Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns - United States, June 2020

Impact of COVID-19-related experiences on health-related quality of life in cancer survivors in the United States

OBJECTIVE

Little evidence exists on the impact of the COVID-19 pandemic on cancer survivors, limiting recommendations to improve health-related quality of life (HRQoL) in this population. We describe survivors' pandemic experiences and examine associations between COVID-19-related exposures, psychosocial experiences, and HRQoL.

METHODS

Between May 2020-April 2021, survivors completed cross-sectional questionnaires capturing COVID-19-related exposures (e.g., exposure to virus, job loss); psychosocial experiences (i.e., COVID-19-related anxiety/depression, disruptions to health care and daily activities/social interactions, satisfaction with providers' response to COVID, financial hardship, perceived benefits of the pandemic, social support, and perceived stress management ability); and HRQoL.

RESULTS

Data were collected from N = 11,325 survivors in the United States. Participants were mostly female (58%), White (89%) and non-Hispanic (88%), and age 63 on average. Breast cancer was the most common diagnosis (23%). Eight percent of participants reported being exposed to COVID-19; 1% tested positive. About 6% of participants lost their jobs, while 24% lost household income. Nearly 30% avoided attending in-person oncology appointments because of the pandemic. Poorer HRQoL was associated with demographic (younger age; female; non-Hispanic White), clinical (Medicare; stage IV disease; hematologic/digestive/respiratory system cancer), and psychosocial factors (low perceived benefits and stress management ability; more disruption to health care and daily activities/social interactions; financial hardship).

CONCLUSIONS

COVID-19-related stressors were associated with various psychosocial experiences in cancer survivors, and these psychosocial experiences were associated with HRQoL above and beyond demographic and clinical factors.

Sampling of healthcare professionals' perspective on point-of-care technologies from 2019-2021: A survey of benefits, concerns, and development

Point-of-care technology (POCT) plays a vital role in modern healthcare by providing a fast diagnosis, improving patient management, and extending healthcare access to remote and resource-limited areas. The objective of this study was to understand how healthcare professionals in the United States perceived POCTs during 2019-2021 to assess the decision-making process of implementing these newer technologies into everyday practice. A 5-point Likert scale survey was sent to respondents to evaluate their perceptions of benefits, concerns, characteristics, and development of point-of-care technologies. The 2021 survey was distributed November 1st, 2021- February 15th, 2022, with a total of 168 independent survey responses received. Of the respondents, 59% identified as male, 73% were white, and 48% have been in practice for over 20 years. The results showed that most agreed that POCTs improve patient management (94%) and improve clinician confidence in decision making (92%). Healthcare professionals were most concerned with potentially not being reimbursed for the cost of the POCT (37%). When asked to rank the top 3 important characteristics of POCT, respondents chose accuracy, ease of use, and availability. It is important to note this survey was conducted during the COVID-19 pandemic. To achieve an even greater representation of healthcare professionals' point of view on POCTs, further work to obtain responses from a larger, more diverse population of providers is needed.

Survival Among Patients With High-Risk Gastrointestinal Cancers During the COVID-19 Pandemic

Importance

Prior reports demonstrated that patients with cancer experienced worse outcomes from pandemic-related stressors and COVID-19 infection. Patients with certain malignant neoplasms, such as high-risk gastrointestinal (HRGI) cancers, may have been particularly affected.

Objective

To evaluate disruptions in care and outcomes among patients with HRGI cancers during the COVID-19 pandemic, assessing for signs of long-term changes in populations and survival.

Design, Setting, and Participants

This retrospective cohort study used data from the National Cancer Database to identify patients with HRGI cancer (esophageal, gastric, primary liver, or pancreatic) diagnosed between January 1, 2018, and December 31, 2020. Data were analyzed between August 23 and September 4, 2023.

Main Outcome and Measures

Trends in monthly new cases and proportions by stage in 2020 were compared with the prior 2 years. Kaplan-Meier curves and Cox regression were used to assess 1-year mortality in 2020 compared with 2018 to 2019. Proportional monthly trends and multivariable logistic regression were used to evaluate 30-day and 90-day mortality in 2020 compared with prior years.

Results

Of the 156 937 patients included in this study, 54 994 (35.0%) were aged 60 to 69 years and 100 050 (63.8%) were men. There was a substantial decrease in newly diagnosed HRGI cancers in March to May 2020, which returned to prepandemic levels by July 2020. For stage, there was a proportional decrease in the diagnosis of stage I (-3.9%) and stage II (-2.3%) disease, with an increase in stage IV disease (7.1%) during the early months of the pandemic. Despite a slight decrease in 1-year survival rates in 2020 (50.7% in 2018 and 2019 vs 47.4% in 2020), survival curves remained unchanged between years (all P > .05). After adjusting for confounders, diagnosis in 2020 was not associated with increased 1-year mortality compared with 2018 to 2019 (hazard ratio, 0.99; 95% CI, 0.97-1.01). The rates of 30-day (2.1% in 2018, 2.0% in 2019, and 2.1% in 2020) and 90-day (4.3% in 2018, 4.4% in 2019, and 4.6% in 2020) operative mortality also remained similar.

Conclusions and Relevance

In this retrospective cohort study, a period of underdiagnosis and increase in stage IV disease was observed for HRGI cancers during the pandemic; however, there was no change in 1-year survival or operative mortality. These results demonstrate the risks associated with gaps in care and the tremendous efforts of the cancer community to ensure quality care delivery during the pandemic. Future research should investigate long-term survival changes among all cancer types as additional follow-up data are accrued.

Mortality for Time-Sensitive Conditions at Urban vs Rural Hospitals During the COVID-19 Pandemic

Importance

COVID-19 pandemic-related disruptions to the health care system may have resulted in increased mortality for patients with time-sensitive conditions.

Objective

To examine whether in-hospital mortality in hospitalizations not related to COVID-19 (non-COVID-19 stays) for time-sensitive conditions changed during the pandemic and how it varied by hospital urban vs rural location.

Design, Setting, and Participants

This cohort study was an interrupted time-series analysis to assess in-hospital mortality during the COVID-19 pandemic (March 8, 2020, to December 31, 2021) compared with the prepandemic period (January 1, 2017, to March 7, 2020) overall, by month, and by community COVID-19 transmission level for adult discharges from 3813 US hospitals in the State Inpatient Databases for the Healthcare Cost and Utilization Project.

Exposure

The COVID-19 pandemic.

Main Outcomes and Measures

The main outcome measure was in-hospital mortality among non-COVID-19 stays for 6 time-sensitive medical conditions: acute myocardial infarction, hip fracture, gastrointestinal hemorrhage, pneumonia, sepsis, and stroke. Entropy weights were used to align patient characteristics in the 2 time periods by age, sex, and comorbidities.

Results

There were 18 601 925 hospitalizations; 50.3% of patients were male, 38.5% were aged 18 to 64 years, 45.0% were aged 65 to 84 years, and 16.4% were 85 years or older for the selected time-sensitive medical conditions from 2017 through 2021. The odds of in-hospital mortality for sepsis increased 27% from the prepandemic to the pandemic periods at urban hospitals (odds ratio [OR], 1.27; 95% CI, 1.25-1.29) and 35% at rural hospitals (OR, 1.35; 95% CI, 1.30-1.40). In-hospital mortality for pneumonia had similar increases at urban (OR, 1.48; 95% CI, 1.42-1.54) and rural (OR, 1.46; 95% CI, 1.36-1.57) hospitals. Increases in mortality for these 2 conditions showed a dose-response association with the community COVID-19 level (low vs high COVID-19 burden) for both rural (sepsis: 22% vs 54%; pneumonia: 30% vs 66%) and urban (sepsis: 16% vs 28%; pneumonia: 34% vs 61%) hospitals. The odds of mortality for acute myocardial infarction increased 9% (OR, 1.09; 95% CI, 1.06-1.12) at urban hospitals and was responsive to the community COVID-19 level. There were significant increases in mortality for hip fracture at rural hospitals (OR, 1.32; 95% CI, 1.14-1.53) and for gastrointestinal hemorrhage at urban hospitals (OR, 1.15; 95% CI, 1.09-1.21). No significant change was found in mortality for stroke overall.

Conclusions and Relevance

In this cohort study, in-hospital mortality for time-sensitive conditions increased during the COVID-19 pandemic. Mobilizing strategies tailored to the different needs of urban and rural hospitals may help reduce the likelihood of excess deaths during future public health crises.

Development of a Follow-Up Measure to Ensure Complete Screening for Colorectal Cancer

Importance

The current quality performance measure for colorectal cancer (CRC) screening is limited to initial screening. Despite low rates, there is no measure for appropriate follow-up with colonoscopy after receipt of an abnormal result of a stool-based screening test (SBT) for CRC. A quality performance measure is needed.

Objective

To develop and test a quality performance measure for follow-up colonoscopy within 6 months of an abnormal result of an SBT for CRC.

