News Scan for Dec 22, 2020

News brief

Researchers highlight sharp drop in US hospital COVID-19 death rates

A study in JAMA Internal Medicine today demonstrates a sharp decline in US hospital COVID-19 mortality rates during the first 6 months of the pandemic, with wide variation across hospitals and poorer outcomes linked to higher county-level case rates.  

Researchers compared outcomes for 38,517 adult COVID-19 patients admitted to 955 US hospitals during an early (Jan 1 to Apr 30) and late (from May 1 to Jun 30) pandemic period. They estimated each hospital's risk-standardized event rate (RSER), which is a measure of average patient risk of 30-day in-hospital mortality or referral to hospice.

The overall mean RSER for 955 hospitals was 11.8%, with a range from 9.1% to 15.7% for the best- and worst-performing hospital quintiles (absolute difference 6.59 percentage points; 95% confidence interval [CI], 6.4% to 6.8%; P < 0.001). Individual hospitals had RSERs that varied widely from 5.7% to 24.7%.

The overall mean RSER for the subset of hospitals (398) with sufficient patient volumes for mortality comparisons declined from 16.6% to 9.3% from the early to late period, with 94% of hospitals (376) improving RSERs by at least 25%. Of the subset of hospitals with high patient volumes, 95 facilities (24.0%) showed more than 50% reduction in in-hospital mortality or hospice referral.

"That rate of relative improvement is striking and encouraging, but perhaps not surprising," the study authors wrote. "Early efforts at treating patients with COVID-19 were based on experience with previously known causes of severe respiratory illness. Later efforts could draw on experiences specific to SARS-CoV-2 infection."

The researchers found that hospital rankings were correlated over time, suggesting that better-performing hospitals continued to outperform. Hospitals with high or increasing county-level COVID-19 burden showed higher RSERs (absolute change 1.14; 95% CI, 0.23 to 2.05).

"One likely reason for this finding is that hospitals do not perform as well when they are overwhelmed," said Leon Boudourakis, MD, and Amit Uppal, MD, in a linked commentary. "In particular, patients with a precarious respiratory status require expert, meticulous therapy to avoid intubation," they added, noting that such care is difficult when hospital capacity is strained.   

"The association between high community COVID-19 case loads and both worse RSERs and greater improvement in RSERs suggests hospitals do worse when they are burdened with cases and is consistent with imperatives to flatten the curve," the study authors wrote. "As case rates of COVID-19 increase across the nation, hospital mortality outcomes may worsen."
Dec 22 JAMA Intern Med study
Dec 22 JAMA Intern Med commentary


Parents say social media, screen time top pandemic concerns for kids

A University of Michigan C.S. Mott Children's Hospital national poll released yesterday spotlights social media and screen time as parents' top concerns for children during the pandemic, with key racial and ethnic differences.

The poll surveyed a nationally representative sample of 2,027 parents with at least one child in the household. Eight of parents' top 10 concerns may be related to efforts to control the COVID-19 pandemic, including overuse of social media and screen time, internet safety, unhealthy eating, depression and suicide, and lack of physical activity.

Overall, 72% of parents ranked overuse of social media and screen time as their top concern, followed by bullying/cyberbullying (62%) and internet safety (62%). Almost half of parents (48%) described COVID-19 disease as a "big problem," ranked tenth overall in parents' top health concerns.

"As children spend more time online because of virtual school and/or not being able to spend time with friends in person, it is not surprising that the top 3 problems are all related to screen use," the poll authors noted.

"This is an especially challenging time for families, with many children experiencing significant changes in routine that may negatively impact their health and wellbeing," said Mott Poll co-director Gary Freed, MD, MPH, in a university news release. "Parents need to have ongoing conversations with their children and teens to guide them on safe internet practices."

Family concerns show key racial and ethnic differences, with black parents rating racism as their top health concern for children and teens. Racism was rated sixth among Hispanic parents but did not make the top 10 of health concerns for white parents.

"Although racism directly affects specific populations, its impact on children's health is a societal concern," Freed said in the release. COVID-19 was ranked second by black parents and eighth by Hispanic parents, but did not make the top 10 list of health concerns among white parents.

