Publications by authors named "Michael Barnett"

374 Publications

COVID-19: An Organizational-theory-guided Holistic Self-caring and Resilience Project.

J Holist Nurs 2021 Apr 16:8980101211007007. Epub 2021 Apr 16.

Founder Watson Caring Science Institute.

In response to the coronavirus disease 2019 (COVID-19) global human caring crisis, this article describes an innovative, theory-guided, holistic practice project at a major academic medical center in Northern California. The purpose of this theory-guided COVID-19 project was to address the self-care needs of caregivers so they could better care for patients/families who are confronting daily pandemic demands. The organization's professional practices are guided by Watson's theory of human caring and Caritas Processes. This setting has 16 Caritas Coaches® who have acquired expertise in human caring from an accredited program of the Watson Caring Science Institute (www.watsoncaringscience.org). Caritas Coaches® were mobilized to implement holistic caring-healing modalities such as aromatherapy and mindfulness meditation throughout the organization. By addressing the self-care needs of caregivers, the organizational culture shifted from fear, fatigue, stress, and burnout, to more intentional conscious, mindful, caring presence, gratitude, and purpose. This study has implications for other institutions regarding theory-guided practice and system responses to self-care needs of staff. This study provides an overview of the project from its origin to implementation and outcomes.
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http://dx.doi.org/10.1177/08980101211007007DOI Listing
April 2021

Generalized Self-Disclosure Explains Variance in Outness Beyond Internalized Sexual Prejudice Among Young Adults.

Arch Sex Behav 2021 Apr 9;50(3):1121-1128. Epub 2021 Mar 9.

Department of Psychology and Counseling, The University of Texas at Tyler, 3900 University Boulevard HPR 235B, Tyler, TX, 75799, USA.

Outness, or self-disclosure of sexual orientation, plays a key role in the sexual identity development of LGB individuals and is linked with mental health. Lower outness has been consistently linked with higher internalized sexual prejudice; however, no extant research has explored the relationship between generalized self-disclosure and outness. The purpose of this study was to investigate the incremental validity of general self-disclosure to explain variance in outness beyond what is accounted for by internalized sexual prejudice among young adults (N = 387; 46 lesbians; 78 gay men; 49 bisexual men; 214 bisexual women). Self-disclosure explained additional variance in outness beyond internalized sexual prejudice. While outness is related to internalized sexual prejudice, general personality characteristics such as self-disclosure may also play a role in LGB individuals' disclosure of their sexual orientation. These findings suggest that while internalized sexual prejudice is still the primary driver of lower outness, lower general self-disclosure may also play an important role. Closeted individuals may be weighing the risks and benefits of disclosing their sexual orientation, as they would with any other personal information. For those struggling with self-disclosure of sexual orientation, clinicians should attend to internalized sexual prejudice while also noting an individual's comfort with general self-disclosure.
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http://dx.doi.org/10.1007/s10508-020-01881-xDOI Listing
April 2021

Changes in Stress and Workplace Shortages Reported by U.S. Critical Care Physicians Treating Coronavirus Disease 2019 Patients.

Crit Care Med 2021 Mar 17. Epub 2021 Mar 17.

Assessment and Research Department, American Board of Internal Medicine, Philadelphia, PA. Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA. Harvard T.H. Chan School of Public Health, Boston, MA. Harvard Medical School, Boston, MA.

Objectives: Eleven months into the coronavirus disease 2019 pandemic, the country faces accelerating rates of infections, hospitalizations, and deaths. Little is known about the experiences of critical care physicians caring for the sickest coronavirus disease 2019 patients. Our goal is to understand how high stress levels and shortages faced by these physicians during Spring 2020 have evolved.

Design: We surveyed (October 23, 2020 to November 16, 2020) U.S. critical care physicians treating coronavirus disease 2019 patients who participated in a National survey earlier in the pandemic (April 23, 2020 to May 3, 2020) regarding their stress and shortages they faced.

Setting: ICU.

Patients: Coronavirus disease 2019 patients.

Intervention: Irrelevant.

Measurement: Physician emotional distress/physical exhaustion: low (not at all/not much), moderate, or high (a lot/extreme). Shortage indicators: insufficient ICU-trained staff and shortages in medication, equipment, or personal protective equipment requiring protocol changes.

Main Results: Of 2,375 U.S. critical care attending physicians who responded to the initial survey, we received responses from 1,356 (57.1% response rate), 97% of whom (1,278) recently treated coronavirus disease 2019 patients. Two thirds of physicians (67.6% [864]) reported moderate or high levels of emotional distress in the Spring versus 50.7% (763) in the Fall. Reports of staffing shortages persisted with 46.5% of Fall respondents (594) reporting a staff shortage versus 48.3% (617) in the Spring. Meaningful shortages of medication and equipment reported in the Spring were largely alleviated. Although personal protective equipment shortages declined by half, they remained substantial.

Conclusions: Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands.
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http://dx.doi.org/10.1097/CCM.0000000000004974DOI Listing
March 2021

The hidden costs of moving care home.

Am J Manag Care 2021 03 1;27(3):e64-e65. Epub 2021 Mar 1.

Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 407, Boston, MA 02115. Email:

As home-based care utilization rises, an exploration of potential unintended consequences is necessary. The authors focus on support gaps, informal caregiving, and failure to meaningfully engage clinicians.
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http://dx.doi.org/10.37765/ajmc.2021.88521DOI Listing
March 2021

Eculizumab in Asian patients with anti-aquaporin-IgG-positive neuromyelitis optica spectrum disorder: A subgroup analysis from the randomized phase 3 PREVENT trial and its open-label extension.

Mult Scler Relat Disord 2021 Feb 20;50:102849. Epub 2021 Feb 20.