Design, Setting, and Participants

This retrospective quality improvement study examined data from January 1, 2016, to December 31, 2020, with 2018 plus 6 months of follow-up as the primary measurement period to verify performance rates, specify a potential measure, and test for validity, reliability, and feasibility. The Optum Labs Data Warehouse (OLDW), a deidentified database of health care claims and clinical data, was accessed. The OLDW contains longitudinal health information on enrollees and patients, representing a diverse mixture of ages and geographic regions across the US. For the database study, adults from 38 health care organizations (HCOs) aged 50 to 75 years who completed an initial CRC SBT with an abnormal result were observed to determine follow-up colonoscopy rates within 6 months. Rates were stratified by race, ethnicity, sex, insurance, and test modality. Three HCOs participated in the feasibility field testing. Data were analyzed from June 1, 2022, to May 31, 2023.

Main Outcome and Measures

The primary outcome consisted of follow-up colonoscopy rates following an abnormal SBT result for CRC. Reliability statistics were also calculated across HCOs, race, ethnicity, and measurement year.

Results

Among 20 581 adults (48.6% men and 51.4% women; 307 [1.5%] Asian, 492 [7.2%] Black, 644 [3.1%] Hispanic, and 17 705 [86.0%] White; mean [SD] age, 63.6 [7.1] years) in 38 health systems, 47.9% had a follow-up colonoscopy following an abnormal SBT result for CRC within 6 months. There was significant variation between HCOs. Notably, significantly fewer Black patients (37.1% [95% CI, 34.6%-39.5%]) and patients with Medicare (49.2% [95% CI, 47.7%-50.6%]) or Medicaid (39.2% [95% CI, 36.3%-42.1%]) insurance received a follow-up colonoscopy. A quality performance measure that tracks rates of follow-up within 6 months of an abnormal SBT result was observed to be feasible, valid, and reliable, with a median reliability statistic between HCOs of 94.5% (range, 74.3%-99.7%).

Conclusions and Relevance

The findings of this observational study of 20 581 adults suggest that a measure of follow-up colonoscopy within defined periods after an abnormal result of an SBT test for CRC is warranted based on low current performance rates and would be feasible to collect by health systems and produce valid, reliable results.

Impact of COVID-19 pandemic on retention in care of native and migrant people with HIV in the ICONA cohort

BACKGROUND

COVID-19 pandemic challenged the UNAIDS 90-90-90 targets. How the COVID-19 pandemic affected HIV retention in care and whether it has disproportionally affected migrant people with HIV (PWH) remained to be investigated.

METHODS

PWH in ICONA Cohort in follow-up in each of the study periods were included: 01/09/2019-29/02/2020 (pandemic period) and 01/03/2018-31/08/2018 (historical period, as a control). Risk of temporary loss to follow-up (LTFU, defined as no data recorded for a person for one year) was analyzed by logistic regression, with migrant status as the main exposure variable. Difference in difference (DID) analysis was applied to evaluate the effect of COVID-19 pandemic in the different risk of LTFU between natives and migrants.

RESULTS

8864 (17.1% migrants) and 8071 (16.8% migrants) PWH constituted the pandemic and the historical period population, respectively. Proportion of PWH defined as LTFU in the pandemic period was 10.5% in native and 19.6% in migrant PWH. After controlling for age, sex and geographical location of enrolling site, risk of temporary LTFU was higher for migrants than native PWH [adjusted odds ratio 1.85 (95%CI 1.54-2.22)] in pandemic period. In PWH contributing to both periods, LTFU was 9.0% (95% CI 8.3-9.8) in natives vs 17.0% (95% CI 14.7-19.4) in migrants during the pandemic. Instead, LTFU was 1.2% (95%CI 0.9, 1.5) in natives vs 2.2% (95% CI 1.3-3.1) in migrants during the historical period, with a resulting DID of 7.0% (95% CI 4.4-9.6).

CONCLUSIONS

A greater proportion of LTFU in migrant PWH was observed in both periods, which remained unaltered over time. Interventions to reduce LTFU of migrants are necessary.

Social participation, positive affect, and negative affect in postoperative patients with hip fractures: A cross-sectional study

This study investigated the social participation, positive affect (PA), and negative affect (NA) of patients with hip fractures after surgery and determined their possible predictive factors. We used a cross-sectional study design to recruit 154 participants with hip fractures post-surgery. Assessment tools included the Barthel Index, the Automatic Thoughts Questionnaire, the Assessment of Life Habits, and the Positive and Negative Affect Schedule. Patients with better functioning in daily living activities experienced more social participation, higher PA, and lower NA. Patients with more positive automatic thoughts experienced more social participation and higher PA. Patients with more negative automatic thoughts experienced more social participation, lower PA, and higher NA. Early rehabilitation and psychosocial interventions should be provided for postoperative hip fracture patients to improve their activities of daily living and emotional well-being.

Impact of COVID-19 pandemic on hemodialysis access thrombosis

BACKGROUND

Delay in care of suspected stenosis or thrombosis can increase the chance of losing a functioning hemodialysis access. Access to care and resources were restricted during the COVID-19 pandemic. To evaluate the impact of the pandemic on arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures we have assessed the number and success of thrombectomies done before and during the COVID-19 pandemic.

METHODS

We examined all AVF and AVG angiograms with and without interventions, including thrombectomies, performed at a single center during April 2017-March 2021 (pre-COVID-19 era) and April 2020-March 2021 (COVID-19 era).

RESULTS

The proportion of procedures that were thrombectomies was higher during the COVID-19 era compared to the pre-COVID-19 era (13.3% vs 8.7%, p = 0.009). The proportion of thrombectomy procedures was higher during COVID-19 for AVF (8.2% vs 3.0%, p < 0.001) but there was no difference for AVG (26.5% vs 27%, p = 0.99). There was a trend toward a higher likelihood of unsuccessful thrombectomy during COVID-19 (33.3% vs 20.4%, p = 0.08).

CONCLUSIONS

More dialysis access thromboses and unsuccessful thrombectomies were noted during the COVID-19 pandemic. This difference could be due to a delay in patients getting procedures to maintain their dialysis accesses.

Myringotomy tube placement: understanding the impact of the coronavirus disease 2019 pandemic

OBJECTIVE

Otolaryngologists perform bilateral myringotomy and tube placement for surgical management for otitis media with effusion. This retrospective study aimed to address the extent to which the coronavirus disease 2019 pandemic and season impact the number of bilateral myringotomy and tube placement procedures performed at a tertiary care centre.

METHODS

A total of 1248 charts of children who underwent bilateral myringotomy and tube placement from January 2018 through February 2021 were reviewed.

RESULTS

The cohort included 41.6 per cent females and 58.4 per cent males, with 63.7 per cent having private insurance. The median age at surgery was 2.6 years. The spring season had the most bilateral myringotomy and tube placement procedures per week. The number of bilateral myringotomy and tube placement procedures performed per week after the onset of the coronavirus disease 2019 pandemic was significantly lower compared to the years prior. There was no difference in number of intra-operative effusions pre-pandemic versus after the pandemic onset.

CONCLUSION

This study sheds light on the impact of the coronavirus disease 2019 pandemic and seasonality on the rates of tympanostomy tube procedures, vital for understanding the temporality of ear infections.

Was there a weekend effect on mortality rates for hospitalized patients with COVID-19 and acute myocardial infarction? Insights from the National Inpatient Sample, 2020

Our study aimed to assess the effect of weekend versus weekday hospital admissions on all-cause mortality in patients with acute myocardial infarction (AMI) and COVID-19 during the COVID-19 pandemic. We analyzed data from the National Inpatient Sample (NIS) 2020, identifying patients with co-existing AMI and COVID-19 admitted on weekdays and weekends. Baseline demographics, comorbidities, and outcomes were assessed. A multivariable regression analysis was conducted, adjusting for confounders to determine the odds of all-cause mortality. Among 74,820 patients, 55,145 (73.7%) were admitted on weekdays, while 19,675 (26.3%) were admitted on weekends. Weekend admissions showed slightly higher proportions of men (61.3% vs. 60%) and whites (56.3% vs. 54.9%) with a median age of 73 years (range: 62-82). The overall all-cause mortality had an odds ratio (OR) of 1.00 (95% CI, 0.92-1.09; P = 0.934). After adjusting for covariates, there was no significant associations between mortality and hospital type (rural: OR = 1.04; 95% CI, 0.78-1.39; P = 0.789; urban teaching: OR = 1.04; 95% CI, 0.94-1.14; P = 0.450) or geographic region (Northeast: OR = 1.16; 95% CI, 0.96-1.39; P = 0.12; Midwest: OR = 0.99; 95% CI, 0.83-1.17; P = 0.871; South: OR = 0.97; 95% CI, 0.85-1.12; P = 0.697; West: OR = 0.94; 95% CI, 0.77-1.15; P = 0.554). There was no significant difference in the rate of all-cause mortality among patients admitted for AMI and COVID-19 between weekdays and weekends.

