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Figure.  COVID-19 Cases by Day in Washtenaw, Wayne, and Livingston Counties, Michigan, and Cumulative Ambulatory Infusions
COVID-19 Cases by Day in Washtenaw, Wayne, and Livingston Counties, Michigan, and Cumulative Ambulatory Infusions

Data taken from the state of Michigan database on COVID-19.6

Table.  Demographics and Clinical Outcomes of Patients Administered Home Infusion of Monoclonal Antibodies
Demographics and Clinical Outcomes of Patients Administered Home Infusion of Monoclonal Antibodies
1.
Centers for Disease Control and Prevention COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. Updated September 10, 2021. Accessed June 9, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
2.
Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Updated September 3, 2021. Accessed June 9, 2021. https://www.covid19treatmentguidelines.nih.gov/
3.
Bhimraj  A, Morgan  RL, Shumaker  AH, Lavergne  V, Baden  L, Cheng  VC, Edwards  KM, Gandhi  R, Gallagher  J, Muller  WJ, O'Horo  JC, Shoham  S, Murad  MH, Mustafa  RA, Sultan  S, Falck-Ytter  Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19—Version 4.3.0. Infectious Diseases Society of America. Updated September 3, 2021. Accessed June 9, 2021. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
4.
Khaldun  J. Expanded Use of Monoclonal Antibody Therapy for High-Risk COVID-19 Patients. Michigan Department of Health and Human Services weekly e-newsletter. April 29, 2021. Accessed June 1, 2021.
5.
Centers for Medicare & Medicaid Services. Monoclonal Antibody COVID-19 Infusion. Updated September 13, 2021. Accessed June 9, 2021. https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion
6.
Michigan.gov. Coronavirus Michigan Data. Updated September 13, 2021. Accessed June 1, 2021. https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173---,00.html
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    Research Letter
    Infectious Diseases
    October 14, 2021

    Administration of Monoclonal Antibody for COVID-19 in Patient Homes

    Author Affiliations
    • 1Department of Medicine, Section of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, Michigan
    • 2Department of Infection Prevention and Control, St Joseph Mercy Hospital, Ann Arbor, Michigan
    • 3Department of Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
    • 4Huron Valley Ambulance, Ann Arbor, Michigan
    • 5Department of Emergency Medicine, St Joseph Mercy Hospital, Ann Arbor, Michigan
    • 6Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, Michigan
    JAMA Netw Open. 2021;4(10):e2129388. doi:10.1001/jamanetworkopen.2021.29388
    Introduction

    The COVID-19 pandemic has currently infected over 33 million people in the US, and over 2.2 million of those infected with the virus have been hospitalized.1 One important tool available for treatment of COVID-19 is neutralizing monoclonal antibodies (MAB). Bamlanivimab (LY-CoV555, Eli Lilly and Company), etesevimab (LY-CoV016, Eli Lilly and Company), and casirivimab/imdevimab (REGN-COV2, Regeneron Pharmaceuticals) were released through emergency use authorization (EUA) by the US Food and Drug Administration.2,3 MABs are recommended by both the National Institutes of Health and the Infectious Diseases Society of America for treatment of COVID-19 in ambulatory patients with mild or moderate COVID-19 with high risk for clinical progression.2,3

    Following the EUA, several factors created implementation challenges for health systems. These included the administration location, infection control considerations, patient identification and enrollment processes, and workforce and resource considerations in facilities already responding to the winter surge of COVID-19. The approach for MAB administration has varied and is often facility specific. Strategies used have included administration in outpatient infusion centers and emergency departments (ED). During the recent spring surge of 2021, the Michigan Department of Human and Health Services reported that up to 30% of patients testing positive for COVID-19 may qualify for MAB and provided a goal that at least 50% of qualifying patients receive MAB.4 Descriptions of novel approaches to promote MAB administration are needed. One strategy implemented by our health system is partnership with community integrated paramedics (CIP) to promote home MAB administration. This cohort study describes our experience and how this strategy may factor into associated outcomes.

    Methods

    From February to May 2021, a team of 3 nurses (B.L., R.V., and R.F.) reviewed new COVID-19–positive polymerase chain reaction tests and clinician referrals from multiple hospitals within the St Joseph Mercy Health System to assess EUA eligibility for MAB administration.2,3 The team contacted and obtained consent from eligible patients and worked with CIP to schedule home infusions. Nursing costs were $1250 weekly as they collectively worked approximately 25 hours per week at approximately $50 per hour. CIP obtained MAB and infusion supplies from the health system. The Michigan Department of Human and Health Services provided MAB for the health system at no cost. Standardized paramedicine protocols were developed for administration, and a medical director provided clinical support and expertise. The Centers for Medicare and Medicaid Services provided reimbursement for MAB administration for patients insured by Medicare at $310 per infusion, increasing to $750 per infusion in early May.5 The health system provided reimbursement to CIP for administration to patients without Medicare at the initial Medicare reimbursement rate, including patients without insurance. Patient demographic and clinical information was abstracted from electronic health records. Race and ethnicity and sex were defined by participant reporting in the health records. A 14-day follow-up period assessed outcomes following infusion.