Department of Neurology, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi 980-8574, Japan; Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima 960-1295, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience (STRINS), Koriyama, 7-115, Yatsuyamada, Koriyama, Fukushima 963-8563, Japan. Electronic address:

Background Eculizumab, a terminal complement inhibitor, significantly reduced the risk of relapse compared with placebo in patients with anti-aquaporin-4 immunoglobulin G-positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) in the PREVENT trial. We report efficacy and safety analyses in Asian patients in PREVENT and its open-label extension (OLE). Methods PREVENT was a double-blind, randomized, phase 3 trial. Patients with AQP4+ NMOSD were randomly assigned (2:1) to receive intravenous eculizumab (maintenance dose, 1200 mg/2 weeks) or placebo. Patients who completed PREVENT could receive eculizumab in an OLE. Analyses were performed in a prespecified subgroup of Asian patients. Results Of 143 patients enrolled, 52 (36.4%) were included in the Asian subgroup (eculizumab, n = 37; placebo, n = 15); 45 Asian patients received eculizumab in the OLE. Most Asian patients (86.5%) received concomitant immunosuppressive therapy. During PREVENT, one adjudicated relapse occurred in patients receiving eculizumab and six occurred in patients receiving placebo in the Asian subgroup (hazard ratio, 0.05; 95% confidence interval: 0.01-0.35; p = 0.0002). An estimated 95.2% of Asian patients remained relapse-free after 144 weeks of eculizumab treatment. Upper respiratory tract infections, headache, and nasopharyngitis were the most common adverse events with eculizumab in the Asian subgroup. Conclusion Eculizumab reduces the risk of relapse in Asian patients with AQP4+ NMOSD, with a benefit-risk profile similar to the overall PREVENT population. The benefits of eculizumab were maintained during long-term therapy. Clinical trial registration ClinicalTrials.gov identifiers: NCT01892345 (PREVENT); NCT02003144 (open-label extension).
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http://dx.doi.org/10.1016/j.msard.2021.102849DOI Listing
February 2021

Development of a Web-Based Mindfulness Program for People With Multiple Sclerosis: Qualitative Co-Design Study.

J Med Internet Res 2021 Mar 2;23(3):e19309. Epub 2021 Mar 2.

School of Psychology, University of Sydney, Sydney, Australia.

Background: Mindfulness-based stress reduction is an efficacious treatment for people with chronic health problems; however, it is highly intensive and time-consuming, which is a barrier for service provision.

Objective: This study aims to develop an internet-delivered adapted version of mindfulness-based stress reduction for people with multiple sclerosis to make the intervention more accessible.

Methods: We co-designed a web-based mindfulness program with end users, that is, people with multiple sclerosis (N=19). Iterative feedback was also collected from a subsample of the initial group of end users (n=11), and the program was reviewed by experts (n=8).

Results: We identified three main themes common to people with multiple sclerosis: dealing with uncertainty and fears for the future, grief and loss, and social isolation. These themes were incorporated into narratives throughout the program. People with multiple sclerosis who reviewed the program gave feedback that the program was relatable, feasible, and acceptable. Experts agreed that the program appropriately represented the main tenets of mindfulness. Iterative feedback was used to further refine the program.

Conclusions: The web-based mindfulness program that we developed was viewed positively by both experts and end users. The program reflects common concerns for people with multiple sclerosis and has the potential to meet important unmet psychological needs. A randomized controlled trial was planned to determine the efficacy of the program.
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http://dx.doi.org/10.2196/19309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967236PMC
March 2021

Nerve biopsy: Current indications and decision tools.

Muscle Nerve 2021 Feb 25. Epub 2021 Feb 25.

Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.

After initial investigation of patients presenting with symptoms suggestive of neuropathy, a clinical decision is made for a minority of patients to undergo further assessment with nerve biopsy. Many nerve biopsies do not demonstrate a definitive pathological diagnosis and there is considerable cost and morbidity associated with the procedure. This highlights the need for appropriate selection of patients, nerves and neuropathology techniques. Additionally, concomitant muscle and skin biopsies may improve the diagnostic yield in some cases. Several advances have been made in diagnostics in recent years, particularly in genomics. The indications for nerve biopsy have consequently changed over time. This review explores the current indications for nerve biopsies and some of the issues surrounding its use. Also included are comments on alternative diagnostic modalities that may help to supplant or reduce the use of nerve biopsy as a diagnostic test. These primarily include extraneural biopsy and neuroimaging techniques such as magnetic resonance neurography and nerve ultrasound. Finally, we propose an algorithm to assist in deciding when to perform nerve biopsies.
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http://dx.doi.org/10.1002/mus.27201DOI Listing
February 2021

Off-topic verbosity: Relationships between verbal abilities and speech characteristics among young and older adults.

Appl Neuropsychol Adult 2021 Feb 23:1-7. Epub 2021 Feb 23.

Department of Psychology & Counseling, University of Texas at Tyler, Tyler, TX, USA.

Off-topic verbosity (OTV) refers to extended speech lacking in relevance and focus. Previous research has found that older adults have higher levels of OTV, and some contend that OTV is indicative of cognitive decline. The purpose of this study was to investigate relationships between verbal cognitive abilities and OTV speech characteristics among young adults ( = 62; age 18-28,  = 20.69) and older adults ( = 76; age 60-98,  = 76.46). Older adults had slower verbal speed and verbal set-shifting than young adults, and they displayed more tangentiality and egocentrism in their speech. Slower set-shifting was associated with increased tangentiality and decreased quantity of speech, particularly in older adults. These results provide some support for the age-related cognitive decline explanation of OTV, as posited by the inhibitory deficit hypothesis.
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http://dx.doi.org/10.1080/23279095.2021.1878461DOI Listing
February 2021

Interferon-β Is Less Effective Than Other Drugs in Controlling the Rate of Retinal Ganglion Cell Loss in MS.

Neurol Neuroimmunol Neuroinflamm 2021 05 17;8(3). Epub 2021 Feb 17.