Changes in cancer incidence rates by stage during the COVID-19 pandemic in the US

The coronavirus disease 2019 (COVID-19) pandemic led to health care disruptions and declines in cancer diagnoses in the United States. However, the impact of the pandemic on cancer incidence rates by stage at diagnosis and race and ethnicity is unknown. This cross-sectional study calculated delay- and age-adjusted incidence rates, stratified by stage at diagnosis and race and ethnicity, and rate ratios (RRs) comparing changes in year-over-year incidence rates (eg, 2020 vs 2019) from 2016 to 2020 for 22 cancer types based on data obtained from the Surveillance, Epidemiology, and End Results 22-registry database. From 2019 to 2020, the incidence of local-stage disease statistically significantly declined for 19 of the 22 cancer types, ranging from 4% (RR = 0.96; 95%CI, 0.93-0.98) for urinary bladder cancer to 18% for colorectal (RR = 0.82; 95%CI, 0.81-0.84) and laryngeal (RR = 0.82; 95%CI, 0.78-0.88) cancers, deviating from pre-COVID stable year-over-year changes. Incidence during the corresponding period also declined for 16 cancer types for regional-stage and six cancer types for distant-stage disease. By race and ethnicity, the decline in local-stage incidence for screening-detectable cancers was generally greater in historically marginalized populations. The decline in cancer incidence rates during the first year of the COVID-19 pandemic occurred mainly for local- and regional-stage diseases across racial and ethnic groups. Whether these declines will lead to increases in advanced-stage disease and mortality rates remain to be investigated with additional data years. Nevertheless, the findings reinforce the importance of strengthening the return to preventive care campaigns and outreach for detecting cancers at early and more treatable stages.

Impact of COVID-19 Pandemic on Health Behaviors and Outcomes by Age Group and Race Ethnicity: Results From Behavioral Risk Factor Surveillance System Data

This study aimed to examine changes in health behaviors and outcomes during early-pandemic (2020) vs pre-pandemic (2019) years by age groups and race/ethnicity. Multivariable logistic regressions were conducted using Behavioral Risk Factor Surveillance System datasets from 2019 (n = 418 268) and 2020 (n = 401 958). All participants reported less likelihood to exercise (aOR, .78; 95% CI: .73-.83) and have poor physical health (aOR, .91; 95% CI: .86-.98) but more likelihood to have excellent general health (aOR, 1.33; 1.17-1.53) during 2020 vs 2019. Compared to 2019, during 2020 (i) Blacks were more likely to exercise (aOR, 1.24; 95% CI: 1.02-1.51) and have excellent general health (aOR, 1.69; 95% CI: 1.13-2.54); (ii) Hispanics were less likely to exercise (aOR, .80; 95% CI: .74-.88), but more likely to have excellent general health (aOR, 2.44; 95% CI: 1.79-3.33) and mental health (aOR, 1.41; 95% CI: 1.15-1.72); and (iii) Whites were less likely to exercise (aOR, .58; 95% CI: .50-.67) and have good physical health (aOR, 0.89; 95% CI: .82-.95). All age groups, except 18-24 years, were less likely to exercise by 18%-39% during 2020 vs 2019. Furthermore, the 55-64 years age-group was 36% more likely to report excellent general health but 14% less likely to have good physical health. Identifying the most vulnerable racial/ethnic and age groups is pivotal to prioritizing public health resources and interventions to mitigate the impact of health crises.

Inequalities in healthcare use during the COVID-19 pandemic

The COVID-19 pandemic led to reductions in non-COVID related healthcare use, but little is known whether this burden is shared equally. This study investigates whether reductions in administered care disproportionately affected certain sociodemographic strata, in particular marginalised groups. Using detailed medical claims data from the Dutch universal health care system and rich full population registry data, we predict expected healthcare use based on pre-pandemic trends (2017 - Feb 2020) and compare these expectations with observed healthcare use in 2020 and 2021. Our findings reveal a 10% decline in the number of weekly treated patients in 2020 and a 3% decline in 2021 relative to prior years. These declines are unequally distributed and are more pronounced for individuals below the poverty line, females, older people, and individuals with a migrant background, particularly during the initial wave of COVID-19 hospitalisations and for middle and low urgency procedures. While reductions in non-COVID related healthcare decreased following the initial shock of the pandemic, inequalities persist throughout 2020 and 2021. Our results demonstrate that the pandemic has not only had an unequal toll in terms of the direct health burden of the pandemic, but has also had a differential impact on the use of non-COVID healthcare.

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel-Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59-80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p < 0.001, and 31.9% vs. 24.1%, p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6-3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups.

Validation of phenomenon and cross-sectional investigation of predictors for a post-COVID-19 surge of osteoporosis outpatients in China

An unexpected surge of osteoporosis outpatients occurred after COVID-19 lockdown was lifted in China. To confirm the observation and identify possible reasons driving patients care seeking behaviors post-pandemic, we compared the outpatient volumes at the osteoporosis clinic in January through May, 2019-2022 and surveyed seven osteoporosis specialists across China to validate the phenomenon before devising an online questionnaire to collect patients' characters and physical activity levels. Univariate and binary logistic regression analyses were calculated to identify predictors of post-lockdown care-seeking. We received 480 valid responses, including 397 (82.7%) patients having visited the clinic after lockdown and 83 (17.3%) having not. Four significant predictors were identified, including being female, experiencing pain, aggravating symptoms, and heightened anxiety during lockdown (P < 0.05). Both groups experienced lower physical activity levels during lockdown, which however was not a significant predictor (P = 0.317). The surge in osteoporosis outpatient visits after COVID-19 lockdown suggests vast latent demand for osteoporosis care accumulated during the pandemic. Four significant factors predict post-lockdown outpatient care-seeking, including being female, experiencing pain and aggravating symptoms, and heightened anxiety levels. Though physical activity levels decreased during lockdown, it failed to predict care-seeking. This demonstrates resilience of osteoporosis patients to resume regular care despite disruption and stress the substantial backlog of unmet healthcare needs.

The Effect of the COVID-19 Pandemic on Non-COVID-19 Deaths: Population-Wide Retrospective Cohort Study

BACKGROUND

Health care avoidance in the COVID-19 pandemic has been widely reported. Yet few studies have investigated the dynamics of hospital avoidance behavior during pandemic waves and inferred its impact on excess non-COVID-19 deaths.

OBJECTIVE

This study aimed to measure the impact of hospital avoidance on excess non-COVID-19 deaths in public hospitals in Hong Kong.

METHODS

This was a retrospective cohort study involving 11,966,786 patients examined between January 1, 2016, and December 31, 2021, in Hong Kong. All data were linked to service, treatment, and outcomes. To estimate excess mortality, the 2-stage least squares method was used with daily tallies of emergency department (ED) visits and 28-day mortality. Records for older people were categorized by long-term care (LTC) home status, and comorbidities were used to explain the demographic and clinical attributes of excess 28-day mortality. The primary outcome was actual excess death in 2020 and 2021. The 2-stage least squares method was used to estimate the daily excess 28-day mortality by daily reduced visits.

RESULTS

Compared with the prepandemic (2016-2019) average, there was a reduction in total ED visits in 2020 of 25.4% (548,116/2,142,609). During the same period, the 28-day mortality of non-COVID-19 ED deaths increased by 7.82% (2689/34,370) compared with 2016-2019. The actual excess deaths in 2020 and 2021 were 3143 and 4013, respectively. The estimated total excess non-COVID-19 28-day deaths among older people in 2020 to 2021 were 1958 (95% CI 1100-2820; no time lag). Deaths on arrival (DOAs) or deaths before arrival (DBAs) increased by 33.6% (1457/4336) in 2020, while non-DOA/DBAs increased only by a moderate 4.97% (1202/24,204). In both types of deaths, the increases were higher during wave periods than in nonwave periods. Moreover, non-LTC patients saw a greater reduction in ED visits than LTC patients across all waves, by more than 10% (non-LTC: 93,896/363,879, 25.8%; LTC: 7,956/67,090, 11.9%). Most of the comorbidity subsets demonstrated an annualized reduction in visits in 2020. Renal diseases and severe liver diseases saw notable increases in deaths.

CONCLUSIONS

We demonstrated a statistical method to estimate hospital avoidance behavior during a pandemic and quantified the consequent excess 28-day mortality with a focus on older people, who had high frequencies of ED visits and deaths. This study serves as an informed alert and possible investigational guideline for health care professionals for hospital avoidance behavior and its consequences.

Impact of the COVID-19 Pandemic and Vaccine Availability on Utilization of Breast Imaging in a Multistate Radiology Practice

Method

Data were obtained from medical health records across 77 Radiology Partners practices in the US. The data provided us with the total monthly mammography, breast ultrasound, and breast MRI procedures from January 2019 to September 2022. An interrupted time-series (ITS) analysis was conducted to evaluate the effect of the COVID-19 pandemic and the COVID-19 vaccination. We chose March 2020 and December 2020 as critical time points in the pandemic and analyzed trends before and after these dates.

