | - Stephanie Hardy
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - William Wertz
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Michael Ondras
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Paula L. Kip
- Wolff Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Graham M. Snyder
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - A. William Pasculle
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical Microbiology Laboratory, UPMC, Pittsburgh, Pennsylvania, USA
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Kip KE, McCreary EK, Collins K, Minnier TE, Snyder GM, Garrard W, McKibben JC, Yealy DM, Seymour CW, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evolving Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19 : A Cohort Study. Ann Intern Med 2023; 176:496-504. [PMID: 37011399 PMCID: PMC10074437 DOI: 10.7326/m22-1286] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Treatment guidelines and U.S. Food and Drug Administration emergency use authorizations (EUAs) of monoclonal antibodies (mAbs) for treatment of high-risk outpatients with mild to moderate COVID-19 changed frequently as different SARS-CoV-2 variants emerged. OBJECTIVE To evaluate whether early outpatient treatment with mAbs, overall and by mAb product, presumed SARS-CoV-2 variant, and immunocompromised status, is associated with reduced risk for hospitalization or death at 28 days. DESIGN Hypothetical pragmatic randomized trial from observational data comparing mAb-treated patients with a propensity score-matched, nontreated control group. SETTING Large U.S. health care system. PARTICIPANTS High-risk outpatients eligible for mAb treatment under any EUA with a positive SARS-CoV-2 test result from 8 December 2020 to 31 August 2022. INTERVENTION Single-dose intravenous mAb treatment with bamlanivimab, bamlanivimab-etesevimab, sotrovimab, bebtelovimab, or intravenous or subcutaneous casirivimab-imdevimab administered within 2 days of a positive SARS-CoV-2 test result. MEASUREMENTS The primary outcome was hospitalization or death at 28 days among treated patients versus a nontreated control group (no treatment or treatment ≥3 days after SARS-CoV-2 test date). RESULTS The risk for hospitalization or death at 28 days was 4.6% in 2571 treated patients and 7.6% in 5135 nontreated control patients (risk ratio [RR], 0.61 [95% CI, 0.50 to 0.74]). In sensitivity analyses, the corresponding RRs for 1- and 3-day treatment grace periods were 0.59 and 0.49, respectively. In subgroup analyses, those receiving mAbs when the Alpha and Delta variants were presumed to be predominant had estimated RRs of 0.55 and 0.53, respectively, compared with 0.71 for the Omicron variant period. Relative risk estimates for individual mAb products all suggested lower risk for hospitalization or death. Among immunocompromised patients, the RR was 0.45 (CI, 0.28 to 0.71). LIMITATIONS Observational study design, SARS-CoV-2 variant presumed by date rather than genotyping, no data on symptom severity, and partial data on vaccination status. CONCLUSION Early mAb treatment among outpatients with COVID-19 is associated with lower risk for hospitalization or death for various mAb products and SARS-CoV-2 variants. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Jeffrey C McKibben
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - David T Huang
- Department of Emergency Medicine and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.T.H.)
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (M.S.)
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
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Snyder GM, Wagester S, Harris PL, Valek AL, Hodges JC, Bilderback AL, Kader F, Tanner CA, Metzger AP, DiNucci SE, Colaianne BV, Chung A, Zapf RL, Kip PL, Minnier TE. Development and implementation of a centralized surveillance infection prevention program in a multi-facility health system: A quality improvement project. Antimicrob Steward Healthc Epidemiol 2023; 3:e56. [PMID: 36970425 PMCID: PMC10031579 DOI: 10.1017/ash.2023.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/24/2023]
Abstract
Objective: To develop, implement, and evaluate the effectiveness of a unique centralized surveillance infection prevention (CSIP) program. Design: Observational quality improvement project. Setting: An integrated academic healthcare system. Intervention: The CSIP program comprises senior infection preventionists who are responsible for healthcare-associated infection (HAI) surveillance and reporting, allowing local infection preventionists (LIPs) a greater portion of their time to non-surveillance patient safety activities. Four CSIP team members accrued HAI responsibilities at 8 facilities. Methods: We evaluated the effectiveness of the CSIP program using 4 measures: recovery of LIP time, efficiency of surveillance activities by LIPs and CSIP staff, surveys characterizing LIP perception of their effectiveness in HAI reduction, and nursing leaders’ perception of LIP effectiveness. Results: The amount of time spent by LIP teams on HAI surveillance was highly variable, while CSIP time commitment and efficiency was steady. Post-CSIP implementation, 76.9% of LIPs agreed that they spend adequate time on inpatient units, compared to 15.4% pre-CSIP; LIPs also reported more time to allot to non-surveillance activities. Nursing leaders reported greater satisfaction with LIP involvement with HAI reduction practices. Conclusion: CSIP programs are a little-reported strategy to ease burden on LIPs with reallocation of HAI surveillance. The analyses presented here will aid health systems in anticipating the benefit of CSIP programs.
