Health Care Policy After the COVID-19 Pandemic

Attitudes and Misconceptions of Coronavirus Disease and Vaccination Among African Americans in Rural Mississippi

Despite the recommendations for COVID-19 preventive health behaviors, it continues to increase alarmingly. This study examined how media coverage, myths, political leaders, and community leaders influence the attitudes and misconceptions about COVID-19 and COVID-19 vaccination uptake in the Mississippi Delta region. This qualitative study employed focus group discussions (FDGs) with representatives from three rural counties in the Mississippi Delta. A thematic analysis approach was used for data analysis. Participants were aware of how COVID-19 is transmitted, the preventative measures that can be used to mitigate the spread of the virus, and misconceptions and beliefs that lingered in their communities. Participants were uncertain about the need for the COVID-19 vaccine in terms of perceived risks (e.g., side effects, efficacy, and safety) and its novelty. Participants also discussed a wide range of COVID-19 misinformation that resulted in distress and distrust of the vaccine and health behavior recommendations. There are varying misconceptions and beliefs about COVID-19 and COVID-19 vaccine among communities in the rural Mississippi Delta. Thus, multi-sectoral collaborations between agencies that can use risk communication frameworks to deliver accurate health information that can resolve misinformation about COVID-19 in rural communities are needed.

Disparities in the use of colorectal cancer screening in a universally insured population during the COVID-19 pandemic

BACKGROUND

Despite the known efficacy of colorectal cancer (CRC) screening, the rates of individuals undergoing such testing have remained lower than target thresholds, even prior to the healthcare disruptions associated with the COVID-19 pandemic. We evaluated the impact of the COVID-19 pandemic on CRC screening within a nationally representative US population and assessed disparities in screening across racial/ethnic groups and socioeconomic (SES) strata.

METHODS

We performed a retrospective cross-sectional study using all eligible TRICARE beneficiaries aged 45-64 years between FY 2018 and 2021. High-risk individuals, those with a previous or current CRC diagnosis, and/or a personal/family history of colonic polyps, were excluded. The pre-COVID-19 period (September 1, 2018-March 31, 2020) was compared to the COVID-19 period (April 1, 2020-September 30, 2021). Secondary analyses were performed, evaluating the interaction between the COVID-19 time period, race, and our proxy for socioeconomic status.

RESULTS

During the study period, we identified 1,749,688 eligible individuals. Following the onset of the COVID-19 pandemic, CRC screening overall decreased from 34% in the pre-pandemic period to 30% following the onset of the pandemic (p < 0.001). This finding persisted even after adjusting for confounders in multivariable analysis (odds ratio [OR] for the pandemic timeframe: 0.79; 95% CI: 0.27, 0.31; p < 0.001). In the setting of SES, in the pandemic period, the odds of individuals from both Senior Enlisted (OR: 0.55; 95% CI: 0.54, 0.56) and Junior Enlisted sponsor ranks (OR: 0.27; 95% CI: 0.25, 0.30) were diminished as compared to Senior Officers.

CONCLUSIONS AND RELEVANCE

We found a 21% reduction in the odds of CRC screening in the context of the COVID-19 pandemic. Reductions in colonoscopies and other types of screening tests were not offset by changes in the use of at-home tests such as Cologuard.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic

BACKGROUND

COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System.

METHODS

We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status.

RESULTS

During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care.

CONCLUSIONS

We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Cross-sectional analysis of avoidable emergency department visits before and during the COVID-19 pandemic

BACKGROUND

COVID-19 had a significant impact on Emergency Departments (ED) with early data suggesting an initial decline in avoidable ED visits. However, the sustained impact over time is unclear. In this study, we analyzed ED discharges over a two-year time period after the COVID-19 pandemic began and compared it with a control time period pre-pandemic to evaluate the difference in ED visit categories, including total, avoidable, and unavoidable visits.