Results

The starting level (at baseline in January 2019) of the total breast imaging procedure volume was estimated at 114,901.5, and this volume appeared to significantly increase every month prior to March 2020 by 4,864.0 (p < 0.0001, CI = [3,077.1, 6,650.9]). In March 2020, there appeared to be a significant decrease in volume by 104,446.3 (p=0.003, CI = [-172,063.1, -36,829.5]), followed by a significant increase in the monthly trend of service volume (relative to the pre-COVID trend) of 20,660.7 per month (p=0.001, CI = [8,828.5, 32,493.0]). In December 2020, there appeared to be a significant decrease in service volume by 69,791.2 (p=0.012, CI = [-123,602.6, -15,979.7]). Compared to the period from March to November 2020, there was a decrease in the monthly trend of service volumes per month by 24,213.9 (p < 0.0001, CI = [-36,027.6, -12,400.2]). After March 2020, the total service volume increased at the rate of 25,524.7 per month (p < 0.0001, CI = [13,828.2, 37,221.2]). In contrast, the service volumes after December 2020 appeared to grow steadily and slowly at a rate of 1,310.8 per month (p=0.118, CI = [-348.8, 2970.3]).

Conclusion

Our study revealed that there has been a recovery and a further increase in breast imaging service volumes compared to prepandemic levels. The increase can be best explained by vaccination rollout, reopening of elective/nonemergency healthcare services, insurance coverage expansion, the decline in the US uninsured rate due to government interventions and policies, and the recovery of jobs with employer-provided medical insurance post-pandemic.

Impact of coronavirus disease 2019 on cancer care: How the pandemic has changed cancer utilization and expenditures

PURPOSE

Since identified in December 2019, the novel coronavirus disease 2019 (COVID-19) has had a global impact on medical resource use and costs for patients with cancer in South Korea. This study aimed to identify the medical use and costs among patients with cancer during the COVID-19 pandemic, to predict these patterns in South Korea in the future.

METHODS

We conducted a secondary claims data analysis using the National Health Insurance Service database for the calendar period of 2019-2020. Monthly relative percent changes in cancer incidence, medical use, and billing costs for medical care utilization by cancer type were calculated. Then, the medical use and costs after January 2020 were predicted using a time series model with data before the COVID-19 outbreak (2014-2019).

RESULTS

The incidence of cancer diagnoses has seen a notable decline since the outbreak of the COVID-19 in 2020 as compared to 2019. Despite the impact of COVID-19, there hasn't been a distinct decline in outpatient utilization when compared to inpatient utilization. While medical expenses for both inpatient and outpatient visits have slightly increased, the number of patients treated for cancer has decreased significantly compared to the previous year. In June 2020, overall outpatient costs experienced the highest increase (21.1%), while individual costs showed the most significant decrease (-4.9%) in June 2020. Finally, the number of hospitalisations and outpatient visits increased slightly from June-July in 2020, reducing the difference between the actual and predicted values. The decrease in the number of inpatient hospitalisations (-22~-6%) in 2020 was also high.

CONCLUSIONS

The overall use of medical services by patients with cancer decreased in 2020 compared with that in the pre-COVID-19 pandemic period. In the future, the government should consider how to recover from the COVID-19 pandemic, and establish permanent health policies for patients with cancer.

Evolving Barriers to Clinical Trial Enrollment and Clinical Care in Neuro-oncology in the Face of COVID-19

The lack of treatments with durable response in neuro-oncology highlights the critical need for clinical trials to advance patient care. The intersection of relatively low incidence, evolving classification schema, and entrenched community, healthcare provider, and organizational factors have been historic challenges against successful trial enrollment and implementation. The additional need for multidisciplinary, often tertiary-level care, further magnifies latent national and international health inequities with rural and under-served populations. The COVID-19 pandemic both unveiled fundamental weaknesses in historical approaches and prompted the necessity of new approaches and systems for conducting clinical trials. Here, we provide an overview of traditional barriers to clinical trial enrollment in neuro-oncology, the effect of COVID-19 on these barriers, and the discovery of additional systemic weaknesses. Finally, we discuss future directions by reflecting on lessons learned with strategies to broaden access of care and streamline clinical trial integration into clinical practice.

Pregnant individuals with uncomplicated pregnancies display pro-inflammatory immune changes when exposed to the COVID-19 pandemic

PROBLEM

The COVID-19 pandemic has been shown to have a detrimental impact on the mental health of pregnant individuals, and chronic stress can alter the immune profile. However, the effects of the COVID-19 pandemic on the immune system in pregnancy are still poorly understood. We aimed to evaluate the impact of pandemic exposure on the maternal immune profile in uncomplicated pregnancies.

METHOD OF STUDY

We collected blood and placenta samples from pregnant individuals exposed and unexposed to the pandemic to compare their immune and inflammatory profiles. We performed co-culture with circulating maternal immune cells and endothelial cells to assess endothelial activation. Statistical analysis was performed using unpaired t-test, Mann-Whitney, or Fisher's exact test as appropriate.

RESULTS

In exposed individuals, we observed a decreased proportion of Th2 cells (p < .0001) and Treg/Th17 ratio (p < .05), as well as an increased Th1/Th2 ratio (p < .0001). Levels of IL-1β (p < .01) and IL-18 (p < .01) were increased in the circulation of exposed participants, whilst other mediators were significantly decreased (IFNγ, IL-8, MCP-1, amongst others). Furthermore, we observed increased production of ICAM, hallmark of endothelial activation, when we co-cultured endothelial cells with immune cells from exposed individuals. Vaccination status impacted the cellular profile with increased proportions of Th1 and B cells in vaccinated participants.

CONCLUSION

Overall, we observed a pro-inflammatory bias in the circulation of pregnant individuals exposed to the COVID-19 pandemic, with otherwise uncomplicated pregnancies. Our work also supports an association between the increased risk of endothelial activation/hypertension and SARS-CoV2 infection, which might be driven in part by exposure to the pandemic and associated stressors.

The Use of Telemedicine for Screening and Addressing Social Needs in a Primary Care Pediatric Population in Brooklyn, New York

The objective of this study was to analyze temporal changes in social needs (SN), comparing those who received routine annual in-person care to those receiving SN screenings through a combination of tele-social care and in-person care biannually. Our prospective cohort study used a convenience sample of patients from primary care practices. Baseline data were collected from April 2019 to March 2020. The intervention group (n = 336) received SN screening and referral telephone outreach from June 2020 to August 2021. The control group (n = 2890) was screened, in person, during routine visits at baseline and summer 2021. We used a repeated-measures logistic regression with general estimating equations to assess incremental change in individual SN for the intervention group. Food, housing, legal and benefit needs increased and peaked at the beginning of the pandemic and decreased after interventions (P < 0.001). There was a 32% decrease in the odds of food insecurity for those in the intervention group compared to the control group (adjusted OR 0.668, 95% confidence interval 0.444-1.004, P = 0.052), and a 75% decrease in the odds of housing insecurity (adjusted OR 0.247, 95% confidence interval 0.150-0.505, P < 0.001). During COVID-19, there was an increase in SN followed by a decrease after interventions were offered. Those who completed tele-social care showed greater improvements in social needs than those in routine care, with the greatest improvements in food and housing needs.

A cross-sectional study on social determinants of mental health during COVID-19 among adults in California

AIM

To explore the impact of structural and intermediary social determinants of health (SDoH) on Californian adults' mental health during the early phase of the COVID-19 pandemic.

DESIGN

This cross-sectional study used data from the 2020 cycle of the California Health Interview Survey, the largest US state-level population health survey.

METHODS

Descriptive statistics and logistic regression were used to analyse the data. Using a general social determinant of health framework, we operationalized different survey questions to measure structural and intermediary determinants of mental health.

RESULTS

Mental health during the early phase of COVID-19 among adults in California was associated with age, gender, health conditions, delayed care, employment status (loss of job or reduced income) and discrimination. People in higher social strata were more likely to have better mental health for many of these factors.

CONCLUSION

This study supports the assertion that material circumstances (such as employment status) and discrimination are associated with experiencing mental health issues among adults in California during COVID-19. Racism is a public health issue, and as nurses, addressing racism is critical. In addition, much work is needed to address SDoH to improve health outcomes, especially among marginalized populations.

IMPACT

This study addressed the knowledge gap concerning the social determinants of mental health among Californian adults during the early phase of the COVID-19 pandemic. Those who had reduced income and those who lost their jobs during the COVID-19 pandemic were 46% and 56%, respectively, more likely to report mental health problems. Those who experienced discrimination in healthcare were 304% more likely to report mental health issues. This research will increase the understanding of the social determinants of health, particularly for those with chronic illnesses and mental health issues during the COVID-19 pandemic.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as we used an existing US state dataset. However, California Health Interview Survey is the largest state health survey in the United States and interviews more than 20,000 households each year representing the health care needs of Californians.