From the Department of Clinical Medicine (Y.Y., S.L.G., A.K.), Macquarie University, NSW, Australia; Save Sight Institute (Y.Y., A.K.), The University of Sydney, NSW, Australia; Brain and Mind Centre (M.H.B.), The University of Sydney, NSW, Australia; Sydney Neuroimaging Analysis Centre (M.H.B.), NSW, Australia; Department of Neurology (C.Y., J.D.E.P.), Royal North Shore Hospital, NSW, Australia; and Sydney Informatics and Data Science Hub (J.G.M.), The University of Sydney, NSW, Australia.

Objective: To investigate the association between disease-modifying therapies (DMTs) and the rate of progressive retinal ganglion cell (RGC) and nerve fiber loss in MS.

Methods: One hundred five relapsing-remitting patients with MS were followed annually for a median of 4.0 years using optical coherence tomography. Twenty-five healthy subjects were also included as normal controls. The rates of global peripapillary retinal nerve fiber layer (pRNFL), temporal RNFL (tRNFL), and ganglion cell inner plexiform layer (GCIPL) thinning were analyzed according to DMT type using a linear mixed-effects model. Optic radiation lesion volume was measured on brain MRI and included as a covariate to minimize the effects of retrograde transsynaptic degeneration.

Results: The annual rates of RNFL and GCIPL thinning were higher in patients treated with "platform" therapies (interferon-β and glatiramer acetate) compared with DMTs of higher clinical efficacy (including fingolimod, dimethyl fumarate, natalizumab, alemtuzumab, rituximab, and ocrelizumab) (difference = -0.22 μm/y, = 0.02 for pRNFL; difference = -0.34 μm/y, = 0.009 for tRNFL; and difference = -0.16 μm/y, = 0.005 for GCIPL). Based on an analysis of individual treatments (interferon-β, glatiramer acetate, fingolimod, and natalizumab), interferon-β was associated with inferior RGC preservation, relative to the other drugs. No effect difference was found between glatiramer acetate, fingolimod, and natalizumab.

Conclusions: Progressive loss of RGCs in patients with MS is more pronounced in patients treated with interferon-β than other DMTs. This finding may have implications for DMT selection in MS.

Classification Of Evidence: This study provides Class IV evidence that for patients with MS, treatment with interferon-β compared with other DMTs leads to a more pronounced rate of retinal ganglion cell loss.
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http://dx.doi.org/10.1212/NXI.0000000000000971DOI Listing
May 2021

Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.

J Am Geriatr Soc 2021 04 21;69(4):875-878. Epub 2021 Feb 21.

Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1111/jgs.17062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014766PMC
April 2021

Variation In Telemedicine Use And Outpatient Care During The COVID-19 Pandemic In The United States.

Health Aff (Millwood) 2021 02;40(2):349-358

Michael Lawrence Barnett is an assistant professor in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston.

Coronavirus disease 2019 (COVID-19) spurred a rapid rise in telemedicine, but it is unclear how use has varied by clinical and patient factors during the pandemic. We examined the variation in total outpatient visits and telemedicine use across patient demographics, specialties, and conditions in a database of 16.7 million commercially insured and Medicare Advantage enrollees from January to June 2020. During the pandemic, 30.1 percent of all visits were provided via telemedicine, and the weekly number of visits increased twenty-three-fold compared with the prepandemic period. Telemedicine use was lower in communities with higher rates of poverty (31.9 percent versus 27.9 percent for the lowest and highest quartiles of poverty rate, respectively). Across specialties, the use of any telemedicine during the pandemic ranged from 68 percent of endocrinologists to 9 percent of ophthalmologists. Across common conditions, the percentage of visits provided during the pandemic via telemedicine ranged from 53 percent for depression to 3 percent for glaucoma. Higher rates of telemedicine use for common conditions were associated with smaller decreases in total weekly visits during the pandemic.
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http://dx.doi.org/10.1377/hlthaff.2020.01786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967498PMC
February 2021

Admission Practices And Cost Of Care For Opioid Use Disorder At Residential Addiction Treatment Programs In The US.

Health Aff (Millwood) 2021 Feb;40(2):317-325

Michael Lawrence Barnett is an assistant professor in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an assistant professor of medicine at Harvard Medical School.

The use of acute, short-term residential care for opioid use disorder has grown rapidly, with policy makers advocating to increase the availability of "treatment beds." However, there are concerns about high costs and misleading recruitment practices. We conducted an audit survey of 613 residential programs nationally, posing as uninsured cash-paying individuals using heroin and seeking addiction treatment. One-third of callers were offered admission before clinical evaluation, usually within one day. Most programs required up-front payments, with for-profit programs charging more than twice as much ($17,434) as nonprofits ($5,712). Recruitment techniques (for example, offering paid transportation) were used frequently by for-profit, but not nonprofit, programs. Practices including admission offers during the call, high up-front payments, and recruitment techniques were common even among programs with third-party accreditation and state licenses. These findings raise concerns that residential programs, including accredited and licensed ones, may be admitting a clinically and financially vulnerable population for costly treatment without assessing appropriateness for other care settings.
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http://dx.doi.org/10.1377/hlthaff.2020.00378DOI Listing
February 2021

Abrupt Discontinuation of Long-term Opioid Therapy Among Medicare Beneficiaries, 2012-2017.

J Gen Intern Med 2021 Jan 29. Epub 2021 Jan 29.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA.

Background: With mounting pressure to reduce opioid use, concerns exist about abrupt withdrawal of treatment for the millions of Americans using long-term opioid therapy (LTOT). However, little is known about how patients are tapered from LTOT nationally.

Objective: Measure national patterns of LTOT discontinuation and adherence to recommended tapering speed.

Design: Observational study of Medicare Part D from 2012 to 2017.