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Affiliation(s)
- Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Author for correspondence: Graham M. Snyder, MD, MS, Falk Medical Building, 3601 Fifth Avenue, Suite 150, Pittsburgh, PA15213. E-mail:
| | | | | | - Abby L. Valek
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
| | | | | | | | - Colleen A. Tanner
- Quality and Risk Management, UPMC Passavant, McCandless, Pennsylvania
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Snyder GM, Wagester S, Harris PL, Valek AL, Hodges JC, Bilderback AL, Kader F, Tanner CA, Metzger AP, DiNucci SE, Colaianne BV, Chung A, Zapf RL, Kip PL, Minnier TE. Healthcare-associated infections during the coronavirus disease 2019 (COVID-19) pandemic and the modulating effect of centralized surveillance. Antimicrob Steward Healthc Epidemiol 2023; 3:e72. [PMID: 37113196 PMCID: PMC10127231 DOI: 10.1017/ash.2023.139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 04/29/2023]
Abstract
We analyzed efficacy of a centralized surveillance infection prevention (CSIP) program in a healthcare system on healthcare-associated infection (HAI) rates amid the coronavirus disease 2019 (COVID-19) pandemic. HAI rates were variable in CSIP and non-CSIP facilities. Central-line-associated bloodstream infection (CLABSI), C. difficile infection (CSI), and surgical-site infection (SSI) rates were negatively correlated with COVID-19 intensity in CSIP facilities.
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Affiliation(s)
- Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Author for correspondence: Graham M. Snyder, MD, MS, Falk Medical Building, 3601 Fifth Avenue, Suite 150, Pittsburgh, PA15213. E-mail:
| | | | | | - Abby L. Valek
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
| | | | | | | | - Colleen A. Tanner
- Quality and Risk Management, UPMC Passavant, McCandless, Pennsylvania
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9
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Wagester S, Smith P, Lutz CT, Chung A, Tanis MD, O'Hare C, Mallon A, Minnier TE, Silvaggio T, Ruscetti A, Chrisman M, Zapf RL, Kip PL, Snyder GM. COVID-19 contagious health care personnel 5-day early return-to-work program. Am J Infect Control 2022:S0196-6553(22)00808-2. [PMID: 36410551 PMCID: PMC9674395 DOI: 10.1016/j.ajic.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND COVID-19 contagious health care personnel (HCP) who are self-isolating for a 10-day period increases burden to workforce shortages. Implementation of a 5-day early return-to-work (RTW) program may reduce self-isolation periods, without increasing transmission risk, during the COVID-19 pandemic. DESIGN AND METHODS This observational cohort quality improvement study included newly diagnosed COVID-19 HCP at a multifacility health care system. The program allowed HCP to return to work 6 days after date of a positive test result if they were not immunocompromised, had mild and improving symptoms, and self-reported a SARS-CoV-2 antigen negative test on day 5. RESULTS Between January 4 and April 3, 2022, 1,023 HCP self-enrolled and 344 (33.6%) self-reported negative test results. Among these, 161 (46.8%) self-reported negative test results on day 5 and were eligible for early RTW on day 6. A total of 714 days were saved from missed work in self-isolation. The number of tests purchased, dispensed, and reported per day of HCP time saved was 4.4. No transmission events were observed originating from HCP who participated in early RTW. CONCLUSION Implementing a 5-day early RTW program that includes HCP self-reporting SARS-CoV-2 antigen test results can increase staffing availability, while maintaining a low risk of SARS-CoV-2 transmission.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Teresa Silvaggio
- Wolff Center, UPMC, Pittsburgh, PA,Workpartners, UPMC, Pittsburgh, PA,Laboratory Service Center, UPMC, Pittsburgh, PA,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Infection Control and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, PA
| | | | | | | | | | - Graham M. Snyder
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Infection Control and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, PA,Address correspondence to Graham M. Snyder MD, MS, Department of Infection Control and Hospital Epidemiology, UPMC Presbyterian, 3601 Fifth Ave, Suite 150, Pittsburgh, PA 15213