The global impact of the COVID-19 pandemic on pediatric spinal care: A multi-centric study

Background

The COVID-19 pandemic has affected healthcare worldwide since December 2019. We aimed to identify the effect of the COVID-19 pandemic on outpatient clinic and surgical volumes and peri-operative complications for pediatric spinal deformities patients.

Methods

In this multi-center retrospective study, outpatient visits (in-person and virtual care) and pediatric spine surgeries volumes in four high-volume pediatric spine centers were compared between March and December 2019 and the same period in 2020. Peri-operative complications were collected and compared in the same periods. Descriptive statistics were calculated, and comparative analyses were performed.

Results

During the 2020 study period, the outpatient visit (in-person and virtual care) volume decreased during local lockdown periods by 71% for new patients (p < 0.001) and 53% for returning patients (p = 0.03). Overall, for 2020, there was a 20% reduction in new patients (p = 0.001) and 21% decrease in returning patients (p < 0.001). During the pandemic, there was also 20% less overall surgical volume of adolescent idiopathic scoliosis (AIS) patients undergoing primary posterior spinal fusion, with a 70% reduction during lockdown times (p < 0.001). Complication rate and profile were similar between periods.

Conclusion

There was a significant decrease in outpatient pediatric spine outpatient visits, particularly new patients, which may increase the proportion of pediatric patients with spinal deformities that present late, meeting surgical indication. This, in combination with the reduction in surgical volume of AIS over the first year of the pandemic, could result in an extended waitlist for surgeries during years to come. Complication rate was similar for both periods, suggesting it is safe to continue elective pediatric spine surgery even in a time of a pandemic.

Level of evidence

level IV.

Adoption of virtual prenatal visits linked to recurrent virtual or forgone visits for postpartum care

BACKGROUND

To investigate the association between prenatal and postpartum visits, with a specific focus on the modality of these visits, and to assess whether barriers to virtual visits experienced during the prenatal period are linked to types of postpartum visits.

METHODS

The repeated cross-sectional study used the Pregnancy Risk Assessment Monitoring System from 2020 through 2021. Women who had prenatal visits and who also reported their postpartum visits were included (n = 11,258). The outcome was the modality of postpartum visits, and the key independent variable was virtual prenatal visit experience. Multinomial logistic regression analysis was performed to examine the relationship of postpartum visits with virtual prenatal visit experience.

RESULTS

Among those who had virtual prenatal visits, about one-third used virtual visits again for postpartum care. Individuals who had virtual prenatal visits showed greater odds of utilizing virtual visits (OR 8.54, 95%CI 7.05-10.35, p=<0.001) or no office visits (OR 1.61, 95%CI 1.25-2.07, p=<0.001) compared to in-person visits during the postpartum period. Women who reported a lack of virtual appointment availability (OR 0.58, 95%CI 0.40-0.86, P = 0.006) or cellular data (OR 0.18, 95%CI 0.05-0.68, p = 0.012) in their prenatal care had lower odds of virtual postpartum visits.

CONCLUSIONS

While virtual prenatal visits are linked to greater virtual visits for postpartum care, they are also associated with increased forgone care. The unavailability of virtual appointments and cellular data is a significant barrier to virtual visits. The findings provide practical implications for advancing equitable and sustainable care in a rapidly changing healthcare landscape.

Prediction models of COVID-19 fatality in nine Peruvian provinces: A secondary analysis of the national epidemiological surveillance system

There are initiatives to promote the creation of predictive COVID-19 fatality models to assist decision-makers. The study aimed to develop prediction models for COVID-19 fatality using population data recorded in the national epidemiological surveillance system of Peru. A retrospective cohort study was conducted (March to September of 2020). The study population consisted of confirmed COVID-19 cases reported in the surveillance system of nine provinces of Lima, Peru. A random sample of 80% of the study population was selected, and four prediction models were constructed using four different strategies to select variables: 1) previously analyzed variables in machine learning models; 2) based on the LASSO method; 3) based on significance; and 4) based on a post-hoc approach with variables consistently included in the three previous strategies. The internal validation was performed with the remaining 20% of the population. Four prediction models were successfully created and validate using data from 22,098 cases. All models performed adequately and similarly; however, we selected models derived from strategy 1 (AUC 0.89, CI95% 0.87-0.91) and strategy 4 (AUC 0.88, CI95% 0.86-0.90). The performance of both models was robust in validation and sensitivity analyses. This study offers insights into estimating COVID-19 fatality within the Peruvian population. Our findings contribute to the advancement of prediction models for COVID-19 fatality and may aid in identifying individuals at increased risk, enabling targeted interventions to mitigate the disease. Future studies should confirm the performance and validate the usefulness of the models described here under real-world conditions and settings.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

Background

Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.

Methods

This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA).

Results

Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.

Conclusion

Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.

Clinical characteristics and outcomes of patients admitted with COVID-19 at a public-sector hospital over the first two waves of SARS-CoV-2 infection in Harare, Zimbabwe: A prospective cohort study

BACKGROUND

We investigated the clinical profile, complications, and outcomes of inpatients with COVID-19 at Parirenyatwa Hospital, Harare, across the first two waves of SARS-CoV-2 infection, and factors associated with mortality.

METHODS

We conducted a prospective cohort study on all patients admitted to the COVID-19 unit. Data were extracted from medical records and negative binomial regression with robust standard errors was used to assess the association between sociodemographic and clinical characteristics and mortality. Cox Regression was used for sensitivity analysis.

RESULTS

Of 563 people admitted with COVID-19 between 2 July 2020 and 19 March 2021, 214 (38.0%) died, 340 were discharged and 9 transferred. The median age was 56 (IQR 44-68) years and 53.8% were male. Overall, 38.8% experienced a complication, the most common being acute kidney injury (17.9%) and hyperglycaemia (13.1%). The most common comorbidity was hypertension (41.3%) followed by diabetes (28.6%), HIV (12.1%), cardiovascular disease (10.9%) and chronic kidney disease (7.8%). Among participants who stayed in the ward for more than 1 night, mortality was higher in patients with comorbidity compared to those without any comorbidity (38.7% vs 25.5%, risk ratio (RR) = 1.52 (95% CI 1.11, 2.07), p = 0.008). After adjusting for oxygen saturation, comorbidities, sex and pregnancy, mortality was higher in the second wave than in the first (adjusted RR 1.23, 95% CI 1.00-1.51, p = 0.05). In the second wave 57/161 (35.4%) deaths were attributed to lack of resources, mainly human resources.

CONCLUSION

The mortality rate was high and clinical COVID-19 care needs to pay careful attention to patient monitoring for complications and management of comorbidities. This will require addressing the critical health workforce shortage issues. Prevention of COVID-19 including vaccination particularly among individuals with comorbidities remains a high priority.

Trends in forgone medical care and unmet needs among Medicare beneficiaries with a history of depression during the COVID-19 pandemic: a national, repeated cross-sectional study

OBJECTIVES

To investigate trends in forgone medical care, basic needs disruption, financial and mental health disruption, engagement of preventive behaviours guidelines, and perceived severity of COVID-19 among community-living Medicare beneficiaries in the USA with and without a self-reported history of depression from Summer 2020 to Winter 2021.

DESIGN/SETTING

A repeated cross-sectional study using a nationally representative sample of Medicare beneficiaries of three rounds of survey data from the Medicare Current Beneficiary Survey COVID-19 Supplement Public Use Files: Summer 2020, Fall 2020 and Winter 2021.

PARTICIPANTS

A total of 28 480 community-dwelling Medicare beneficiaries.

MAIN OUTCOME MEASURES

Forgone medical care, basic needs disruption, financial and mental health disruption, engagement of preventive behaviours guidelines, and perceived severity of COVID-19.

RESULTS

In the study sample, 7629 (27%) had a history of depression. After adjusting for potential confounders, weighted multivariable logistic regression models showed that Medicare beneficiaries with a history of depression had higher odds of foregone medical care (OR: 1.29, 95% CI 1.16 to 1.42, p<0.001), of basic need disruption (OR: 1.49, 95% CI 1.33 to 1.67, p<0.001), and of financial and mental health disruption (OR: 1.75, 95% CI 1.60 to 1.91, p<0.001) during the COVID-19 pandemic when compared with those without a history of depression. No statistically significant differences were observed in engagement of essential preventive behaviours or perception of COVID-19 severity.

CONCLUSIONS

COVID-19 pandemic may exacerbate existing barriers to healthcare access and financial and social needs, possibly leading to persistent unmet needs among Medicare beneficiaries with a history of depression beyond the pandemic.