Participants: Using claims for a 20% sample of Medicare beneficiaries, we included patients on LTOT for 1 year or more, defined as those with ≥ 4 consecutive quarters with > 60 days of opioids supplied in each quarter.

Main Measures: Our primary outcome was discontinuation of LTOT, defined as at least 60 consecutive days without opioids supplied. We additionally examined whether discontinuation of LTOT was "tapered" or "abrupt" by comparing LTOT users' daily MME dose in the last month of therapy to their average daily dose in a baseline period of 7 to 12 months before discontinuation. By the last month of therapy, patients with "abrupt" discontinuation had a < 50% reduction in their average daily dose at baseline.

Key Results: From 2012 to 2017, there were 258,988 LTOT users, 17,617 of whom discontinued therapy. Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase (p < 0.001). There was a similar increase in annual discontinuation rate for LTOT users on lower (26-90 MME, 5.8% to 8.7%, p < 0.001) vs. higher doses (> 90 MME, 5.3% to 7.7%, p < 0.001). The majority of LTOT discontinuations were stopped abruptly, and increased over time (70.1% to 81.2%, 2012-2017, p < 0.001).

Conclusions: Medicare beneficiaries on LTOT were increasingly likely to have their therapy discontinued from 2012 to 2017. The vast majority of discontinuing users, even those on high doses, had less than 50% reduction in dose, which is inconsistent with existing guidelines.
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http://dx.doi.org/10.1007/s11606-020-06402-zDOI Listing
January 2021

Telehealth in Palliative Care: Communication Strategies From the COVID-19 Pandemic.

Clin J Oncol Nurs 2021 Feb;25(1):17-22

University of Alabama at Birmingham.

Palliative care was once believed to be too high-touch to be delivered via telehealth. However, numerous studies have demonstrated the positive effects of palliative care delivered through telehealth. Because the COVID-19 pandemic has quickly shifted how health care is delivered to patients with cancer, particularly because of their immunocompromised status and the risks associated with unnecessary exposures in the clinic, previous lessons from palliative care research studies can be used to inform practice. This article presents a case study that illustrates evidence and best practices for continuing to deliver palliative care via telehealth after COVID-19 restrictions are lifted.
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http://dx.doi.org/10.1188/21.CJON.17-22DOI Listing
February 2021

Aerospace Implications of Key Neurological Conditions.

Aerosp Med Hum Perform 2021 Feb;92(2):113-119

The neurological impact (or lack thereof) of certain medical histories and imaging findings is important to understand in the context of air and spaceflight. There are a number of neurological conditions that, if present in pilots and astronauts, carry variable (and sometimes adverse) functional implications for safety and overall mission success. In this systematic overview, the authors will refer to the relevant clinical and radiological features of brain tumors and vascular anomalies, cerebral edema and intracranial hypertension, concussion and the traumatic brain injury (TBI) spectrum, hematomas, cerebrospinal fluid circulation anomalies including hydrocephalus and sequestrations, spinal degenerative changes, and cerebral ischemia and demyelination. It is notable that these last two conditions have recently been reported to be a complication in some people with coronavirus disease 2019 (COVID-19). A paradigm for practical neurological workup of symptomatic pilots and astronauts will be discussed, as will the controversial notion of pre-emptive radiological screening (vs. not screening) in asymptomatic or clinically occult situations. The concepts of medical surveillance in the setting of known or diagnosed pathologies, and expert panel review and simulator and flight checks in complex neurological cases, are also elaborated on in this paper. We believe this overview will contribute toward the enhancement of a broad understanding of neurological conditions, their clinical workup, and their precautionary management in the setting of aviation and aerospace.
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http://dx.doi.org/10.3357/AMHP.5744.2021DOI Listing
February 2021

Targeting B cells to modify MS, NMOSD, and MOGAD: Part 2.

Neurol Neuroimmunol Neuroinflamm 2021 01 16;8(1). Epub 2020 Dec 16.

From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco.

Ocrelizumab, rituximab, ofatumumab, ublituximab, inebilizumab, and evobrutinib are immunotherapies that target various B cell-related proteins. Most of these treatments have proven efficacy in relapsing and progressive forms of MS and neuromyelitis optica spectrum disease (NMOSD) or are in advanced stages of clinical development. Currently, ocrelizumab and inebilizumab are licensed for treatment of MS and NMOSD, respectively. This part of the review focuses on monoclonal antibody B cell-depleting strategies in NMOSD and the emerging related myelin oligodendrocyte glycoprotein (MOG) immunoglobulin G-associated disease (MOGAD). Case series and phase 2/3 studies in these inflammatory disorders are assessed. The safety profile of long-term B-cell depletion in MS, NMOSD, and MOGAD will be highlighted. Finally implications of the current coronavirus disease 2019 pandemic on the management of patients with these disorders and the use of B cell-depleting agents will be discussed.
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http://dx.doi.org/10.1212/NXI.0000000000000919DOI Listing
January 2021

Targeting B Cells to Modify MS, NMOSD, and MOGAD: Part 1.

Neurol Neuroimmunol Neuroinflamm 2021 01 16;8(1). Epub 2020 Dec 16.

From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich-Heine-University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology (M.B., H.-P.H.), Brain and Mind Centre, Department of Neurology, University of Sydney, New South Wales, Australia; and UCSF Weill Institute of Neurosciences (S.S.Z.), Department of Neurology, University of California at San Francisco.