"This is likely due to the higher rates of COVID-19 infections in Black and Hispanic communities relative to the general population," the poll authors note. "Children who have lost family members to COVID-19 may need special attention and mental health services."
Dec 21 University of Michigan poll
Dec 21 University of Michigan news release


Study links pandemic to drop in common outpatient antibiotics

A study today in Open Forum Infectious Diseases shows that the COVID-19 pandemic had an immediate and sustained impact on the most commonly prescribed outpatient antibiotics in the United States.

To measure the impact of the pandemic on outpatient antibiotic prescribing, researchers from the University of Pittsburgh and the VA Pittsburgh Healthcare System examined monthly prescription fill data from the IQVIA National Prescription Audit databases over a 6-year period (July 2014 through July 2020). Their analysis showed that prescription fills for the 10 most common outpatient antibiotics decreased significantly (from 13% to 56%) in April 2020 compared with the pre-pandemic period (August 2014 through March 2020).

From May through July 2020, monthly prescription fills of seven of those antibiotics steadily rebounded and exceeded pre-pandemic trends. But monthly fills for three outpatient antibiotics—azithromycin, amoxicillin-clavulanate, and levofloxacin—did not rebound, and along with amoxicillin, they did not return to pre-pandemic levels. Amoxicillin, azithromycin, and amoxicillin-clavulanate are the top three outpatient antibiotics based on monthly fills, and among the most common inappropriately prescribed antibiotics in the United States.

The authors of the study say the sharp drop in antibiotic prescription fills at the beginning of the pandemic were likely due to suspension of non-emergent and non-COVID-19 healthcare services, and that increased prescribing of many outpatient antibiotics in the following months reflected resumption of those services.

On the other hand, they suggest the sustained reduction in prescribing of azithromycin, amoxicillin, amoxicillin-clavulanate, and levofloxacin could be explained by patients being less likely to seek outpatient care for respiratory complaints, clinicians being more reluctant to prescribe those antibiotics, or a reduction in respiratory infections linked to COVID-19 restrictions.

They conclude that more research is needed to understand the long-term impact of the pandemic on outpatient prescribing and antibiotic resistance.

"It will be important to identify factors that contributed to sustained reductions in use of oral azithromycin, amoxicillin-clavulanate, levofloxacin and amoxicillin below baseline levels in the first months of the pandemic," they write. "If inappropriate prescriptions were curtailed, insights might provide a foundation for developing successful outpatient stewardship strategies in the future."
Dec 22 Open Forum Infect Dis abstract


FDA approves Ebola treatment Ebanga for adults and children

The Food and Drug Administration (FDA) yesterday approved the human monoclonal antibody Ebanga (Ansuvimab-zykl, or mAb114) to treat Zaire ebolavirus infection. Similar to the first FDA-approved Ebola treatment, Inmazeb (REGN-EB3), the treatment blocks the virus's attachment to the cell receptor.

Also similar to Inmazeb, Ebanga was part of the 2018-19 PALM Trial in the Democratic Republic of the Congo (DRC). In an intervention group of 120 adults and 54 children, the single-dose infusion lowered mortality rate to 35.1%, compared with 49.4% in the control group. The pretrial dosage—one infusion of 50 milligrams per kilogram—did not receive any revision, and a press release from Ridgeback Biotherapeutics LP, the maker of Ebanga, notes that this is the first FDA-approved Ebola treatment available in a lyophilized (freeze-dried) form.

The most common side effects overlap with those of the Ebola virus, such as fever, quickened heart rate and breathing, diarrhea, vomiting, low blood pressure, and chills. If hypersensitivity occurs, the FDA says to stop the treatment. Those who receive Ebanga should make sure not to receive the live-virus vaccine concurrently in order to keep the vaccine as effective as possible.

Prior to approval, Ridgeback Biotherapeutics received breakthrough therapy designation, orphan drug designation, and $14 million in funding and expertise from the US Biomedical Advanced Research and Development Authority. The treatment was originally derived from a human survivor of the 1995 Ebola outbreak in Kikwit, DRC. Researchers discovered that the survivor still had antibodies 11 years after infection.
Dec 21 FDA press release
Dec 22 Ridgeback Biotherapeutics
press release
Oct 15 CIDRAP News story "FDA approves first Ebola treatment"

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