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10
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McCreary EK, Kip KE, Collins K, Minnier TE, Snyder GM, Steiner A, Meyers R, Borneman T, Adam M, Thurau L, Yealy DM, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evaluation of Bebtelovimab for Treatment of COVID-19 During the SARS-CoV-2 Omicron Variant Era. Open Forum Infect Dis 2022; 9:ofac517. [PMID: 36324319 PMCID: PMC9619560 DOI: 10.1093/ofid/ofac517] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/26/2022] Open
Abstract
Background Monoclonal antibody (mAb) treatment is associated with decreased risk of hospitalization and death in high-risk outpatients with mild to moderate coronavirus disease 2019 (COVID-19) caused by early severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants. Bebtelovimab exhibits in vitro activity against the Omicron variant and its sublineages; however, clinical data are lacking. Methods A retrospective cohort study was conducted comparing bebtelovimab-treated patients with propensity score–adjusted and matched nontreated control groups. Participants included high-risk outpatients eligible for bebtelovimab treatment under Emergency Use Authorization with a positive SARS-CoV-2 test from March 30 to May 28, 2022. Treated patients received single-dose intravenous treatment with bebtelovimab. The primary outcome was hospitalization or death over 28 days. Results Before matching/statistical adjustment, mAb-treated patients were, on average, 10 years older than nontreated patients (61.6 vs 51.3 years) and had higher prevalence of obstructive sleep apnea, hypertension, chronic kidney disease, cancer, organ or cell transplant, and immunocompromised status (standardized mean differences ≥0.20). The adjusted odds ratio (OR) of hospitalization or death comparing 1006 treated with 2023 nontreated patients was 0.50 (95% CI, 0.31–0.80). Among 930 treated and 930 propensity score–matched nontreated patients, the incidence of hospitalization or death was 3.1% vs 5.5%, respectively (conditional OR, 0.53; 95% CI, 0.32–0.86). The lower odds ratio of hospitalization or death associated with bebtelovimab treatment was most evident in older patients, those with immunocompromised status, and fully vaccinated patients. Conclusions Monoclonal antibody treatment with bebtelovimab among COVID-19 outpatients is associated with lower odds of hospitalization or death, particularly among immunocompromised and older patients.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Kevin E Kip
- Clinical Analytics , UPMC, Pittsburgh, PA , USA
| | | | | | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Ashley Steiner
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Tina Borneman
- UPMC Corporate Pharmacy Service Center , Pittsburgh, PA , USA
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Lauren Thurau
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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11
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Haidar G, Agha M, Bilderback A, Lukanski A, Linstrum K, Troyan R, Rothenberger S, McMahon DK, Crandall MD, Sobolewksi MD, Nathan Enick P, Jacobs JL, Collins K, Klamar-Blain C, Macatangay BJC, Parikh UM, Heaps A, Coughenour L, Schwartz MB, Dueker JM, Silveira FP, Keebler ME, Humar A, Luketich JD, Morrell MR, Pilewski JM, McDyer JF, Pappu B, Ferris RL, Marks SM, Mahon J, Mulvey K, Hariharan S, Updike GM, Brock L, Edwards R, Beigi RH, Kip PL, Wells A, Minnier T, Angus DC, Mellors JW. Prospective Evaluation of Coronavirus Disease 2019 (COVID-19) Vaccine Responses Across a Broad Spectrum of Immunocompromising Conditions: the COVID-19 Vaccination in the Immunocompromised Study (COVICS). Clin Infect Dis 2022; 75:e630-e644. [PMID: 35179197 PMCID: PMC8903515 DOI: 10.1093/cid/ciac103] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We studied humoral responses after coronavirus disease 2019 (COVID-19) vaccination across varying causes of immunodeficiency. METHODS Prospective study of fully vaccinated immunocompromised adults (solid organ transplant [SOT], hematologic malignancy, solid cancers, autoimmune conditions, human immunodeficiency virus [HIV]) versus nonimmunocompromised healthcare workers (HCWs). The primary outcome