Ocrelizumab, rituximab, ofatumumab, ublituximab, inebilizumab, and evobrutinib are immunotherapies that target various B cell-related proteins. Most of these treatments have proven efficacy in relapsing and progressive forms of MS and neuromyelitis optica spectrum disease (NMOSD), or are in advanced stages of clinical development. Currently, ocrelizumab, ofatumumab, and inebilizumab are licensed for treatment of MS and NMOSD, respectively. This review focuses on the current state of knowledge about the role of B lymphocytes in immune-mediated pathophysiology and its implications for the mode of action. To understand the significance of this breakthrough in the context of the current MS therapeutic armamentarium, this review more closely examines the clinical development of CD20 depletion and the pioneering contribution of rituximab. Phase 3 and the recently published postmarketing studies will be highlighted to better understand the relevant efficacy data and safety aspects of long-term B-cell depletion.
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http://dx.doi.org/10.1212/NXI.0000000000000918DOI Listing
January 2021

Differentiating axonal loss and demyelination in chronic MS lesions: A novel approach using single streamline diffusivity analysis.

PLoS One 2021 6;16(1):e0244766. Epub 2021 Jan 6.

Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia.

We describe a new single-streamline based approach to analyse diffusivity within chronic MS lesions. We used the proposed method to examine diffusivity profiles in 30 patients with relapsing multiple sclerosis and observed a significant increase of both RD and AD within the lesion core (0.38+/-0.09 μm2/ms and 0.30+/-0.12 μm2/ms respectively, p<0.0001 for both) that gradually and symmetrically diminished away from the lesion. T1-hypointensity derived axonal loss correlated highly with ΔAD (r = 0.82, p<0.0001), but moderately with ΔRD (r = 0.60, p<0.0001). Furthermore, the trendline of the ΔAD vs axonal loss intersected both axes at zero indicating close agreement between two measures in assessing the degree of axonal loss. Conversely, the trendline of the ΔRD function demonstrated a high positive value at the zero level of axonal loss, suggesting that even lesions with preserved axonal content exhibit a significant increase of RD. There was also a significant negative correlation between the level of preferential RD increase (ΔRD-ΔAD) in the lesion core and the degree of axonal damage (r = -0.62, p<0.001), indicating that ΔRD dominates in cases with milder axonal loss. Modelling diffusivity changes in the core of chronic MS lesions based on the direct proportionality of ΔAD with axonal loss and the proposed dual nature of ΔRD yielded results that were strikingly similar to the experimental data. Evaluation of lesions in a sizable cohort of MS patients using the proposed method supports the use of ΔAD as a marker of axonal loss; and the notion that demyelination and axonal loss independently contribute to the increase of RD in chronic MS lesions. The work highlights the importance of selecting appropriate patient cohorts for clinical trials of pro-remyelinating and neuroprotective therapeutics.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244766PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787472PMC
January 2021

Effect of Disease-Modifying Therapy on Disability in Relapsing-Remitting Multiple Sclerosis Over 15 Years.

Neurology 2021 02 28;96(5):e783-e797. Epub 2020 Dec 28.

From CORe (T.K., I.D., S.S., C.M.), Department of Medicine, University of Melbourne; MS Centre (T.K., I.D., S.S., C.M.), Department of Neurology, Royal Melbourne Hospital, Australia; Karolinska Institute (T.S.), Stockholm, Sweden; Department of Neuroscience (T.S., V.J., A.v.d.W., O.S., H.B.), Central Clinical School, Monash University, Melbourne; Burnet Institute (T.S.), Melbourne, Australia; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), General University Hospital and Charles University in Prague, Czech Republic; Department of Basic Medical Sciences, Neuroscience and Sense Organs (M. Trojano), University of Bari, Italy; Hospital Universitario Virgen Macarena (G.I.), Sevilla, Spain; Department of Neuroscience, Imaging and Clinical Sciences (A.L.), University "G. d'Annunzio," Chieti; Department of Biomedical and Neuromotor Sciences (A.L.), University of Bologna, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy; Hopital Notre Dame (A.P., M.G., P.D.), Montreal; CHUM and Universite de Montreal (A.P., M.G., P.D.); CISSS Chaudière-Appalache (P.G.), Levis, Canada; Department of Neurology (V.J., A.v.d.W., O.S., H.B.), Alfred Hospital, Melbourne, Australia; Neuro Rive-Sud (F. Grand'Maison), Quebec, Canada; Department of Neuroscience (P.S., D.F.), Azienda Ospedaliera Universitaria, Modena, Italy; Isfahan University of Medical Sciences (V.S.), Isfahan, Iran; Amiri Hospital (R. Alroughani), Kuwait City, Kuwait; Zuyderland Ziekenhuis (R.H.), Sittard, the Netherlands; Medical Faculty (M. Terzi), 19 Mayis University, Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Karadeniz Technical University, Trabzon, Turkey; School of Medicine and Public Health (J.L.-S.), University Newcastle; Department of Neurology (J.L.-S.), John Hunter Hospital, Newcastle, Australia; UOC Neurologia (E.P.), Azienda Sanitaria Unica Regionale Marche-AV3, Macerata, Italy; Cliniques Universitaires Saint-Luc (V.V.P.), Brussels, Belgium; University of Parma (F. Granella); C. Mondino National Neurological Institute (R.B.), Pavia; Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino (D.S.), Italy; Flinders University (M. Slee), Adelaide; Westmead Hospital (S.V.), Sydney, Australia; Nemocnice Jihlava (R. Ampapa), Czech Republic; University of Queensland (P.M.), Brisbane; Royal Brisbane and Women's Hospital (P.M.), Brisbane, Australia; Hospital Germans Trias i Pujol (C.R.-T.), Badalona, Spain; CSSS Saint-Jérôme (J.P.), Canada; Hospital Universitario Donostia (J.O.), Paseo de Begiristain, San Sebastián, Spain; Hospital Italiano (E.C.), Buenos Aires, Argentina; Brain and Mind Centre (M.B.), University of Sydney, Australia; INEBA-Institute of Neuroscience Buenos Aires (M.L.S.), Argentina; Hospital de Galdakao-Usansolo (J.L.S.-M.), Galdakao, Spain; Liverpool Hospital (S. Hodgkinson), Sydney, Australia; Jahn Ferenc Teaching Hospital (C.R.), Budapest, Hungary; Craigavon Area Hospital (S. Hughes), UK; Jewish General Hospital (F.M.), Montreal, Canada; Deakin University (C.S.), Geelong; Monash Medical Centre (E.B.), Melbourne, Australia; South East Trust (O.G.), Belfast, UK; Perron Institute (A.K.), University of Western Australia, Nedlands; Institute of Immunology and Infectious Diseases (A.K.), Murdoch University; Sir Charles Gairdner Hospital (A.K.), Perth, Australia; Department of Neurology (T.C.), Faculty of Medicine, University of Debrecen, Hungary; Bombay Hospital Institute of Medical Sciences (B.S.), Mumbai, India; St Vincents Hospital (N.S.), Fitzroy, Melbourne, Australia; Veszprém Megyei Csolnoky Ferenc Kórház zrt (I.P.), Veszprem, Hungary; Royal Hobart Hospital (B.T.), Australia; Semmelweis University Budapest (M. Simo), Hungary; Central Military Emergency University Hospital (C.-A.S.), Bucharest; Titu Maiorescu University (C.-A.S.), Bucharest, Romania; BAZ County Hospital (A.S.), Miskolc, Hungary; and Box Hill Hospital (H.B.), Melbourne, Australia.

