Nirmatrelvir Plus Ritonavir for Early COVID-19 in a Large U.S. Health System : A Population-Based Cohort Study.

BACKGROUND: In the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain. OBJECTIVE: To assess whether nirmatrelvir plus ritonavir reduces risk for hospitalization or death among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. DESIGN: Population-based cohort study analyzed to emulate a clinical trial using inverse probability-weighted models to account for anticipated bias in treatment. SETTING: A large health care system providing care for 1.5 million patients in Massachusetts and New Hampshire during the Omicron wave (1 January to 17 July 2022). PATIENTS: 44 551 nonhospitalized adults (90.3% with ≥3 vaccine doses) aged 50 years or older with COVID-19 and no contraindications for nirmatrelvir plus ritonavir. MEASUREMENTS: The primary outcome was a composite of hospitalization within 14 days or death within 28 days of a COVID-19 diagnosis. RESULTS: During the study period, 12 541 (28.1%) patients were prescribed nirmatrelvir plus ritonavir, and 32 010 (71.9%) were not. Patients prescribed nirmatrelvir plus ritonavir were more likely to be older, have more comorbidities, and be vaccinated. The composite outcome of hospitalization or death occurred in 69 (0.55%) patients who were prescribed nirmatrelvir plus ritonavir and 310 (0.97%) who were not (adjusted risk ratio, 0.56 [95% CI, 0.42 to 0.75]). Recipients of nirmatrelvir plus ritonavir had lower risk for hospitalization (adjusted risk ratio, 0.60 [CI, 0.44 to 0.81]) and death (adjusted risk ratio, 0.29 [CI, 0.12 to 0.71]). LIMITATION: Potential residual confounding due to differential access to COVID-19 vaccines, diagnostic tests, and treatment. CONCLUSION: The overall risk for hospitalization or death was already low (1%) after an outpatient diagnosis of COVID-19, but nirmatrelvir plus ritonavir reduced this risk further. PRIMARY FUNDING SOURCE: National Institutes of Health.

Nirmatrelvir plus ritonavir for early COVID-19 and hospitalization in a large US health system.

Background: In the EPIC-HR trial, nirmatrelvir plus ritonavir led to an 88% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. Clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain. Objective: To assess whether nirmatrelvir plus ritonavir reduces risk of hospitalization among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune evasive SARS-CoV-2 lineages. Design: Population-based cohort study analyzed to emulate a clinical trial utilizing two-stage, inverse-probability weighted models to account for anticipated bias in testing and treatment. Setting: A large healthcare system providing care for 1.5 million patients in Massachusetts and New Hampshire during Omicron wave (January 1 to May 15, 2022) with staged access and capacity to prescribe nirmatrelvir plus ritonavir. Patients: 30,322 non-hospitalized adults (87.2% vaccinated) aged 50 and older with COVID-19 and without contraindications to nirmatrelvir plus ritonavir. Measurement: Primary outcome was hospitalization within 14 days of COVID-19 diagnosis. Results: During the study period, 6036 (19.9%) patients were prescribed nirmatrelvir plus ritonavir and 24,286 (80.1%) patients were not. Patients prescribed nirmatrelvir were more likely to be older, have more comorbidities, and be unvaccinated. Hospitalization occurred in 40 (0.66%) and 232 (0.96%) patients prescribed and not prescribed nirmatrelvir plus ritonavir, respectively. The adjusted risk ratio was 0.55 (95% confidence interval 0.38 to 0.80, p = 0.002). Observed risk reduction was greater among unvaccinated patients and obese patients. Limitations: Potential for residual confounding due to differential access and uptake of COVID-19 vaccines, diagnostics, and treatment. Conclusions: The overall risk of hospitalization was already low (<1%) following an outpatient diagnosis of COVID-19, but this risk was 45% lower among patients prescribed nirmatrelvir plus ritonavir. Funding: National Institutes of Health (P30 AI060354 and R01 CA236546).

How Stressed Are They?: Levels and Sources of Stress in Doctor of Physical Therapy Students.