was the proportion with a reactive test (seropositive) for immunoglobulin G to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain. Secondary outcomes were comparisons of antibody levels and their correlation with pseudovirus neutralization titers. Stepwise logistic regression was used to identify factors associated with seropositivity. RESULTS A total of 1271 participants enrolled: 1099 immunocompromised and 172 HCW. Compared with HCW (92.4% seropositive), seropositivity was lower among participants with SOT (30.7%), hematological malignancies (50.0%), autoimmune conditions (79.1%), solid tumors (78.7%), and HIV (79.8%) (P < .01). Factors associated with poor seropositivity included age, greater immunosuppression, time since vaccination, anti-CD20 monoclonal antibodies, and vaccination with BNT162b2 (Pfizer) or adenovirus vector vaccines versus messenger RNA (mRNA)-1273 (Moderna). mRNA-1273 was associated with higher antibody levels than BNT162b2 or adenovirus vector vaccines after adjusting for time since vaccination, age, and underlying condition. Antibody levels were strongly correlated with pseudovirus neutralization titers (Spearman r = 0.89, P < .0001), but in seropositive participants with intermediate antibody levels, neutralization titers were significantly lower in immunocompromised individuals versus HCW. CONCLUSIONS Antibody responses to COVID-19 vaccines were lowest among SOT and anti-CD20 monoclonal recipients, and recipients of vaccines other than mRNA-1273. Among those with intermediate antibody levels, pseudovirus neutralization titers were lower in immunocompromised patients than HCWs. Additional SARS-CoV-2 preventive approaches are needed for immunocompromised persons, which may need to be tailored to the cause of immunodeficiency.
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Affiliation(s)
- Ghady Haidar
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mounzer Agha
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amy Lukanski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kelsey Linstrum
- Health Care Innovation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rachel Troyan
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah K McMahon
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Melissa D Crandall
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michele D Sobolewksi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - P Nathan Enick
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jana L Jacobs
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cynthia Klamar-Blain
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bernard J C Macatangay
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Urvi M Parikh
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amy Heaps
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lindsay Coughenour
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marc B Schwartz
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeffrey M Dueker
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary E Keebler
- Department of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew R Morrell
- Division of Pulmonary and Critical Care, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John F McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bhanu Pappu
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stanley M Marks
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Mahon
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Katie Mulvey
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Division of Transplantation, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Glenn M Updike
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania, USAand
| | - Lorraine Brock
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert Edwards
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania, USAand
| | - Richard H Beigi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania, USAand
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alan Wells
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- Health Care Innovation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John W Mellors
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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12