Objective: To test the hypothesis that immunotherapy prevents long-term disability in relapsing-remitting multiple sclerosis (MS), we modeled disability outcomes in 14,717 patients.

Methods: We studied patients from MSBase followed for ≥1 year, with ≥3 visits, ≥1 visit per year, and exposed to MS therapy, and a subset of patients with ≥15-year follow-up. Marginal structural models were used to compare the cumulative hazards of 12-month confirmed increase and decrease in disability, Expanded Disability Status Scale (EDSS) step 6, and the incidence of relapses between treated and untreated periods. Marginal structural models were continuously readjusted for patient age, sex, pregnancy, date, disease course, time from first symptom, prior relapse history, disability, and MRI activity.

Results: A total of 14,717 patients were studied. During the treated periods, patients were less likely to experience relapses (hazard ratio 0.60, 95% confidence interval [CI] 0.43-0.82, = 0.0016), worsening of disability (0.56, 0.38-0.82, = 0.0026), and progress to EDSS step 6 (0.33, 0.19-0.59, = 0.00019). Among 1,085 patients with ≥15-year follow-up, the treated patients were less likely to experience relapses (0.59, 0.50-0.70, = 10) and worsening of disability (0.81, 0.67-0.99, = 0.043).

Conclusion: Continued treatment with MS immunotherapies reduces disability accrual by 19%-44% (95% CI 1%-62%), the risk of need of a walking aid by 67% (95% CI 41%-81%), and the frequency of relapses by 40-41% (95% CI 18%-57%) over 15 years. This study provides evidence that disease-modifying therapies are effective in improving disability outcomes in relapsing-remitting MS over the long term.

Classification Of Evidence: This study provides Class IV evidence that, for patients with relapsing-remitting MS, long-term exposure to immunotherapy prevents neurologic disability.
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http://dx.doi.org/10.1212/WNL.0000000000011242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884998PMC
February 2021

Blunted sweating does not alter the rise in core temperature in people with multiple sclerosis exercising in the heat.

Am J Physiol Regul Integr Comp Physiol 2021 03 9;320(3):R258-R267. Epub 2020 Dec 9.

Thermal Ergonomics Laboratory, Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.

The purpose of this study is to determine whether thermoregulatory capacity is altered by multiple sclerosis (MS) during exercise in the heat. Sixteen MS participants (EDSS: 2.9 ± 0.9; 47 ± 8 yr; 77.6 ± 14.0 kg) and 14 healthy control (CON) participants (43 ± 11 yr; 78.6 ± 17.0 kg) cycled at a heat production of 4 W·kg for 60 min at 30°C, 30% relative humidity (RH) (Warm). A subset of eight MS (EDSS: 2.6 ± 0.5; 44 ± 8 yr; 82.3 ± 18.2 kg) and 8 CON (44 ± 12 yr; 81.2 ± 21.1 kg) also exercised at 35°C, 30% RH (Hot). Rectal temperature (T), mean skin (T) temperature, and local sweat rate (LSR) on the upper back (LSR) and forearm (LSR) were measured. All CON, and only 9 of 16 and 7 of 8 MS participants completed 60 min of exercise in Warm and Hot trials, respectively. All MS participants who were unable to complete exercise stopped with a ΔT between 0.2 and 0.5°C. The time to reach a ΔT of 0.2°C was similar (MS: 28 ± 15 min, CON: 32 ± 18 min; = 0.51). For MS participants, completing 60-min of exercise in Warm, ΔT ( = 0.13), ΔT ( = 0.45), LSR ( = 0.69), and LSR ( = 0.54) was similar to CON, but ΔT (body temperature) (MS: 0.16 ± 0.13°C, CON: 0.07 ± 0.06°C; = 0.02) and onset time (MS: 16 ± 10 min, CON: 8 ± 5 min; = 0.02) for sweating were greater in MS. Similarly, in Hot, ΔT ( = 0.52), ΔT ( = 0.06), LSR ( = 0.59), and LSR ( = 0.08) were similar, but ΔT (MS: 0.19 ± 0.16°C, CON: 0.06 ± 0.04°C; = 0.04) and onset time (MS: 13 ± 7 min, CON: 6 ± 3 min; = 0.02) for sweating were greater in MS. Even at 35°C, a delayed sweating onset did not alter heat loss to sufficiently affect exercise-induced rises in core temperature. Heat intolerance with MS does not seem attributable to thermoregulatory impairments.
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http://dx.doi.org/10.1152/ajpregu.00090.2020DOI Listing
March 2021

Overlapping central and peripheral nervous system syndromes in MOG antibody-associated disorders.