METHODS

This was a retrospective, cross-sectional study assessing the distribution of visits with ED discharges from two hospitals within a health system over a three-year time period (1/1/2019-12/31/2021). Visits were categorized using the expanded NYU-EDA algorithm modified to include COVID-19-related visits. Categories included: Emergent - Not Preventable/Avoidable, Emergent - Preventable/Avoidable, Emergent - Primary Care Treatable, Non-Emergent, Mental Health, Alcohol, Substance Abuse, Injury, and COVID-19. Chi-square testing was conducted to investigate differences within the time period before COVID-19 (1/1/2019-12/31/2019) and both initial (1/1/2020-12/31/2020) and delayed (1/1/2021-12/31/2021) COVID-19 time frames and ED visit categories, as well as post hoc testing using Fisher's exact tests with Bonferroni correction. ANOVA with post hoc Bonferroni testing was used to determine differences based on daily census for each ED visit category.

RESULTS

A total of 228,010 ED discharges (Hospital #1 = 126,858; Hospital #2 = 101,152) met our inclusion criteria over the three-year period. There was a significant difference in the distribution of NYU-EDA categories between the two time periods (pre-COVID-19 versus during COVID-19) for the combined hospitals (p < 0.001), Hospital #1 (p < 0.001), and Hospital #2 (p < 0.001). When examining daily ED discharges, there was a decline in all categories from 2019 to 2020 except for "Emergent - Not Preventable/Avoidable" which remained stable and "Substance Abuse" which increased. From 2020 to 2021, there were no differences in ED avoidable visits. However, there were increases in discharged visits related to "Injuries", "Alcohol", and "Mental health" and a decrease in "COVID-19".

CONCLUSION

Our study identified a sustained decline in discharged avoidable ED visits during the two years following the beginning of the COVID-19 pandemic, which was partially offset by the increase in COVID-19 visits. This work can help inform ED and healthcare systems in resource allocation, hospital staffing, and financial planning during future COVID-19 resurgences and pandemics.

Healthcare Policy Agenda for a Sustainable Healthcare System in Korea: Building Consensus Using the Delphi Method

BACKGROUND

The purpose of this study is to suggest priority tasks necessary for building a sustainable healthcare system in Korea based on the Delphi consensus among healthcare professionals.

METHODS

Twenty-five items covering the three categories that make up healthcare policy (healthcare demand, supply, and environment) were selected based on a literature evaluation. Email surveys were also analyzed using a two-round modified Delphi method. Of 59 experts, 21 completed the first and second rounds. Each item asked about the degree of importance and urgency, and the answers were rated on a 9-point Likert scale. A coefficient of variation less than 50% for each item in the Delphi survey meant that consensus was reached. Only items that meet a predetermined threshold are prioritized (agreement ≥ 90%, average importance score and urgency score ≥ 6.5).

RESULTS

Eight items that satisfy all three criteria were set as priorities for a sustainable healthcare system. These tasks are "Securing the financial soundness of the National Health Insurance (NHI)," "Solving the problem of low fertility," "Strengthening response to public health crises such as infectious or environmental diseases," "Bio-health technology innovation using D.N.A (Data, Network, AI)," "Intensive management of dementia patients," "Mental healthcare and suicide prevention," "Reform of the operation structure of the NHI Service," and "Reform the healthcare delivery system and payment system."

CONCLUSION

The eight items for which consensus was reached in this study should be prioritized for Korea's sustainable healthcare system. Health policy makers will need to put considerable effort into researching and establishing these priorities.

Injury-Related Emergency Department Visits During the COVID-19 Pandemic

INTRODUCTION

On March 13, 2020, the U.S. declared COVID-19 to be a national emergency. As communities adopted mitigation strategies, there were potential changes in the trends of injuries treated in emergency department. This study provides national estimates of injury-related emergency department visits in the U.S. before and during the pandemic.