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Huang DT, McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Nakayama A, Zapf RL, Kip PL, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Seymour CW. Effectiveness of Casirivimab-Imdevimab and Sotrovimab During a SARS-CoV-2 Delta Variant Surge: A Cohort Study and Randomized Comparative Effectiveness Trial. JAMA Netw Open 2022; 5:e2220957. [PMID: 35834252 PMCID: PMC10881222 DOI: 10.1001/jamanetworkopen.2022.20957] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The effectiveness of monoclonal antibodies (mAbs), casirivimab-imdevimab and sotrovimab, is unknown in patients with mild to moderate COVID-19 caused by the SARS-CoV-2 Delta variant. Objective To evaluate the effectiveness of mAb against the Delta variant compared with no mAb treatment and to ascertain the comparative effectiveness of casirivimab-imdevimab and sotrovimab. Design, Setting, and Participants This study comprised 2 parallel studies: (1) a propensity score-matched cohort study of mAb treatment vs no mAb treatment and (2) a randomized comparative effectiveness trial of casirivimab-imdevimab and sotrovimab. The cohort consisted of patients who received mAb treatment at the University of Pittsburgh Medical Center outpatient infusion centers and emergency departments from July 14 to September 29, 2021. Participants were patients with a positive SARS-CoV-2 test result who were eligible to receive mAbs according to emergency use authorization criteria. Exposure For the trial, patients were randomized to either intravenous casirivimab-imdevimab or sotrovimab according to a system therapeutic interchange policy. Main Outcomes and Measures For the cohort study, risk ratio (RR) estimates for the primary outcome of hospitalization or death by 28 days were compared between mAb treatment and no mAb treatment using propensity score-matched models. For the comparative effectiveness trial, the primary outcome was hospital-free days (days alive and free of hospitalization) within 28 days after mAb treatment, where patients who died were assigned -1 day in a bayesian cumulative logistic model adjusted for treatment location, age, sex, and time. Inferiority was defined as a 99% posterior probability of an odds ratio (OR) less than 1. Equivalence was defined as a 95% posterior probability that the OR was within a given bound. Results A total of 3069 patients (1023 received mAb treatment: mean [SD] age, 53.2 [16.4] years; 569 women [56%]; 2046 had no mAb treatment: mean [SD] age, 52.8 [19.5] years; 1157 women [57%]) were included in the prospective cohort study, and 3558 patients (mean [SD] age, 54 [18] years; 1919 women [54%]) were included in the randomized comparative effectiveness trial. In propensity score-matched models, mAb treatment was associated with reduced risk of hospitalization or death (RR, 0.40; 95% CI, 0.28-0.57) compared with no treatment. Both casirivimab-imdevimab (RR, 0.31; 95% CI, 0.20-0.50) and sotrovimab (RR, 0.60; 95% CI, 0.37-1.00) were associated with reduced hospitalization or death compared with no mAb treatment. In the clinical trial, 2454 patients were randomized to receive casirivimab-imdevimab and 1104 patients were randomized to receive sotrovimab. The median (IQR) hospital-free days were 28 (28-28) for both mAb treatments, the 28-day mortality rate was less than 1% (n = 12) for casirivimab-imdevimab and less than 1% (n = 7) for sotrovimab, and the hospitalization rate by day 28 was 12% (n = 291) for casirivimab-imdevimab and 13% (n = 140) for sotrovimab. Compared with patients who received casirivimab-imdevimab, those who received sotrovimab had a median adjusted OR for hospital-free days of 0.88 (95% credible interval, 0.70-1.11). This OR yielded 86% probability of inferiority for sotrovimab vs casirivimab-imdevimab and 79% probability of equivalence. Conclusions and Relevance In this propensity score-matched cohort study and randomized comparative effectiveness trial, the effectiveness of casirivimab-imdevimab and sotrovimab against the Delta variant was similar, although the prespecified criteria for statistical inferiority or equivalence were not met. Both mAb treatments were associated with a reduced risk of hospitalization or death in nonhospitalized patients with mild to moderate COVID-19 caused by the Delta variant. Trial Registration ClinicalTrials.gov Identifier: NCT04790786.