PURPOSE: Stress has detrimental effects on psychological well-being, cognitive function, and physiological health. While students in many healthcare programs experience high levels of stress, it is unknown whether this is true for Doctor of Physical Therapy (DPT) students. The purpose of this study was to explore the levels and sources of stress experienced by first- and second-year DPT students. METHODS: Study participants included first- and second-year DPT students from eight physical therapist education programs in the Midwestern United States. In this cross-sectional, descriptive study, participants completed a survey during the didactic portion of their curriculum that included demographic information, the 10-item Perceived Stress Scale (PSS), and the Undergraduate Sources of Stress (USOS) Scale. RESULTS: The response rate was 84% with a total of 545 returned surveys. The mean PSS score was 15.7 out of a possible 40, with a range from 0 to 34. There were significant differences in levels of stress between universities and based on sex, with females reporting greater levels of stress than males. Respondents identifying higher levels of exercise, sleep, and social support reported lower levels of stress. DISCUSSION: Participants in this study reported lower mean PSS scores compared to age-matched norms and students in other healthcare programs.

Developing a framework for interprofessional collaborative practice, cultural fluency, and ecological approaches to health.

This paper describes the development of a framework for reducing health disparities inclusive of interprofessional collaborative practice, cultural humility, and ecological approaches to health; the identification of common core competencies for students from various disciplines; and relevant assessment instruments to measure attainment of those competencies. The framework, associated logic model and initiatives, and core competencies were created through an iterative process involving multiple stakeholders. Using the framework as the outcome, a logic model was created to identify short, medium, and long-term activities and outcomes. Faculty were involved in the identification of core competencies and relevant validated assessment instruments. Future work will include mapping competencies across the curricula in a school of health at a liberal arts university and longitudinal assessment of students to evaluate attainment of competencies.

Identifying Fall Prevention Content in Graduate Healthcare Curricula.

ISSUE: An interprofessional team-based approach to fall prevention is advocated to address the public health issue of fall-related injuries. The purpose of this study was to analyze fall-related curricular content across graduate physician assistant, nursing, occupational therapy, and physical therapy healthcare programs. METHODS: The research team conducted a qualitative thematic analysis of fall risk, assessment, and intervention content in graduate program textbooks, curricular narrative, and course objectives. OUTCOME: The four curricular themes identified were universal fall risks, varied assessments, discipline-based interventions, and minimal interprofessional approaches. All curricula universally covered fall risks. Curricular coverage of fall assessment varied by discipline. The physician assistant and nursing curricula focused on assessing fall risk and safety, while the occupational and physical therapy covered standardized functional assessments. The disciplines of physical and occupational therapy provided curricular instruction in restorative or compensatory interventions. All curricula included the interventions of patient and caregiver education and environmental modifications. Curricular coverage of an interprofessional approach to fall prevention was minimal. CONCLUSION: This study identified universal fall risks, varied fall assessments, and discipline-based fall interventions across four graduate healthcare curricula. There was minimal evidence of education in an interprofessional approach to fall prevention.

Looking through a new lens, exploring the interdependent relationship between interprofessional education and collaborative practice with Polarity ThinkingTM.

The context of interprofessional education (IPE) and collaborative practice (IPCP) has led to calls for greater alignment, coordination, and coalitions among education and healthcare delivery systems. One method to evaluate and improve these coalitions is the Polarity ThinkingTM framework. Polarities, such as IPE and IPCP, can represent interdependent pairs of different but complementary values or perspectives. This project investigates the IPE and IPCP polarity as perceived by educators and practitioners using survey research and an in-person summit to examine how the interdependent relationship between IPE and IPCP can support efficient, effective, and integrated care. Eighteen participants registered to attend the Association of Schools Advancing Health Professions (ASAHP) Summit on Healthcare Workforce Readiness for IPCP were surveyed in July 2018. Fifteen of the registered participants responded to the survey, which consisted of demographic questions and 16 items specific to the respondents' experiences with IPE and IPCP. The resulting Polarity Map®, generated based on responses to the pre-conference survey, showed that neither the IPE or IPCP poles were strongly supported. However, survey respondents did indicate more frequent positive outcomes with IPCP than experienced with IPE. Additionally, using the Polarity Map® as a guide, Summit participants generated action steps and early warning signs to support IPE and IPCP values. While the sample size was limited, the study can be used as an example of managing the IPE-IPCP polarity through broad engagement of stakeholders to better leverage IPE and IPCP to achieve efficient, effective, and integrated healthcare.