Telehealth use during the early COVID-19 public health emergency and subsequent health care costs and utilization

Telehealth utilization increased during the COVID-19 pandemic, yet few studies have documented associations of telehealth use with subsequent medical costs and health care utilization. We examined associations of telehealth use during the early COVID-19 public health emergency (March-June 2020) with subsequent total medical costs and health care utilization among people with heart disease (HD). We created a longitudinal cohort of individuals with HD using MarketScan Commercial Claims data (2018-2022). We used difference-in-differences methodology adjusting for patients' characteristics, comorbidities, COVID-19 infection status, and number of in-person visits. We found that using telehealth during the stay-at-home order period was associated with a reduction in total medical costs (by -$1814 per person), number of emergency department visits (by -88.6 per 1000 persons), and number of inpatient admissions (by -32.4 per 1000 persons). Telehealth use increased per-person per-year pharmacy prescription claims (by 0.514) and average number of days' drug supply (by 0.773 days). These associated benefits of telehealth use can inform decision makers, insurance companies, and health care professionals, especially in the context of disrupted health care access.

Perceptions of senior nursing students on how the COVID-19 pandemic influenced their clinical practice in the Northwest Province, South Africa: a qualitative study

OBJECTIVE

To explore and describe senior nursing students' perspectives on clinical practice during COVID-19 and provide the most up-to-date information on the quality of clinical experience for nursing students in relation to nursing practice, nursing education, and nursing research.

DESIGN

The research design that was employed is a qualitative, explorative, descriptive in order to explore and describe nursing students' perceptions of clinical, training during the COVID-19 pandemic.

SETTING

The study took place in a local university located in the Northwest province, South Africa.

PARTICIPANTS

The population consisted of 16 senior nursing students who had been exposed to clinical practice during the COVID-19 pandemic. There were 14 women and 2 men. Study included full-time, registered undergraduate nursing students who enrolled in 2019. All nursing students who did not engage in clinical practice before or during COVID-19 were exempt.

INTERVENTIONS

There were no direct interventions in this study; however, few recommendations were made for each of the themes that emerged in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The researchers' aim with the study was to find out the nursing students' perspective on clinical training during a global pandemic, through interviews and focus group discussions. The researcher did in fact receive such feedback from the participants.

RESULTS

Four major themes emerged: (1) the lack of preceptors to facilitate clinical teaching; (2) not allowed to work in COVID-19 wards; (3) difficulties with online classes and tests and (4) poor communication.

CONCLUSION

The COVID-19 pandemic influenced how students viewed and experienced clinical training, which in turn had an impact on their learning experiences. These effects also had some impact on their experiences and decisions to continue working as professional nurses.

Factors associated with delay or avoidance of medical care during the COVID-19 pandemic in Armenia: results from a nationwide survey

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems throughout the world. Many patients faced delays and cancellation of care due to scaled back services, mobility restrictions, and concerns related to the risk of infection. The present study aimed to assess the prevalence of and risk factors associated with the avoidance or delay of medical care due to COVID-19 in Armenia.

METHODS

We conducted a cross-sectional telephone survey of 3,483 adults across Armenia. We used stratified two-stage cluster sampling to select the participants from different age groups proportionate to their size in the population. Logistic regression analysis assessed the association of risk factors with avoidance/delay of routine, urgent/emergency, and any medical care.

RESULTS

The mean age of the sample was 49.5 (SD = 14.8), ranging from 18 to 90. About 9.9% of the respondents avoided/delayed any type of medical care; whereas 5.5% avoided/delayed urgent/emergency care and 6.6% routine care. In the adjusted analysis, female gender and higher monthly expenditures were associated with avoidance/delay of routine medical care. Factors associated with delay/avoidance of urgent/emergency care included female gender and higher perceived threat of COVID-19. Younger age, female gender, higher perceived threat and not being vaccinated against COVID-19 were associated with avoidance/delay of any medical care in the adjusted analysis.

CONCLUSION

Since avoiding or delaying care might increase morbidity and mortality associated with conditions not related to COVID-19, identifying population groups that are more likely to avoid care is important. Targeting such groups with educational interventions focusing on the risks of using versus not using medical care in times of pandemic might be crucial. Ensuring the provision of in-home healthcare services for high-risk groups might help to address important medical care needs during the pandemic.

A prospective cohort study of presenteeism and increased risk of unemployment among Japanese workers during the COVID-19 pandemic

OBJECTIVES

Presenteeism adversely affects workers' quality of life, leading to further deterioration of their health and affecting their ability to continue working. Unemployment is one of the most serious consequences for workers experiencing presenteeism. A worker's ability to work depends on the degree of mismatch between their health status and job demands and work factors. The COVID-19 pandemic has affected workers' experiences of presenteeism as well as their employment status. We examined the association between presenteeism and risk of job resignations and unemployment among Japanese workers during the COVID-19 pandemic.

METHODS

A prospective study of 27 036 internet monitors was conducted, starting in December 2020, with 18 560 (68.7%) participating in the follow-up by December 2021. The Work Functioning Impairment Scale (WFun) was used to measure the degree of work function impairment.

RESULTS

The group with the highest WFun scores had higher odds ratios (ORs) for both retirement and unemployment for health reasons than the group with the lowest WFun scores. ORs were 2.99 (95% CI, 2.48-3.62; P < .001) and 1.82 (95% CI, 1.65-2.00; P < .001), respectively.

CONCLUSIONS

Workers with work functioning impairment are at increased risk of resignation or unemployment. Management strategies for workers with work functioning impairment are needed to reduce their disadvantages in employment.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments

OBJECTIVE

Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions.

METHODS

The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR).

RESULTS

Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic.

CONCLUSION

Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Preoperative Concerns of Older US Adults and Decisions About Elective Surgery

This cross-sectional study examines the preoperative concerns among US adults aged 50 to 80 years who considered elective surgery.

Optic Neuritis and Cranial Neuropathies Diagnosis Rates before Coronavirus Disease 2019, in the Initial Pandemic Phase, and Post-Vaccine Introduction

PURPOSE

To compare rates of diagnosis of neuro-ophthalmic conditions across the Coronavirus Disease 2019 (COVID-19) pandemic with pre-pandemic levels.

DESIGN

Multicenter, retrospective, observational study.

PARTICIPANTS

Patients seen for eye care between March 11, 2019, and December 31, 2021.

METHODS

A multicenter electronic health record database, Sight Outcomes Research Collaborative (SOURCE), was queried for new diagnoses of neuro-ophthalmic conditions (cranial nerve [CN] III, IV, VI, and VII palsy; diplopia; and optic neuritis) and new diagnoses of other ophthalmic conditions from January 1, 2016, to December 31, 2021. Data were divided into 3 periods (pre-COVID, pre-COVID vaccine, and after introduction of COVID vaccine), with a 3-year look-back period. Logistic regressions were used to compare diagnosis rates across periods. Two-sample z-test was used to compare the log odds ratio (OR) of the diagnosis in each period with emergent ocular conditions: retinal detachment (RD) and acute angle-closure glaucoma (AACG).

MAIN OUTCOME MEASURES

Diagnosis rate of neuro-ophthalmic conditions in each study period.

RESULTS

A total of 323 261 unique patients (median age 59 years [interquartile range, 43-70], 58% female, 68% White) across 5 academic centers were included, with 180 009 patients seen in the pre-COVID period, 149 835 patients seen in the pre-COVID vaccine period, and 164 778 patients seen in the COVID vaccine period. Diagnosis rates of CN VII palsy, diplopia, glaucoma, and cataract decreased from the pre-COVID period to the pre-vaccine period. However, the optic neuritis diagnoses increased, in contrast to a decrease in RD diagnoses (P = 0.021). By comparing the diagnosis rates before and after widespread vaccination, all eye conditions evaluated were diagnosed at higher rates in the COVID vaccination period compared with pre-COVID and pre-vaccine periods. The log OR of neuro-ophthalmic diagnosis rates across every period comparison were largely similar to emergency conditions (RD and AACG, P > 0.05). However, the log OR of cataract and glaucoma diagnoses were different to RD or AACG (P < 0.05) in each period comparison.

CONCLUSIONS

Neuro-ophthalmic diagnoses had a similar reduction in diagnosis rates as emergent eye conditions in the first part of the pandemic, except optic neuritis. After widespread COVID-19 vaccination, all ophthalmic diagnosis rates increased compared with pre-pandemic rates, and the increase in neuro-ophthalmic diagnosis rates did not exceed the increase in RD and AACG diagnosis rates.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Telehealth Use and Healthcare Utilization Among Individuals with Type 2 Diabetes During the COVID-19 Pandemic: Evidence From Louisiana Medicaid Claims

INTRODUCTION

The impact of telehealth use on healthcare utilization is limited, especially among Medicaid beneficiaries with type 2 diabetes. Considering the rapid adoption of telehealth during the COVID-19 pandemic, this study examined associations between telehealth use and healthcare utilization among Medicaid beneficiaries with type 2 diabetes.