Neurol Neuroimmunol Neuroinflamm 2021 01 3;8(1). Epub 2020 Dec 3.

From the Inflammatory Neuropathy Group (S. Rinaldi, A.D., J.F.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital; University of Oxford; Department of Neurology (S. Rinaldi, S.R.I.), Oxford University Hospitals NHS Foundation Trust, UK; Department of Neurology (H.N.B., M.H.B.), Royal Prince Alfred Hospital, Sydney; Brain and Mind Centre (H.N.B., T.A.H., M.H.B., S.W.R., F.B., R.C.D.), University of Sydney; Department of Neurology (J.W.), St George Hospital, Sydney; Department of Neurology (T.A.H., S.W.R., S. Ramanathan), Concord Repatriation General Hospital, Sydney; Menzies Institute of Health Queensland (S.A.B.), Griffith University; Department of Neurology (S.A.B.), Gold Coast University Hospital, Australia; Autoimmune Neurology Group (P.W., S.R.I., S. Ramanathan), Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital; University of Oxford, UK; Brain Autoimmunity and Clinical Neuroimmunology Groups (F.B., R.C.D., S. Ramanathan), Kids Neuroscience Centre, Kids Research at the Children's Hospital at Westmead, Sydney; Faculty of Medicine and Health (F.B., R.C.D., S. Ramanathan), University of Sydney; School of Medical Sciences (F.B.), Discipline of Applied Medical Science, Faculty of Medicine and Health, University of Sydney, Australia; and TY Nelson Department of Paediatric Neurology (R.C.D.), Children's Hospital at Westmead, Sydney, Australia.

Objective: Antibodies to myelin oligodendrocyte glycoprotein (MOG) are associated with CNS demyelination inclusive of optic neuritis (ON) and transverse myelitis (TM). To examine whether peripheral nervous system (PNS) involvement is associated with MOG antibody-associated disorders (MOGAD), we performed detailed characterization of an Australasian MOGAD cohort.

Methods: Using a live cell-based assay, we diagnosed 271 adults with MOGAD (2013-2018) and performed detailed clinical and immunologic characterization on those with likely PNS involvement.

Results: We identified 19 adults with MOGAD and PNS involvement without prior TM. All patients had CNS involvement including ON (bilateral [n = 3], unilateral [n = 3], and recurrent [n = 7]), a cortical lesion (n = 1), meningoencephalitis (n = 1), and subsequent TM (n = 4). Clinical phenotyping and neurophysiology were consistent with acute inflammatory demyelinating polyneuropathy (n = 1), myeloradiculitis (n = 3), multifocal motor neuropathy (n = 1), brachial neuritis (n = 2), migrant sensory neuritis (n = 3), and paresthesia and/or radicular limb pain (n = 10). Onset MRI spine was consistent with myeloradiculitis with nerve root enhancement in 3/19 and normal in 16/19. Immunotherapy resulted in partial/complete PNS symptom resolution in 12/15 (80%) (steroids and/or IV immunoglobulin n = 9, rituximab n = 2, and plasmapheresis n = 1). We identified serum antibodies targeting neurofascin 155, contactin-associated protein 2, or GM1 in 4/16 patients with MOGAD PNS compared with 0/30 controls ( = 0.01). There was no binding to novel cell surface antigens using an in vitro myelinating sensory neuronal coculture model.

Conclusions: Myeloradiculitis, combined central and peripheral demyelination syndromes, and inflammatory neuropathies may be associated with MOGAD and may be immunotherapy responsive. We identified a subgroup who may have pathology mediated by coexistent autoantibodies.
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http://dx.doi.org/10.1212/NXI.0000000000000924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803332PMC
January 2021

Latency of Multifocal Visual Evoked Potential in Multiple Sclerosis: A Visual Pathway Biomarker for Clinical Trials of Remyelinating Therapies.

J Clin Neurophysiol 2020 Nov 20. Epub 2020 Nov 20.

Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.

Purpose: Acute focal demyelination is the characteristic feature of multiple sclerosis, with the majority of damaged axons undergoing limited remyelination and forming chronic lesions. Potential remyelinating agents are currently under development and there is therefore an urgent need for reliable in vivo biomarkers of remyelination. This study aimed to investigate potential changes in multifocal visual evoked potentials' (mfVEPs) latency in a cohort of relapsing-remitting multiple sclerosis (RRMS) patients. The potential sample size required for a remyelination-based clinical trial using different treatment effect sizes and the mfVEP latency as an outcome measure was also estimated.

Methods: A total of 50 RRMS consecutive patients with no previous history of optic neuritis in at least one eye and 15 normal controls of similar age and gender composition were prospectively enrolled. Fifteen patients had a history of unilateral ON more than 12 months earlier, whereas 41 patients demonstrated optic radiations lesions on MRI at baseline. Most patients were on disease modifying therapy. A mfVEP was recorded at baseline and 12 months later.

Results: At baseline, the mfVEP latency in RRMS patients was delayed compared with normal controls in both optic neuritis and nonoptic neuritis eyes. Latency delay was significantly correlated to optic radiation lesion volume (R = 0.38, P < 0.001). There was no significant latency change in multiple sclerosis patients' eyes or optic neuritis and nonoptic neuritis eyes over the follow-up period with latency remaining remarkably constant. This was despite the fact that 46 of 50 patients were on disease-modifying therapies, implying current treatments do not affect myelination in chronic RRMS cases. Sample size calculations to evaluate an additional or alternative remyelinating agent, based on a 40% treatment effect, revealed that a relatively small sample size (78 patients) would be required to demonstrate efficacy in future trials of remyelination therapies.