METHODS

A secondary retrospective cohort study was conducted using trained, on-site hospital coders collecting data for injury-related emergency department cases from medical records from a nationally representative sample of 66 U.S. hospital emergency departments. Injury emergency department visit estimates in the year before the pandemic (January 1, 2019-December 31, 2019) were compared with estimates of the year of pandemic declaration (January 1, 2020-December 31, 2020) for overall nonfatal injury-related emergency department visits, motor vehicle, falls-related, self-harm-, assault-related, and poisoning-related emergency department visits.

RESULTS

There was an estimated 1.7 million (25%) decrease in nonfatal injury-related emergency department visits during April through June 2020 compared with those of the same timeframe in 2019. Similar decreases were observed for emergency department visits because of motor vehicle‒related injuries (199,329; 23.3%) and falls-related injuries (497,971; 25.1%). Monthly 2020 estimates remained relatively in line with 2019 estimates for self-harm‒, assault-, and poisoning-related emergency department visits.

CONCLUSIONS

These findings provide updates for clinical and public health practitioners on the changing profile of injury-related emergency department visits during the COVID-19 pandemic. Understanding the short- and long-term impacts of the pandemic is important to preventing future injuries.

Impact of COVID-19 on perinatal care: Perceptions of family physicians in the United States

BACKGROUND

Patient-centered care is the best practice in the care of pregnant and postpartum patients. The COVID-19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient-centered care more difficult. This study aimed to understand the impact of the COVID-19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States.

METHODS

From October 5 to November 4, 2020, we surveyed mid- to late-career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID-19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion-crystallization approach was used to analyze qualitative data provided as open-text comments.

RESULTS

Of the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID-19 on perinatal care in free-text comments. Eight themes emerged related to the impact of COVID-19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID-19 was on patient experience.

CONCLUSIONS

Family physicians who provided perinatal care during the COVID-19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient-centered and family-centered care. Continued research is needed to understand the long-term impact of policies affecting the delivery of patient-centered perinatal care and to inform more evidence-based, proactive policies to be implemented in future pandemic or disaster situations.

Analysis of the effects of the first and second/third waves of the COVID-19 pandemic on an Interdisciplinary Endoscopy Unit in a German 'hotspot' area: a single-center experience

BACKGROUND

Since December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed a pandemic threat to global health. We are now in the fourth wave of this pandemic. As the pandemic developed, the requirements and therapeutic endoscopic procedures for SARS-CoV-2-positive patients underwent changes.

METHODS

Analysis of implications for an endoscopy unit during the first and second/third waves of the COVID-19 pandemic with a focus on COVID-19-related process changing. Addressed are number of SARS-CoV-2-positive patients and endoscopic examinations performed in patients who tested positive for SARS-CoV-2 during the various waves, adherence to scheduled examinations, rotation of staff to COVID-dedicated structures and, finally, impact of vaccination on infection rate among endoscopic staff.

RESULTS

During the first wave, 10 SARS-CoV-2-positive in-house patients underwent a total of 22 gastrointestinal (GI) endoscopic procedures. During the second and third waves, 59 GI endoscopies were performed in 38 patients. While in the first wave, GI bleeding was the main indication for endoscopy (82%), in the second and third waves the main indication for endoscopy was endoscopic insertion of deep feeding tubes (78%; p < 0.001). During the first wave, 5 (17%) of 29 Interdisciplinary Endoscopy Unit (IEU) staff members were moved to designated COVID wards, which was not necessary during the following waves. Lack of protective clothing was critical during the first wave, but not in the later waves. Screening tests for patients and staff were widely available after the first wave, and IEU staff was vaccinated during the second wave.

CONCLUSION

Strategies to ensure safe endoscopies with respect to preventing transmission of SARS-CoV-2 from patients to staff were effective. Organizational adjustments allowed the routine program to continue unaffected. Indications for GI endoscopies changed over time: during the first wave, GI endoscopies were performed for life-threatening indications, whereas later supportive procedures were the main indication.

Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform

Health systems worldwide are experiencing profound shocks resulting from the COVID-19 pandemic, with increased attention to health system resilience and researching ways to endure shocks. Pre-COVID-19, Ireland had begun a ten-year programme of reform, Sláintecare, aiming to deliver universal, timely access to integrated care. This study examines whether and how the Irish government's pandemic response contributed to health system reform and increased resilience including delivering universal healthcare. Documentary analysis identified and critiqued relevant government, health system and budgetary documents, published March 2020 - May 2021. Thirteen national policy documents were found, showing increased policy rhetoric and intent to implement reform, demonstrated by increased policy alignment with and budgetary allocation to Sláintecare, alongside implementation of key innovations. Ireland's health system response to COVID-19 offers a unique opportunity to advance understanding of government efforts to reform amidst a global pandemic. It indicated policy intent and funding to manage the Irish COVID-19 crisis, but to also build health system resilience through implementing Sláintecare. This case study has international significance, enabling policy development with potential for long-term health system transformation.

An assessment of government measures in combatting COVID-19 using ISM and DEMATEL modelling

Purpose

The purpose of this paper is to evaluate the interplay of various measures used by different governments around the world in combatting COVID-19.

Design/methodology/approach

The research uses the interpretative structural modelling (ISM) for assessing the powerful measures amongst the recognized ones, whereas to establish the cause-and-effect relations amongst the variables, the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method is used. Both approaches utilized in the study aid in the comprehension of the relationship amongst the assessed measures.

Findings

According to the ISM model, international support measures have the most important role in reducing the risk of COVID-19. There has also been a suggestion of a relationship between economic and risk measures. Surprisingly, no linkage factor (unstable one) was reported in the research. The study indicates social welfare measures, R&D measures, centralized power and decentralized governance measures and universal healthcare measures as independent factors. The DEMATEL analysis reveals that the net causes are social welfare measures, centralized power and decentralized government, universal health coverage measure and R&D measures, while the net effects are economic measures, green recovery measures, risk measures and international support measures.

Originality/value

The study includes a list of numerous government measures deployed throughout the world to mitigate the risk of COVID-19, as well as the structural links amongst the identified government measures. The Matrice d'Impacts croises-multiplication applique and classment analysis can help the policymakers in understanding measures used in combatting COVID-19 based on their driving and dependence power. These insights may assist them in employing these measures for mitigating the risks associated with COVID-19 or any other similar pandemic situation in the future.

International survey of audiologists during the COVID-19 pandemic: effects on the workplace

OBJECTIVE

This study surveyed the effects of the COVID-19 pandemic on the audiology workplace.

DESIGN

The study used a cross-sectional survey design for audiologists across the globe (n = 337) using an online survey (June-August 2020) focussing on changes to the workplace during the pandemic.

RESULTS

Participants represented varied work settings and audiology services. Only a third (31.5%) provided psychosocial support, which may be important during the pandemic, as part of their services. Almost all (97%) audiologists reported changes to their workplace, with 76.4% reporting reduced caseloads during the COVID-19 pandemic. When rating their current and anticipated work conditions, 38.7% reported reduced working hours although only 13.8% anticipated reduced working hours in 6-months' time. Audiologists ranked services such as access to hearing assessment, hearing device adjustment and maintenance, and general audiological support as being more important during the pandemic than services such as psychosocial, emotional and tinnitus support.

CONCLUSIONS

The COVID-19 pandemic has resulted in significant disruptions to audiological practice that highlights the need to adapt and incorporate new audiological practices including telehealth, to ensure patients have continued access to care and clinics remain sustainable during the ongoing COVID-19 pandemic and recovery phase.

The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review

BACKGROUND

Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions.

METHODS

A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021.

FINDINGS

During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed.

INTERPRETATION

Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.

Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology?

The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large, urban, academic hospital system

Background

The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic.

Methods

We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions.

Results

While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020.

Conclusions

Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.