'Do-Not-Resuscitate (DNR)' Status Determines Mortality in Patients with COVID-19

 AlbertAlhatemMDaOdetteSpruijtMBChB, FRACP, FRAChPMbDebra S.HellerMDaRavi J.ChokshiMD, MPHcRobert ASchwartzMD, MPH, DSc (Hon), FRCP EdinadW.ClarkLambertMD. PhDad

DOI: https://doi.org/10.1016/j.clindermatol.2020.11.013

PDF: https://www.sciencedirect.com/science/article/pii/S0738081X20302315/pdfft?md5=951a468e348daf476fbb314eae7c9140&pid=1-s2.0-S0738081X20302315-main.pdf

ABSTRACT

Objective

To investigate the influence of DNR status on mortality of hospital inpatients who died of COVID-19.

Design

This is a retrospective, observational cohort study of all patients admitted to two New Jersey hospitals between March 15 and May 15, 2020 who had, or developed, COVID-19 (1270 patients). Of these, 640 patients died (570 (89.1 percent) with and 70 (10.9 percent) without a DNR order at the time of admission) and 630 survived (180 (28.6 percent) with and 450 (71.4 percent) without a DNR order when admitted). Among the 120 patients without COVID-19 who died during this interval, 110 (91.7 percent) had a DNR order when admitted.

Results

Deceased positive SARS-CoV-2 patients were significantly more likely to have a DNR order on admission compared to recovered positive SARS-COV-2 patients (p < 0.05), similar to those who tested negative for SARS-COV-2. COVID-19 DNR patients had a higher mortality compared to COVID-19 non-DNR patients (log rank p < 0.001). DNR patients had a significantly increased hazard ratio of dying (HR 2.2 [1.5-3.2], p <0.001) compared to non-DNR patients, a finding that remained significant in the multivariate model.

Conclusion

The risk of death from COVID-19 was significantly influenced by the patients’ DNR status.

https://www.sciencedirect.com/science/article/pii/S0738081X20302315

Delta, Alitalia 'Quarantine-Free' Flights 1st Push To Jump Start Travel Industry

 It appears the airline industry is ready to move forward and break free from the significant pressure Covid has put on its businesses over the last year. To do this, airlines have to convince people to start traveling again.

And what better way to do this than to offer a taste of the days of yonder? 

That's why Delta and Alitalia are now offering “quarantine free” flights between the US and Italy, according to FT. They are the first flights between the U.S. and Europe not subject to quarantines in months. 

Passengers on "select flights" from Atlanta to Rome will no longer have to self-isolate if they test negative for Covid 3 times on their flight. They are going to be asked to take a PCR test 72 hours before departure and then rapid tests at both the Atlanta and Italian airports.

This comes as part of a broader push by airlines to allow this type of testing to replace quarantine restrictions. 

Airlines and airports are also pushing for a softening of rules about takeoff and landing slots into next year. The rules, during normal operations, dictate carriers could lose slots if they aren't used 80% of the time. 

The rules have been suspended due to Covid but are due to come back online at the end of March. Three major aviation bodies are calling for the rule to be waived for another 6 months. 

The Airports Council International, International Air Transport Association and the Worldwide Airport Coordinators Group said in a joint statement said: "The existing slot rules were never designed to cope with a prolonged industry collapse."

While it's not a flash flood-style reopening of travel as it once was, the quarantine-free flights and continued flexibility from airports could mark two of the first necessary and preliminary steps the industry has to take in order to help itself start normalizing heading into 2021. 

https://www.zerohedge.com/medical/delta-and-alitalia-offer-quarantine-free-flights-first-push-jump-start-travel-industry

Aetna pilot harnesses CVS pharmacists to tag Medicaid members' social needs

 A new Aetna pilot program aims to harness its parent company's pharmacy reach to help address members' social needs.

Through the HealthTag initiative, CVS Health pharmacists and pharmacy employees are empowered to offer more personalized information when Aetna Medicaid members come to pick up prescriptions, providing the members with health information beyond how to take their medications appropriately.

Inside the prescription bag, members are provided additional details on how to access community services to address social concerns like food, housing or transportation. The network of these organizations is backed by Unite Us, a social care coordination program.

Aetna will pilot the program at CVS pharmacies in West Virginia and Louisiana.

R.J. Briscione, senior director for social determinants of health strategy at CVS Health, told Fierce Healthcare that the program is an example of Aetna taking advantage of the opportunities available as an integrated part of CVS.