    This study was prepared in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. This study was approved by the St Joseph Mercy Hospital institutional review board and determined to be exempt from patient consent with a waiver of HIPAA authorization. Data were analyzed using Microsoft Excel 365 version 2002 (Microsoft Corporation) and SPSS version 26 (IBM Corporation).

    Results

    Among 144 patients administered MAB in the home (Figure), 83 (57.6%) were women and 125 (86.8%) were White individuals. The mean (SD) age was 60.1 (14.2) years (Table). Twenty patients (13.9%) were part of households where multiple members received infusions. Eight patients (5.6%) were hospitalized following home infusion because of worsening COVID-19 symptoms for a mean (SD) length of stay of 3.3 (2.2) days. None required intubation and all were successfully discharged. One patient (0.7%) developed a hypersensitivity reaction requiring hospitalization and 2 patients (1.4%) required an ED visit for hypersensitivity reactions without admission.

    Discussion

    During our recent COVID-19 surge in Michigan, home MAB infusion provided a critical framework to prevent high-risk patients from seeking ED care and requiring hospitalization. We provided MAB infusion to 144 patients, both insured and uninsured, in a successful partnership between the health system and CIP. Limitations included the inability to track the total number of eligible patients for MAB and outcomes for patients who refused treatment. At a time when physical and health care worker resources were significantly strained, our real-world approach leveraged the ability of nurses to identify, triage, and coordinate home MAB infusions while successfully preventing high risk patients from progression to severe disease and hospitalization.

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    Article Information

    Accepted for Publication: August 11, 2021.

    Published: October 14, 2021. doi:10.1001/jamanetworkopen.2021.29388

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Malani AN et al. JAMA Network Open.

    Corresponding Author: Anurag N. Malani, MD, 5333 McAuley Dr, Ste 6007, Ypsilanti, MI 48197 (Anurag.Malani@stjoeshealth.org).

    Author Contributions: Drs Malani and Collins had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Malani, LaVasseur, Fair, Collins.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Malani, LaVasseur, Fowler, Collins.

    Critical revision of the manuscript for important intellectual content: Malani, LaVasseur, Fair, Domeier, Vershum, Collins.

    Statistical analysis: Malani, Vershum, Collins.

    Administrative, technical, or material support: Malani, LaVasseur, Fair, Domeier, Vershum, Fowler.

    Supervision: Malani, LaVasseur, Domeier.

    Conflict of Interest Disclosures: Dr Collins reported receiving consulting fees from the American Society of Health-System Pharmacists outside the submitted work. No other disclosures were reported.

    Additional Contributions: The authors thank Rana Craft, PharmD (St Joseph Mercy Ann Arbor), Stephanie Couch (St Joseph Mercy Ann Arbor), and Amy Chapman (Livingston Emergency Medical Services) for assistance with implementation of our home MAB infusion program. No additional compensation was provided beyond the terms of employment.

    References
    1.
    Centers for Disease Control and Prevention COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. Updated September 10, 2021. Accessed June 9, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
    2.
    Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Updated September 3, 2021. Accessed June 9, 2021. https://www.covid19treatmentguidelines.nih.gov/
    3.
    Bhimraj  A, Morgan  RL, Shumaker  AH, Lavergne  V, Baden  L, Cheng  VC, Edwards  KM, Gandhi  R, Gallagher  J, Muller  WJ, O'Horo  JC, Shoham  S, Murad  MH, Mustafa  RA, Sultan  S, Falck-Ytter  Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19—Version 4.3.0. Infectious Diseases Society of America. Updated September 3, 2021. Accessed June 9, 2021. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
    4.
    Khaldun  J. Expanded Use of Monoclonal Antibody Therapy for High-Risk COVID-19 Patients. Michigan Department of Health and Human Services weekly e-newsletter. April 29, 2021. Accessed June 1, 2021.
    5.
    Centers for Medicare & Medicaid Services. Monoclonal Antibody COVID-19 Infusion. Updated September 13, 2021. Accessed June 9, 2021. https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion
    6.
    Michigan.gov. Coronavirus Michigan Data. Updated September 13, 2021. Accessed June 1, 2021. https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173---,00.html
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