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Affiliation(s)
- David T. Huang
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tami E. Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | | | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
| | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - David A. Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Octavia M. Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert D. Bart
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Services Division, UPMC, Pittsburgh, Pennsylvania
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Stephanie K. Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jason N. Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Caroline J. Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Rachel L. Zapf
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
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13
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McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Nakayama A, Zapf RL, Kip PL, Seymour CW, Huang DT. The comparative effectiveness of COVID-19 monoclonal antibodies: A learning health system randomized clinical trial. Contemp Clin Trials 2022; 119:106822. [PMID: 35697146 PMCID: PMC9187853 DOI: 10.1016/j.cct.2022.106822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Background Monoclonal antibodies (mAb) that neutralize SARS-CoV-2 decrease hospitalization and death compared to placebo in patients with mild to moderate COVID-19; however, comparative effectiveness is unknown. We report the comparative effectiveness of bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab. Methods A learning health system platform trial in a U.S. health system enrolled patients meeting mAb Emergency Use Authorization criteria. An electronic health record-embedded application linked local mAb inventory to patient encounters and provided random mAb allocation. Primary outcome was hospital-free days to day 28. Primary analysis was a Bayesian model adjusting for treatment location, age, sex, and time. Inferiority was defined as 99% posterior probability of an odds ratio < 1. Equivalence was defined as 95% posterior probability the odds ratio is within a given bound. Findings Between March 10 and June 25, 2021, 1935 patients received treatment. Median hospital-free days were 28 (IQR 28, 28) for each mAb. Mortality was 0.8% (1/128), 0.8% (7/885), and 0.7% (6/922) for bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab, respectively. Relative to casirivimab-imdevimab (n = 922), median adjusted odds ratios were 0.58 (95% credible interval [CI] 0.30–1.16) and 0.94 (95% CI 0.72–1.24) for bamlanivimab (n = 128) and bamlanivimab-etesevimab (n = 885), respectively. These odds ratios yielded 91% and 94% probabilities of inferiority of bamlanivimab versus bamlanivimab-etesevimab and casirivimab-imdevimab, and an 86% probability of equivalence between bamlanivimab-etesevimab and casirivimab-imdevimab. Interpretation Among patients with mild to moderate COVID-19, bamlanivimab-etesevimab or casirivimab-imdevimab treatment resulted in 86% probability of equivalence. No treatment met prespecified criteria for statistical equivalence. Median hospital-free days to day 28 were 28 (IQR 28, 28) for each mAb. Funding and registration This work received no external funding. The U.S. government provided the reported mAb. This trial is registered at ClinicalTrials.gov, NCT04790786.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judith A Shovel
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Octavia M Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert D Bart
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Caroline J Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rachel L Zapf
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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14
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Ruscetti A, Chrisman M, Wagester S, Smith P, O'Hare C, Mallon A, Chung A, Lutz CT, Minnier TE, Zapf RL, Kip PL, Snyder GM. Healthcare personnel early return-to-work program after higher-risk SARS-CoV-2 exposure: A learning health system quality improvement project. Am J Infect Control 2022; 50:542-547. [PMID: 35131348 PMCID: PMC8813718 DOI: 10.1016/j.ajic.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
Abstract
Background Incidence of health care personnel (HCP) with a higher-risk SARS-CoV-2 exposure and subsequent 14-day quarantine period adds substantial burden on the workforce. Implementation of an early return-to-work (RTW) program may reduce quarantine periods for asymptomatic HCP and reduce workforce shortages during the COVID-19 pandemic. Methods This observational quality improvement study included asymptomatic HCP of a multi-facility health care system with higher-risk workplace or non-household community SARS-CoV-2 exposure ≤4 days. The program allowed HCP to return to work 8 days after exposure if they remained asymptomatic through day 7 with day 5-7 SARS-CoV-2 nucleic acid amplification test result negative. Results Between January 4 and June 25, 2021, 384 HCP were enrolled, 333 (86.7%) remained asymptomatic and of these, 323 (97%) tested negative and were early RTW eligible. Mean days in quarantine was 8.16 (SD 2.40). Median day of early RTW was 8 (range 6-9, IQR 8-8). Mean days saved from missed work was 1.84 (SD 0.52). A total of 297 (92%) HCP did RTW ≤10 days from exposure and days saved from missed work was 546.48. Conclusions Implementing an HCP early RTW program is a clinical approach for COVID-19 workplace safety that can increase staffing availability, while maintaining a low risk of SARS-CoV-2 transmission.