Conclusions: Given its known sensitivity for latency changes and the stability found in this RRMS population, the mfVEP represents an ideal biomarker to assess the degree of latency recovery that may be achieved by remyelination in multiple sclerosis.
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http://dx.doi.org/10.1097/WNP.0000000000000757DOI Listing
November 2020

Expansion of chronic lesions is linked to disease progression in relapsing-remitting multiple sclerosis patients.

Mult Scler 2020 Nov 20:1352458520974357. Epub 2020 Nov 20.

Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia/Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.

Background: Slow-burning inflammation is putatively associated with lesion expansion and leads to progressive loss of axons and disability worsening.

Objective: To investigate the incidence and extent of chronic white matter lesion expansion in relapsing-remitting multiple sclerosis (RRMS) patients and to evaluate its relationship with biomarkers of disease progression.

Methods: Pre- and post-gadolinium T1, fluid-attenuated inversion recovery (FLAIR) and diffusion tensor images were acquired from 33 patients. Lesional activity were analysed between baseline and 48 months using custom-designed software.

Results: A total of 569 lesions were identified as chronic at baseline, of which 261 were expanding, 236 were stable and 72 were shrinking. In addition, 139 new lesions (both confluent and free-standing) were observed. Chronic lesion expansion was associated with patient's age and accounted for the bulk (67.3%) of total brain lesion volume increase, while only 32.7% was attributable to new lesion formation. Change in chronic lesion volume correlated with the rate of brain atrophy ( = -0.57,  = 0.001), change of Expanded Disability Status Scale (EDSS;  = 0.38,  = 0.03) and an increase of isotropic diffusivity inside the lesions ( = 0.75,  < 0.001).

Conclusion: Expansion of chronic lesions in RRMS patients is the primary determinant of increased T2 total lesion load. It significantly contributes to disease progression and partially driving axonal loss inside the lesions and brain damage outside of lesional tissue.
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http://dx.doi.org/10.1177/1352458520974357DOI Listing
November 2020

Neurological manifestations of severe acute respiratory syndrome coronavirus 2-a controversy 'gone viral'.

Brain Commun 2020 17;2(2):fcaa149. Epub 2020 Sep 17.

Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany.

Severe acute respiratory syndrome coronavirus 2 first appeared in December 2019 in Wuhan, China, and developed into a worldwide pandemic within the following 3 months causing severe bilateral pneumonia (coronavirus disease 2019) with in part fatal outcomes. After first experiences and tentative strategies to face this new disease, several cases were published describing severe acute respiratory syndrome coronavirus 2 infection related to the onset of neurological complaints and diseases such as, for instance, anosmia, stroke or meningoencephalitis. Of note, there is still a controversy about whether or not there is a causative relation between severe acute respiratory syndrome coronavirus 2 and these neurological conditions. Other concerns, however, seem to be relevant as well. This includes not only the reluctance of patients with acute neurological complaints to report to the emergency department for fear of contracting severe acute respiratory syndrome coronavirus 2 but also the ethical and practical implications for neurology patients in everyday clinical routine. This paper aims to provide an overview of the currently available evidence for the occurrence of severe acute respiratory syndrome coronavirus 2 in the central and peripheral nervous system and the neurological diseases potentially involving this virus.
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http://dx.doi.org/10.1093/braincomms/fcaa149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543269PMC
September 2020

Changes in Health Care Use and Outcomes After Turnover in Primary Care.

JAMA Intern Med 2021 Feb;181(2):186-194

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Disruptions of continuity of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors.

Objectives: To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes.

Design, Setting, And Participants: This cohort study used nationally representative Medicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017.

Exposure: Patients' loss of a PCP.

Main Outcomes And Measures: Primary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined.

Results: During the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, -19.8% to -16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending ($189 [95% CI, $30-$347]) per beneficiary-year after PCP exit. These shifts were most pronounced for patients of exiting PCPs in solo practice, whose beneficiaries had 21.5% (95% CI, -23.8% to -19.3%) fewer primary care visits, 8.8% (95% CI, 7.6%-10.0%) more specialty care visits, 4.4% more emergency department visits (95% CI, 2.1%-6.7%), and $260 (95% CI, $12-$509) in increased spending.

Conclusions And Relevance: Loss of a PCP was associated with lower use of primary care and increased use of specialty, urgent, and emergency care among Medicare beneficiaries. Interrupting primary care relationships may negatively impact health outcomes and future engagement with primary care.
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http://dx.doi.org/10.1001/jamainternmed.2020.6288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670398PMC
February 2021

Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US.

JAMA Intern Med 2021 03;181(3):388-391

Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.5928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670397PMC
March 2021

Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery.

JAMA 2020 11;324(18):1869-1877

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model.

Objective: To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).

Design, Setting, And Participants: Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics.

Exposures: Admission to a BPCI model 3-participating SNF.

Main Outcomes And Measures: The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission.

Results: There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions.

Conclusions And Relevance: Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.
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http://dx.doi.org/10.1001/jama.2020.19181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656279PMC
November 2020

Classifying Electronic Consults for Triage Status and Question Type.

Proc Conf Assoc Comput Linguist Meet 2020 Jul;2020:1-6

Boston Children's Hospital, Boston, MA.

Electronic consult (eConsult) systems allow specialists more flexibility to respond to referrals more efficiently, thereby increasing access in under-resourced healthcare settings like safety net systems. Understanding the usage patterns of eConsult system is an important part of improving specialist efficiency. In this work, we develop and apply classifiers to a dataset of eConsult questions from primary care providers to specialists, classifying the messages for how they were triaged by the specialist office, and the underlying type of clinical question posed by the primary care provider. We show that pre-trained transformer models are strong baselines, with improving performance from domain-specific training and shared representations.
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http://dx.doi.org/10.18653/v1/2020.nlpmc-1.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603636PMC
July 2020

COVID-19 Test Result Turnaround Time for Residents and Staff in US Nursing Homes.

JAMA Intern Med 2021 04;181(4):556-559

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.7330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600050PMC
April 2021