He said teams across the company's business segments are invested in ways to get at patients' social determinants of health.

"There’s really a lot of work going on across CVS and Aetna," Briscione said.

As evidence of this, the HealthTag effort is part of the broader Destination: Health initiative, which includes a slew of social programs across CVS Health. Other projects launched under the Destination: Health banner include a digital tool that will allow Aetna's employer clients to track workers' social needs along with millions in investments in affordable housing.

Briscione said the program is designed to identify Aetna Medicaid members who could use additional interventions to address their social needs, but who might otherwise not receive those potential services.

Patients also have fairly frequent interactions with a pharmacist and oftentimes see them more often than primary care physicians or other providers, he said, so their accessibility and reach makes them an ideal conduit for this information on social services.

"It's a really nice and natural place to go," he said.

While Destination: Health was not launched under the pandemic, initiatives like HealthTag have had to adapt to the realities of COVID-19. 

Briscione said one of the biggest challenges was working with Unite Us to ensure the community health organizations were able to provide needed services while many of their traditional, in-person approaches were shuttered.

The teams at Aetna and Unite Us played a key role in assisting them in adapting to virtual care demands, for example, he said.

"Frankly, a lot of the community-based organizations in the network weren’t quite prepared for having to basically serve their members virtually," he said. "It's really all about adaptability."

https://www.fiercehealthcare.com/payer/aetna-pilot-harnesses-cvs-pharmacists-to-address-medicaid-members-social-needs

CVS Caremark chief: Biggest challenges in distributing COVID-19 vaccine

 With the distribution of a COVID-19 vaccine looming, companies in the pharmaceutical supply chain are working overtime to plan for all contingencies.

At CVS Caremark, that means considering both the physical infrastructure needed to disseminate multiple, multi-dose vaccines with highly specific storage needs, as well as the data analytics necessary to track where they're going, Alan Lotvin, M.D., president of Caremark and executive vice president of CVS Health, told Fierce Healthcare.

As both Pfizer and Moderna's emerging vaccines require two doses, getting them out to every American will require substantial resource investment to deliver some-660 million doses, he said.

"That requires quite an army of vaccinators, of logistics to get the product around the country," Lotvin said.

In addition, it will be critical to effectively harness analytics to track which vaccines members received to ensure they get the appropriate boosters, Lotvin said. It's unclear what the side effects may be if there were a mix-up.

"Someone's going to have to keep track of who got what vaccine," Lotvin said.

CVS is tackling the vaccine challenge from multiple angles, both as a large pharmacy benefit manager and as a huge national retail chain. CVS Pharmacy has, alongside its peers, signed on to assist the Trump administration in distributing a vaccine rapidly to nursing homes, and is pushing for pharmacy technicians to be able to administer COVID-19 vaccines.

In addition to building up the infrastructure needed for immediate distribution, Lotvin said plenty of questions still remain about what could happen long-term.

For example, it's not yet clear if a course of COVID-19 vaccinations will be enough for protection over a long period, or if it will become an annual inoculation like influenza. Plus, with multiple products on the market, consumer demand could be quite uneven, especially if one vaccine proves to be notably more effective than another over time, he said.

Wide distribution of a vaccine also doesn't mean the virus will vanish, Lotvin said.

"I still think that even once we get to a reasonable amount of vaccination we’re going to continue to maintain masks and social distancing for a while," he said. "The disease isn't going to go away."

The work required to effectively disseminate the coming COVID-19 vaccine or therapies for the virus doesn't eliminate the traditional role of PBMs like Caremark in the market, so Lotvin said the team has put in a lot of effort to ensure drug distribution continues smoothly in a way that allows for social distancing, as well as to prevent gaps in care for specialty pharmacy patients.

Lotvin said Caremark had to "substantially change all of the workflows in the dispensing facilities" to enable social distancing, and that it was able to do so without hampering distribution to members.

It has also been active in working with employers on returning to work through its Return Ready platform, which has garnered interest from existing Caremark clients and from new customers. About 40% of those who signed on with the platform were not previously CVS Customers, CVS Health CEO Larry Merlo told investors earlier this month.

Lotvin said the program is admittedly not one for every single employer, as it's quite expensive and rigorous to administer. However, the response has been "outstanding" from the companies that have adopted it.