METHODS

Using Louisiana Medicaid claims data from March 2019 to August 2021, the associations were examined using a difference-in-difference model with propensity score weighting. Demographic characteristics, baseline comorbidities and healthcare utilization, and zip code level environmental factors were included in the analysis. The monthly frequency of healthcare services, including in-person outpatient visits, inpatient visits, emergency department (ED) visits and hemoglobin A1C (HbA1C) tests, were measured as outcomes. Several sensitivity analyses were conducted across different subgroups.

RESULTS

We included 48,992 beneficiaries with type 2 diabetes in the study of 27,340 beneficiaries in the telehealth group and 21,652 beneficiaries in the non-telehealth group. Of 1000 beneficiaries per month, the telehealth group had significantly more utilization compared to the non-telehealth group, with an increase of 195.049 in-person outpatient visits (95% CI: 166.169 to 223.929, p < 0.001), 3.816 inpatient visits (95% CI: 2.539 to 5.093, p < 0.001), 10.499 ED visits (95% CI: 7.287 to 13.712, p < 0.001) and 14.153 HbA1c tests (95% CI: 11.431 to 16.875, p < 0.001, respectively. Excluding beneficiaries who had ED or inpatient visits in the 30 days prior to receiving telehealth visits, overall ED visits significantly decreased for the telehealth group versus the non-telehealth group over time, by 9.456 visits (95% CI: - 12.356 to - 6.557, p < 0.001) per 1000 beneficiaries per month on average.

CONCLUSION

The study found that telehealth was associated with a significant increase in healthcare utilization in general but has the potential to decrease ED and inpatient utilization for some groups among low-income populations with diabetes.

Causes and costs of global COVID-19 vaccine inequity

Despite the rapid development of safe and effective COVID-19 vaccines and the widely recognized health and economic benefits of vaccination, there exist stark differences in vaccination rates across country income groups. While more than 70% of the population is fully vaccinated in high-income countries, vaccination rates in low-income countries are only around 30%. The paper reviews the factors behind global COVID-19 vaccine inequity and the health, social, and economic costs triggered by this inequity. The main contributors to vaccine inequity include vaccine nationalism, intellectual property rights, constraints in manufacturing capacity, poor resilience of healthcare systems, and vaccine hesitancy. Vaccine inequity has high costs, including preventable deaths and cases of illnesses in low-income countries, slow economic recovery, and large learning losses among children. Increasing vaccination rates in low-income countries is in the self-interest of higher-income countries as it may prevent the emergence of new variants and continuous disruptions to global supply chains.

Determinants of Breast Cancer Screening Adherence During the COVID-19 Pandemic in a Cohort at Increased Inherited Cancer Risk in the United States

BACKGROUND

We examined neighborhood characteristics concerning breast cancer screening annual adherence during the COVID-19 pandemic.

METHODS

We analyzed 6673 female patients aged 40 or older at increased inherited cancer risk in 2 large health care systems (NYU Langone Health [NYULH] and the University of Utah Health [UHealth]). Multinomial models were used to identify predictors of mammogram screening groups (non-adherent, pre-pandemic adherent, pandemic period adherent) in comparison to adherent females. Potential determinants included sociodemographic characteristics and neighborhood factors.

RESULTS

Comparing each cancer group in reference to the adherent group, a reduced likelihood of being non-adherent was associated with older age (OR: 0.97, 95% CI: 0.95, 0.99), a greater number of relatives with cancer (OR: 0.80, 95% CI: 0.75, 0.86), and being seen at NYULH study site (OR: 0.42, 95% CI: 0.29, 0.60). More relatives with cancer were correlated with a lesser likelihood of being pandemic period adherent (OR: 0.89, 95% CI: 0.81, 0.97). A lower likelihood of being pre-pandemic adherent was seen in areas with less education (OR: 0.77, 95% CI: 0.62, 0.96) and NYULH study site (OR: 0.35, 95% CI: 0.22, 0.55). Finally, greater neighborhood deprivation (OR: 1.47, 95% CI: 1.08, 2.01) was associated with being non-adherent.

CONCLUSION

Breast screening during the COVID-19 pandemic was associated with being older, having more relatives with cancer, residing in areas with less educational attainment, and being seen at NYULH; non-adherence was linked with greater neighborhood deprivation. These findings may mitigate risk of clinically important screening delays at times of disruptions in a population at greater risk for breast cancer.

Hyperlocal lessons from the COVID-19 pandemic: Toward an equity-centered implementation science approach

COVID-19 vaccination campaigns across the US were implemented to mitigate the disproportionate hospitalizations and unnecessary deaths across many communities that experienced unequal gaps in initial vaccine distribution rollout and uptake. In parallel, the COVID-19 pandemic created declines in routine vaccination coverage for adults, adolescents, and children; particularly, in communities experiencing overlapping social disadvantage. Community-based efforts offer a solution to narrow immunization gaps but have not been replicated consistently nor demonstrated widespread success during the pandemic as evidenced by prevailing disparities in immunization uptake. We offer an equity centered implementation science approach that involves co-designing, co-implementing, and co-evaluating solutions with the community and all partners investing in the shared goal of sustainable improvement in health outcomes.

Difficulty Obtaining Daily Necessities and Difficulty Obtaining SCI Services During the COVID-19 Pandemic Among People With Spinal Cord Injury

OBJECTIVE

To describe the self-reported difficulties during the COVID-19 pandemic on the lives of persons with traumatic spinal cord injury (SCI), and to identify the factors measured prior the pandemic that predict the number of difficulties obtaining daily necessities and difficulties obtaining SCI services during the pandemic.

DESIGN

Cohort study.

SETTING

A state SCI outcomes follow-up database in the southeastern United States.

PARTICIPANTS

297 participants (N=297) met the following eligibility criteria: (1) ≥18 years of age, (2) traumatic SCI, (3) minimum of 1-year post-injury, and (4) having completed a longitudinal study questionnaire immediately prior to the pandemic (between 12/1/2019 and 03/11/2020).

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

The outcome measures were the self-reported number of difficulties obtaining daily necessities (difficulties to get food, medication, and routine medical/dental care) and difficulties obtaining SCI services during the pandemic (difficulties to get treatment for SCI-related problems, to maintain regular SCI equipment, and to get SCI supplies).

RESULTS

Among 297 eligible participants, 247 (83%) have completed the follow-up during the pandemic between December 2020 and December 2021. There were 22% participants having at least 1 difficulty obtaining daily necessities and 19% participants having at least 1 difficulty obtaining SCI services. Younger, ambulatory participants, cervical 1-4 injury level, lower household income, more health conditions, and no routine health care access prior to the pandemic were associated with greater number of difficulties obtaining daily necessities. Women, non-ambulatory participants, marital relation, having need for physical assistance, more health conditions, and no routine health care access prior to the pandemic related to greater number of difficulties obtaining SCI services.

CONCLUSIONS

People with SCI have experienced living difficulties during the COVID-19 pandemic. Of particular importance, no routine health care access and more health conditions are related to more difficulties obtaining both daily necessities and SCI services after controlling the socio-demographics and injury characteristics.

Prior Emergency Medical Services Utilization Among People Who Had an Accidental Opioid-Involved Fatal Drug Overdose-Rhode Island, 2018-2020

OBJECTIVE

To help understand whether decreased emergency medical services (EMS) utilization due to the COVID-19 pandemic contributed to increased accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island.

METHODS

We identified accidental opioid-involved fatal drug overdoses among Rhode Island residents that occurred from January 1, 2018, through December 31, 2020. We linked decedents by name and date of birth to the Rhode Island EMS Information System to obtain EMS utilization history.

RESULTS

Among 763 people who had an accidental opioid-involved fatal overdose, 51% had any EMS run and 16% had any opioid overdose-related EMS run in the 2 years before death. Non-Hispanic White decedents were significantly more likely than decedents of other races and ethnicities to have any EMS run (P < .001) and any opioid overdose-related EMS run (P = .05) in the 2 years before death. Despite a 31% increase in fatal overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, EMS utilization in the prior 2 years, prior 180 days, or prior 90 days did not vary by time frame of death.

CONCLUSION

In Rhode Island, decreased EMS utilization because of the COVID-19 pandemic was not a driving force behind the increase in overdose fatalities observed in 2020. However, with half of people who had an accidental opioid-involved fatal drug overdose having an EMS run in the 2 years before death, emergency care is a potential opportunity to link people to health care and social services.