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15
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McCreary EK, Bariola JR, Wadas RJ, Shovel JA, Wisniewski MK, Adam M, Albin D, Minnier T, Schmidhofer M, Meyers R, Marroquin OC, Collins K, Garrard W, Berry LR, Berry S, Crawford AM, McGlothlin A, Linstrum K, Nakayama A, Montgomery SK, Snyder GM, Yealy DM, Angus DC, Kip PL, Seymour CW, Huang DT, Kip KE. Association of Subcutaneous or Intravenous Administration of Casirivimab and Imdevimab Monoclonal Antibodies With Clinical Outcomes in Adults With COVID-19. JAMA Netw Open 2022; 5:e226920. [PMID: 35412625 PMCID: PMC9006104 DOI: 10.1001/jamanetworkopen.2022.6920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Monoclonal antibody (mAb) treatment decreases hospitalization and death in high-risk outpatients with mild to moderate COVID-19; however, only intravenous administration has been evaluated in randomized clinical trials of treatment. Subcutaneous administration may expand outpatient treatment capacity and qualified staff available to administer treatment, but the association with patient outcomes is understudied. OBJECTIVES To evaluate whether subcutaneous casirivimab and imdevimab treatment is associated with reduced 28-day hospitalization and death compared with nontreatment among mAb-eligible patients and whether subcutaneous casirivimab and imdevimab treatment is clinically and statistically similar to intravenous casirivimab and imdevimab treatment. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study evaluated high-risk outpatients in a learning health system in the US with mild to moderate COVID-19 symptoms from July 14 to October 26, 2021, who were eligible for mAb treatment under emergency use authorization. A nontreated control group of eligible patients was also studied. EXPOSURES Subcutaneous injection or intravenous administration of the combined single dose of 600 mg of casirivimab and 600 mg of imdevimab. MAIN OUTCOMES AND MEASURES The primary outcome was the 28-day adjusted risk ratio or adjusted risk difference for hospitalization or death. Secondary outcomes included 28-day adjusted risk ratios and differences in hospitalization, death, a composite end point of emergency department admission and hospitalization, and rates of adverse events. Among 1959 matched adults with mild to moderate COVID-19, 969 patients (mean [SD] age, 53.8 [16.7] years; 547 women [56.4%]) who received casirivimab and imdevimab subcutaneously had a 28-day rate of hospitalization or death of 3.4% (22 of 653 patients) compared with 7.0% (92 of 1306 patients) in nontreated controls (risk ratio, 0.48; 95% CI, 0.30-0.80; P = .002). Among 2185 patients treated with subcutaneous (n = 969) or intravenous (n = 1216; mean [SD] age, 54.3 [16.6] years; 672 women [54.4%]) casirivimab and imdevimab, the 28-day rate of hospitalization or death was 2.8% vs 1.7%, which resulted in an adjusted risk difference of 1.5% (95% CI, -0.6% to 3.5%; P = .16). Among all infusion patients, there was no difference in intensive care unit admission (adjusted risk difference, 0.7%; 95% CI, -3.5% to 5.0%) or need for mechanical ventilation (adjusted risk difference, 0.2%; 95% CI, -5.8% to 5.5%). CONCLUSIONS AND RELEVANCE In this cohort study of high-risk outpatients with mild to moderate COVID-19 symptoms, subcutaneously administered casirivimab and imdevimab was associated with reduced hospitalization and death when compared with no treatment. These results provide preliminary evidence of potential expanded use of subcutaneous mAb treatment, particularly in areas that are facing treatment capacity and/or staffing shortages.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Kelsey Linstrum
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | | | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David T. Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
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16
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Hodges JC, Bilderback AL, Bridge CM, Wagester S, Colaianne BV, Babiker A, Minnier T, Zapf RL, Kip PL, Snyder GM. Assessment of the effectiveness of ultraviolet-C disinfection on transmission of hospital-acquired pathogens from prior room occupants. Antimicrob Steward Healthc Epidemiol 2022; 2:e110. [PMID: 36483381 PMCID: PMC9726560 DOI: 10.1017/ash.2022.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of ultraviolet-C (UV-C) disinfection as an adjunct to standard chlorine-based disinfectant terminal room cleaning in reducing transmission of hospital-acquired multidrug-resistant organisms (MDROs) from a prior room occupant. DESIGN A retrospective cohort study was conducted to compare rates of MDRO transmission by UV-C status from January 1, 2016, through December 31, 2018. SETTING Acute-care, single-patient hospital rooms at 6 hospitals within an academic healthcare system in Pennsylvania. METHODS Transmission of hospital-acquired MDRO infection was assessed in patients subsequently assigned to a single-patient room of a source occupant with carriage of 1 or more MDROs on or during admission. Acquisition of 5 pathogens was compared between exposed patients in rooms with standard-of-care chlorine-based disinfectant terminal cleaning with or without adjunct UV-C disinfection. Logistic regression analysis was used to estimate the adjusted risk of pathogen transfer with adjunctive use of UV-C disinfection. RESULTS In total, 33,771 exposed patient admissions were evaluated; the source occupants carried 46,688 unique pathogens. Prior to the 33,771 patient admissions, 5,802 rooms (17.2%) were treated with adjunct UV-C disinfection. After adjustment for covariates, exposed patients in rooms treated with adjunct UV-C were at comparable risk of transfer of any pathogen (odds ratio, 1.06; 95% CI, 0.84-1.32; P = .64). CONCLUSION Our analysis does not support the use of UV-C in addition to post-discharge cleaning with chlorine-based disinfectant to lower the risk of prior room occupant pathogen transfer.