"The actual people who are experiencing it are feeling a lot safer," he said.

https://www.fiercehealthcare.com/payer/cvs-caremark-chief-biggest-challenges-distributing-a-covid-19-vaccine

Over 100K died in nursing homes, long-term care facilities from COVID-19: Kaiser

 More than 100,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19 since the start of the pandemic, a new analysis from Kaiser Family Foundation.

Nationwide, the 100,033 deaths from long-term care facilities make up 40% of all COVID-19 deaths, according to the analysis released Wednesday.

“The disproportionate number of COVID-19 deaths in long-term care facilities serves as a reminder that residents and staff in these places continue to bear a high burden of the uncontrolled pandemic,” Kaiser said in a release. “And it raises questions about whether nursing homes and other facilities are able to protect their residents and, if not, what actions can to be taken to mitigate the threat posed by the virus.”

The foundation discovered that in 18 states half or more of their COVID-19 deaths were linked to long-term care facilities.

In three states—New Hampshire, Rhode Island and Connecticut—nursing home and long-term care facility deaths accounted for more than 70% of the state’s COVID-19 deaths.

The disproportionate number of deaths comes as some nursing homes eased restrictions on visitors and come ahead of the Thanksgiving holiday.

“Post-Thanksgiving surges in cases are unlikely to spare this community and will likely lead to an even higher death toll in long-term care facilities, raising questions about whether nursing homes and other facilities are able to protect their residents,” the analysis said.

The analysis is based on data from states.

“The number of states independently reporting long-term deaths due to COVID-19 has increased from 30 states in April to 50 states (all but Alaska) in November, which suggests that the total number of deaths reported in the first few months of the pandemic is an undercount,” KFF said.

States can also vary widely on how they report deaths. Some have included assisted living and residential facilities while others only focused on deaths in nursing facilities.

The Centers for Medicare & Medicaid Services has made several moves aimed at clamping down on nursing homes that became major hot spots at the onset of the pandemic.

The agency rolled out new training and guidelines to nursing homes on infection control and other best practices.

The Department of Health and Human Services also announced last month it will dole out $333 million in performance payments to more than 10,000 nursing homes that reduced COVID-19 infections and deaths over a two-month period.

https://www.fiercehealthcare.com/hospitals/kff-more-than-100k-died-nursing-homes-long-term-care-facilities-from-covid-19

JetBlue, Virgin Atlantic set to roll out COVID-19 'health pass' app in December

 Following a successful test with United Airlines in October, four more major airlines plan to start offering passengers a digital health pass to certify they are COVID-19-free.

JetBlue, Lufthansa, Swiss International Airlines, United Airlines, and Virgin Atlantic will begin the roll-out of CommonPass mobile app in December to help bring back global travel. The health pass app will be used on select flights departing from New York, Boston, London, and Hong Kong.

The CommonPass mobile app, created by the Commons Project Foundation and the World Economic Forum, was developed to enable travelers to share their COVID-19 test status across borders using a trusted framework for the first time.

The Commons Project Foundation announced Tuesday the Airport Council International (ACI) World, representing nearly 2,000 airports globally and five leading global airlines have joined the CommonTrust Network.

At present, COVID-19 test results for travel are frequently shared on pieces of paper—or photos of the paper—from unknown labs, often written in languages foreign to those inspecting them. The lack of a standard test result format and certification system leave room for confusion and falsification of results.

The purpose of CommonPass and the CommonPass framework is to enable safer airline and cross-border travel by giving both travelers and governments confidence in each traveler's verified COVID-19 status, according to Commons Project Foundation officials.

"As the world works to overcome the pandemic, all countries face the challenge of how to reopen borders for travel and commerce while protecting their populations’ health,” ACI World Director General Luis Felipe de Oliveira said in a statement. “Key to this will be a globally harmonized approach underpinned by cooperation and consistency between all players in the aviation industry.”

“The CommonTrust Network and CommonPass will help to foster this consistent approach, especially as it will include more than just the aviation industry,” said de Oliveira.

United Airlines tested the digital health pass on a flight from London to Newark, New Jersey in October. It was the first transatlantic trial of CommonPass, following a successful earlier trial with Cathay Pacific Airways between Hong Kong and Singapore earlier this month, according to the organizations.

"We are excited to be one of the first airlines in the world to partner with CommonPass to provide another layer of safety to air travel in the United States and around the world. Reliable testing, combined with digital health passes, is another way to restore customer confidence and safely restore air travel," said Joanna Geraghty, president, and chief operating officer at JetBlue. 

Digital COVID-19 health passports will likely play a big role in global travel going forward. 