Impact of the COVID-19 Pandemic on Inpatient Utilization for Acute Neurologic Disease

Background and Objective: The initial months of the Corona Virus 2019 (COVID-19) pandemic resulted in decreased hospitalizations. We aimed to describe differences in hospitalizations and related procedures across neurologic disease. Methods: In our retrospective observational study using the California State Inpatient Database and state-wide population-level estimates, we calculated neurologic hospitalization rates for a control period from January 2019 to February 2020 and a COVID-19 pandemic period from March to December 2020. We calculated incident rate ratios (IRR) for neurologic hospitalizations using negative binomial regression and compared relevant procedure rates over time. Results: Population-based neurologic hospitalization rates were 29.1 per 100,000 (95% CI 26.9-31.3) in April 2020 compared to 43.6 per 100,000 (95% CI 40.4-46.7) in January 2020. Overall, the pandemic period had 13% lower incidence of neurologic hospitalizations per month (IRR 0.87, 95% CI 0.86-0.89). The smallest decreases were in neurotrauma (IRR 0.92, 95% CI 0.89-0.95) and neuro-oncologic cases (IRR 0.93, 95% CI 0.87-0.99). Headache admissions experienced the greatest decline (IRR 0.62, 95% CI 0.58-0.66). For ischemic stroke, greater rates of endovascular thrombectomy (5.6% vs 5.0%; P < .001) were observed in the pandemic. Among all neurologic disease, greater rates of gastrostomy (4.0% vs 3.5%; P < .001), intubation/mechanical ventilation (14.3% vs 12.9%, P < .001), and tracheostomy (1.4 vs 1.2%; P < .001) were observed during the pandemic. Conclusions: During the first months of the COVID-19 pandemic there were fewer hospitalizations to varying degrees for all neurologic diagnoses. Rates of procedures indicating severe disease increased. Further study is needed to determine the impact on triage, patient outcomes, and cost consequences.

Health care barriers and perceived mental health among adults in Canada during the COVID-19 pandemic: a population-based cross-sectional study

INTRODUCTION

The perceived mental health of individuals in Canada who faced health care barriers during the COVID-19 pandemic is underexplored.

METHODS

We analyzed data collected March to June 2021 from adults who reported needing health care services within the past 12 months in the Survey on Access to Health Care and Pharmaceuticals during the Pandemic. Unadjusted and adjusted logistic regression analyses examined the associations between health care barriers (appointment scheduling problems, delaying contacting health care) and high self-rated mental health and perceived worsening mental health compared to before the pandemic, overall and stratified by gender, age group, number of chronic health conditions and household income tertile.

RESULTS

Individuals who experienced pandemic-related appointment changes or had appointments not yet scheduled were less likely to have high self-rated mental health (aOR = 0.81 and 0.64, respectively) and more likely to have perceived worsening mental health (aOR = 1.50 and 1.94, respectively) than those with no scheduling problems. Adults who delayed contacting health care for pandemic-related reasons (e.g. fear of infection) or other reasons were less likely to have high self-rated mental health (aOR = 0.52 and 0.45, respectively) and more likely to have perceived worsening mental health (aOR = 2.31 and 2.43, respectively) than those who did not delay. Delaying contacting health care for pandemic-related reasons was associated with less favourable perceived mental health in all subgroups, while the association between perceived mental health and pandemic-related appointment changes was significant in some groups.

CONCLUSION

Health care barriers during the pandemic were associated with less favourable perceived mental health. These findings could inform health care resource allocation and public health messaging.

Economic Costs of Diabetes in the U.S. in 2022

OBJECTIVE

This study updates previous estimates of the economic burden of diagnosed diabetes, with calculation of the health resource use and indirect costs attributable to diabetes in 2022.

RESEARCH DESIGN AND METHODS

We combine the demographics of the U.S. population in 2022 with diabetes prevalence, from national survey data, epidemiological data, health care cost data, and economic data, into a Cost of Diabetes Economic Model to estimate the economic burden at the population and per capita levels. Health resource use and associated medical costs are analyzed by age, sex, race/ethnicity, comorbid condition, and health service category. Data sources include national surveys (2015-2020 or most recent available), Medicare standard analytic files (2020), and administrative claims data from 2018 to 2021 for a large commercially insured population in the U.S.

RESULTS

The total estimated cost of diagnosed diabetes in the U.S. in 2022 is $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes. For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion).

CONCLUSIONS

The inflation-adjusted direct medical costs of diabetes are estimated to rise 7% from 2017 and 35% from 2012 calculations (stated in 2022 dollars). Following decades of steadily increasing prevalence of diabetes, the overall estimated prevalence in 2022 remains relatively stable in comparison to 2017. However, the absolute number of people with diabetes has grown and contributes to increased health care expenditures, particularly per capita spending on inpatient hospital stays and prescription medications. The enormous economic toll of diabetes continues to burden society through direct medical and indirect costs.

Exploring Preventive Health Care Utilization Among Black/African American Men

Black/African American (BAA) men have the lowest life expectancy among other major demographic groups in the United States, with BAA male mortality rates 40% higher than their White male counterparts. Despite known benefits of preventive health care utilization, BAA men are 43% more likely to use the emergency department for usual care. Many intersecting factors like medical mistrust and religion have been identified as common barriers BAA men face in health care utilization with few studies exploring factors that impact their current preventive health care utilization. In addition, BAA men's perceptions of health and ability to identify or seek help have always been disproportionately lower than other racial groups despite higher rates of preventable diseases. Using the tenets of the Andersen Healthcare Utilization Model, this cross-sectional study of 176 BAA men explores BAA men's current preventive health care practices while examining the intersection of predisposing, enabling, and need factors on BAA men's preventive health care utilization. While it is well known that higher income levels and higher education positively influence health care utilization, the intersection of religious affiliation and higher levels of medical mistrust was associated with BAA men's decreased engagement with health care as religion posed as a buffer to health care utilization. This study demonstrated that BAA men's perception of health differed by sexual orientation, educational status, and income. However, across all groups the participants' perspective of their health was not in alignment with their current health outcomes. Future studies should evaluate the impact of masculine norms as potential enabling factors on BAA men's preventive health care utilization.

Addressing Chronic Conditions and Social Determinants of Health During the COVID-19 Pandemic

Chronic conditions or diseases are defined as persistent conditions lasting ≥ 1 year requiring either ongoing medical attention or limiting daily living or both (Agency for Healthcare Research and Quality (AHRQ) in Programs: SHARE approach workshop, Agency for Healthcare Research and Quality (AHRQ) (2016) Programs: SHARE approach workshop 2016. https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/index.html . Accessed 20 Jan 2017). Physical chronic conditions, including diabetes, hypertension, heart disease, arthritis, and stroke, are prevalent, especially in the older population. Over 90% of older adults have at least 1 and 77% have ≥ 2 chronic conditions (American Diabetes Association (ADA) in Statistics about diabetes, American Diabetes Association (ADA) (2023) Statistics about diabetes. https://diabetes.org/about-us/statistics/about-diabetes . Accessed 20 Apr 2023). Chronic conditions account for $4.1 trillion of the nation's annual healthcare expenditure (Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion in Health and economic costs of chronic conditions, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Health and Economic Costs of Chronic Conditions (2022). https://www.cdc.gov/chronicdisease/about/costs/index.htm . Accessed 7 Jan 2023). There are marked disparities based on age, color, and income, with older people, people of color, and lower-income people having higher treatment costs or even lost wages in response to having chronic conditions. Chronic conditions are the on-the-top leading causes for death with diabetes being the top 7th in the USA in 2019 (Ferguson in Metabolic Syndrome Related Dis, Ferguson et al., Metab Syndr Relat Disord 21:177-187, 2023).

Thinking Clearly: A Preventative Cognitive Health Visit Integrated in Primary Care

OBJECTIVE

The pandemic contributed to increased mental and cognitive health concerns as well as reduced utilization of preventive and treatment focused care. Deferred care can contribute to negative clinical outcomes, including increased acuity of mental and cognitive health concerns that benefit from early intervention. A new visit type was launched with the aim of reaching patients who may need care and supporting early identification of cognitive and mental health issues.

METHODS

We developed the Healthy Mind visit, a preventative visit administered by Primary Care Providers (PCPs) within outpatient clinics. The Healthy Mind visit included use of a pre-visit mental health screener as well as a brief computerized cognitive assessment. The clinical interaction focused on identifying mental and cognitive health concerns and developing a plan for wellness. Outcomes data collection occurred over nearly 2.5 years and focused on analyzing booking patterns, depression screening and follow-up, and clinical outcomes such as health confidence and post-visit motivation.

RESULTS

The visit was effective in supporting depression screening and follow-up with 29.6% of those participating in a Healthy Mind visit receiving a PHQ-9, and 82.5% of patients with elevated PHQ-9 scores attending a subsequent visit with their PCP. Improvements in health confidence and high patient reported motivation post-visit represent other notable clinical outcomes. The visit also promoted care utilization, with 73.5% of patients who attended a Healthy Mind visit being new to the practice or those who had not attended an appointment in the past 6 months.

CONCLUSIONS

The Healthy Mind visit, with a focus on mental and cognitive health, was successful in reaching patients who may not have otherwise sought care and supported positive clinical outcomes including early identification and treatment of depression and increased health confidence.

RECOMMENDATIONS

These findings reflect the importance of developing innovative programs to connect patients with care, especially those who may have deferred care due to a variety of factors. Focusing on mental and cognitive health with the use of innovative tools such as a computerized assessment, can drive patient interest in care offerings and support positive clinical outcomes.