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Affiliation(s)
- Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Christine M. Bridge
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suzanne Wagester
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bonnie V. Colaianne
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel L. Zapf
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Author for correspondence: Graham M. Snyder, MD, MS, Falk Medical Building, 3601 Fifth Avenue, Suite 150, Pittsburgh, PA15213. E-mail:
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17
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Nace DA, Kip KE, Mellors JW, Peck Palmer OM, Shurin MR, Mulvey K, Crandall M, Sobolewski MD, Enick PN, McCormick KD, Jacobs JL, Kane AL, Lukanski A, Kip PL, Wells A. Antibody Responses After mRNA-Based COVID-19 Vaccination in Residential Older Adults: Implications for Reopening. J Am Med Dir Assoc 2021; 22:1593-1598. [PMID: 34129831 PMCID: PMC8196346 DOI: 10.1016/j.jamda.2021.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 01/13/2023]
Abstract
Objective COVID-19 disproportionately impacts residents in long-term care facilities. Our objective was to quantify the presence and magnitude of antibody response in vaccinated, older adult residents at assisted living, personal care, and independent living communities. Design A cross-sectional quality improvement study was conducted March 15 – April 1, 2021 in the greater Pittsburgh region. Setting and Population Participants were older adult residents at assisted living, personal care, and independent living communities, who received mRNA-based COVID-19 vaccine. Conditions that impair immune responses were exclusionary criteria. Methods Sera were collected to measure IgG anti-SARS-CoV-2 antibody level with reflex to total anti-SARS-CoV-2 immunoglobulin levels, and blinded evaluation of SARS-CoV-2 pseudovirus neutralization titers. Descriptive statistics, Pearson correlation coefficients, and multiple linear regression analysis evaluated relationships between factors potentially associated with antibody levels. Spearman correlations were calculated between antibody levels and neutralization titers. Results All participants (N = 70) had received two rounds of vaccination and were found to have antibodies with wide variation in relative levels. Antibody levels trended lower in males, advanced age, current use of steroids, and longer length of time from vaccination. Pseudovirus neutralization titer levels were strongly correlated (P < .001) with Beckman Coulter antibody levels [D614 G NT50, rs = 0.91; B.1.1.7 (UK) NT50, rs = 0.91]. Conclusions and Implications Higher functioning, healthier, residential older adults mounted detectable antibody responses when vaccinated with mRNA-based COVID-19 vaccines. Data suggests some degree of immunity is present during the immediate period following vaccination. However, protective effects remain to be determined in larger studies as clinical protection is afforded by ongoing adaptive immunity, which is known to be decreased in older adults. This study provides important preliminary results on level of population risk in older adult residents at assisted living, personal care, and independent living communities to inform reopening strategies, but are not likely to be translatable for residents in nursing homes.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John W Mellors
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Michael R Shurin
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katie Mulvey
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa Crandall
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michele D Sobolewski
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - P Nathan Enick
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin D McCormick
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jana L Jacobs
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - April L Kane
- Senior Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amy Lukanski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA; Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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