Improving Patient-Reported Outcomes in Stroke Care using Remote Blood Pressure Monitoring and Telehealth.

BACKGROUND: Inequities in health care access leads to suboptimal medication adherence and blood pressure (BP) control. Informatics-based approaches may deliver equitable care and enhance self-management. Patient-reported outcomes (PROs) complement clinical measures to assess the impact of illness on patients' well-being in poststroke care. OBJECTIVES: The aim of this study was to determine the feasibility of incorporating PROs into Telehealth After Stroke Care (TASC) and to explore the effect of this team-based remote BP monitoring program on psychological distress and quality of life in an underserved urban setting. METHODS: Patients discharged home from a Comprehensive Stroke Center were randomized to TASC or usual care for 3 months. They were provided with a BP monitor and a tablet that wirelessly transmitted data to a cloud-based platform, which were integrated with the electronic health record. Participants who did not complete the tablet surveys were contacted via telephone or e-mail. We collected the Patient-Reported Outcomes Measurement Information System Managing Medications and Treatment (PROMIS-MMT), Patient Activation Measure (PAM), Neuro-QOL (Quality of Life in Neurological Disorders) Cognitive Function, Neuro-QOL Depression, and Patient Health Questionnaire-9 (PHQ-9). T-tests and linear regression were used to evaluate the differences in PRO change between the arms. RESULTS: Of the 50 participants, two-thirds were Hispanic or non-Hispanic Black individuals. Mechanisms of PRO submission for the arms included tablet (62 vs. 47%), phone (24 vs. 37%), tablet with phone coaching (10 vs. 16%), and e-mail (4 vs. 0%). PHQ-9 depressive scores were nominally lower in TASC at 3 months compared with usual care (2.7 ± 3.6 vs. 4.0 ± 4.1; p = 0.06). No significant differences were observed in PROMIS-MMT, PAM, or Neuro-QoL measures. CONCLUSION: Findings suggest the feasibility of collecting PROs through an interactive web-based platform. The team-based remote BP monitoring demonstrated a favorable impact on patients' well-being. Patients equipped with appropriate resources can engage in poststroke self-care to mitigate inequities in health outcomes.

The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care.

Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.

A randomized double-blind controlled trial of convalescent plasma in adults with severe COVID-19.

BACKGROUNDAlthough convalescent plasma has been widely used to treat severe coronavirus disease 2019 (COVID-19), data from randomized controlled trials that support its efficacy are limited.METHODSWe conducted a randomized, double-blind, controlled trial among adults hospitalized with severe and critical COVID-19 at 5 sites in New York City (USA) and Rio de Janeiro (Brazil). Patients were randomized 2:1 to receive a single transfusion of either convalescent plasma or normal control plasma. The primary outcome was clinical status at 28 days following randomization, measured using an ordinal scale and analyzed using a proportional odds model in the intention-to-treat population.RESULTSOf 223 participants enrolled, 150 were randomized to receive convalescent plasma and 73 to receive normal control plasma. At 28 days, no significant improvement in the clinical scale was observed in participants randomized to convalescent plasma (OR 1.50, 95% confidence interval [CI] 0.83-2.68, P = 0.180). However, 28-day mortality was significantly lower in participants randomized to convalescent plasma versus control plasma (19/150 [12.6%] versus 18/73 [24.6%], OR 0.44, 95% CI 0.22-0.91, P = 0.034). The median titer of anti-SARS-CoV-2 neutralizing antibody in infused convalescent plasma units was 1:160 (IQR 1:80-1:320). In a subset of nasopharyngeal swab samples from Brazil that underwent genomic sequencing, no evidence of neutralization-escape mutants was detected.CONCLUSIONIn adults hospitalized with severe COVID-19, use of convalescent plasma was not associated with significant improvement in day 28 clinical status. However, convalescent plasma was associated with significantly improved survival. A possible explanation is that survivors remained hospitalized at their baseline clinical status.TRIAL REGISTRATIONClinicalTrials.gov, NCT04359810.FUNDINGAmazon Foundation, Skoll Foundation.

Distinct antibody responses to SARS-CoV-2 in children and adults across the COVID-19 clinical spectrum.