Three airline alliances—oneworld, SkyTeam, and Star Alliance—called for a globally harmonized approach for validation and authentication of testing and vaccination, highlighting CommonPass.

"The recent digital ‘health pass’ trials, such as CommonPass, are presenting a strong case for using digital technology to deliver harmonized standards in the validation and verification of accredited passenger health data," according to a statement from airline alliances, whose 58 member airlines represent over 60% of world airline capacity.

The International Air Transport Association (IATA) also announced this week it is in the final development phase of the IATA Travel Pass, a digital health pass that will support the safe reopening of borders.

The IATA said the travel pass would come to market in several months and will feature a global registry of health requirements, a global registry of testing and vaccination centers, a lab app to share test results, and a contactless travel app that creates a digital passport for travelers.

https://www.fiercehealthcare.com/tech/five-airlines-set-to-roll-out-covid-19-health-pass-app-december

What CVS And Walgreens Can Do That Amazon Can’t: Give You A Covid-19 Shot

 CVS Health, Walgreens and other neighborhood pharmacies are touting their ability to administer Covid-19 vaccines once available as online retail giant Amazon pushes deeper into the prescription business.

The stocks of major brick-and-mortar drugstore chains were hit hard with Tuesday’s announcement that Amazon is launching a new online store called “Amazon Pharmacy” that allows its U.S. customers to order prescription drugs to their homes with its Prime customers receiving free delivery of their medications.

But drugstore chains including CVS, Rite Aid, Walgreens and Walmart are ramping up marketing of their in-person healthcare services, particularly during the Covid-19 pandemic opening hundreds of diagnostic testing facilities and making plans to administer vaccines against the virus once they become available. And that could mean tens of millions of customers in the coming months inside the brick-and-mortar of drugstore chains, grocers and retailers with pharmacies given recent news that Covid-19 vaccines made by Moderna and Pfizer are nearing U.S. approval.

“The United States government will make a supply of the COVID-19 vaccine available to CVS Health when authorized and available to administer in pharmacies nationwide,” CVS said in an e-mail to customers last week. “We will offer it to the public through our 10,000 locations, following established vaccine prioritization guidelines.”

Last week, the Trump administration unveiled a list of drugstore chains, independent pharmacies, grocers and retailers that have signed on to administer Covid-19 vaccines. Neither Amazon nor its Whole Foods grocery unit were on the list.

The distribution of Covid-19 vaccinations will be complicated but these drugstores say they will be prepared.

CVS chief executive Larry Merlo said in an interview this month that CVS drugstores with a pharmacy will have expanded cold storage and related facilities for vaccines.

Some vaccines in late-stage U.S. testing need to be stored at minus 80 degrees Celsius, which is minus 112 degrees Fahrenheit. Such storage and distribution of Covid-19 vaccines is key to the massive logistics effort that will be needed to reach hundreds of millions of Americans.

“When that vaccine is available and we get the call (asking), ‘are you ready’ we are going to be in a position to say, ‘where do you want us to go,’” Merlo said in the interview. “There are going to be different storage and handling requirements. We are ensuring that we have those capabilities in our stores.”

Drugstores with pharmacies are expected to play a key role along with hospitals, mobile vaccination vehicles as well as state, local and federal health agencies to make sure Americans are vaccinated via an effective implementation plan, the Centers for Disease Control & Prevention told a panel of experts advising the Food and Drug Administration last month.

More broadly, the ability to administer vaccines during the pandemic is part of a broader strategy of brick-and-mortar retail pharmacy chains to fill their stores with healthcare services, making drugstores and convenient location for everything from a physical and urgent care to a diagnostic test.

CVS, for example, is in the second year of its three-year plan to have 1,500 HealthHubs by the end of next year that include hundreds of new healthcare items and services. And Walgreens earlier this year said it will invest $1 billion in its primary care partner VillageMD to open 500 to 700 physician-staffed clinics inside its drugstores in more than 30 U.S. markets within the next five years.

“With more than 9,000 stores in local communities across the country, Walgreens offers unparalleled access to a trusted and personal relationship and expertise with our network of more than 25,000 pharmacists nationwide, providing specialized support for chronic, complex conditions, medication therapy management and vaccinations,” Walgreens spokeswoman Kelli Teno said.

https://www.forbes.com/sites/brucejapsen/2020/11/18/heres-something-cvs-and-walgreens-can-do-that-amazon-cant-give-you-a-covid-19-shot/