Clinical manifestations of COVID-19 caused by the new coronavirus SARS-CoV-2 are associated with age1,2. Adults develop respiratory symptoms, which can progress to acute respiratory distress syndrome (ARDS) in the most severe form, while children are largely spared from respiratory illness but can develop a life-threatening multisystem inflammatory syndrome (MIS-C)3-5. Here, we show distinct antibody responses in children and adults after SARS-CoV-2 infection. Adult COVID-19 cohorts had anti-spike (S) IgG, IgM and IgA antibodies, as well as anti-nucleocapsid (N) IgG antibody, while children with and without MIS-C had reduced breadth of anti-SARS-CoV-2-specific antibodies, predominantly generating IgG antibodies specific for the S protein but not the N protein. Moreover, children with and without MIS-C had reduced neutralizing activity as compared to both adult COVID-19 cohorts, indicating a reduced protective serological response. These results suggest a distinct infection course and immune response in children independent of whether they develop MIS-C, with implications for developing age-targeted strategies for testing and protecting the population.

Antibody responses to SARS-CoV2 are distinct in children with MIS-C compared to adults with COVID-19.

Clinical manifestations of COVID-19 caused by the novel coronavirus SARS-CoV-2 are associated with age. While children are largely spared from severe respiratory disease, they can present with a SARS-CoV-2-associated multisystem inflammatory syndrome (MIS-C) similar to Kawasaki's disease. Here, we show distinct antibody (Ab) responses in children with MIS-C compared to adults with severe COVID-19 causing acute respiratory distress syndrome (ARDS), and those who recovered from mild disease. There was a reduced breadth and specificity of anti-SARS-CoV-2-specific antibodies in MIS-C patients compared to the COVID patient groups; MIS-C predominantly generated IgG Abs specific for the Spike (S) protein but not for the nucleocapsid (N) protein, while both COVID-19 cohorts had anti-S IgG, IgM and IgA Abs, as well as anti-N IgG Abs. Moreover, MIS-C patients had reduced neutralizing activity compared to COVID-19 cohorts, indicating a reduced protective serological response. These results suggest a distinct infection course and immune response in children and adults who develop severe disease, with implications for optimizing treatments based on symptom and age.

The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review.

BACKGROUND: The prevalence of diabetes mellitus is ubiquitous. Complications and costs of diabetes are rising and are depleting limited resources. It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions. An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit. Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting. OBJECTIVES: The review objective was to conduct a systematic review and meta-analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c, blood pressure and cholesterol measurements/levels for adult patients with type II diabetes in outpatient settings. SEARCH STRATEGY: A three-step literature search for studies in English language from 1990 to 2010 was conducted utilising (a) a primary search of Medline, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials, (b) a secondary search of non-indexed databases, and (c) a search of the grey literature. In addition, a manual review of the reference lists of all identified reports and articles was performed to identify additional studies. INCLUSION CRITERIA: All randomised and quasi-experimental studies of adult patients (>18) with type II diabetes mellitus seen in outpatient health settings were considered if they met one or more of the following diagnostic outcome measurements: haemoglobin A1c, systolic and diastolic blood pressure, and low density lipoprotein cholesterol. CRITICAL APPRAISAL, DATA COLLECTION AND ANALYSIS: Each of the eligible articles was reviewed by two independent reviewers. Disagreements between the reviewers were resolved through discussion, or with a third reviewer. Studies that met the inclusion criteria were assessed for methodological quality using the JBI standardized critical appraisal tools. Data extraction was undertaken using the standardised data extraction tool from JBI-MAStARI. MAIN RESULTS: The search strategy identified 2,040 articles in the published and unpublished literature. Of these, 11 randomised controlled trials and 4 quasi-experimental trials met the inclusion criteria and represented 2240 patients included in the final review.There are clear benefits of group medical visits for patients' HbA1c levels which are consistent in the post-intervention and change from baseline effect sizes. The most significant effect observed is with the change from baseline results. Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe. There is no evidence that group visits improve LDL cholesterol values of the group visit participants. CONCLUSIONS: Group medical visits should be considered by clinicians as an effective non-pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure. IMPLICATIONS FOR PRACTICE: The evidence suggests that the most powerful model of Group medical visits (GMV) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs. IMPLICATIONS FOR RESEARCH: Future research should include this GMV intervention in randomised controlled trials across different health systems and socio-economic and ethnic groups.