Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021

Generalizability of Heat-related Health Risk Associations Observed in a Large Healthcare Claims Database of Patients with Commercial Health Insurance

BACKGROUND

Extreme ambient heat is unambiguously associated with a higher risk of illness and death. The Optum Labs Data Warehouse (OLDW), a database of medical claims from US-based patients with commercial or Medicare Advantage health insurance, has been used to quantify heat-related health impacts. Whether results for the insured subpopulation are generalizable to the broader population has, to our knowledge, not been documented. We sought to address this question, for the US population in California from 2012 to 2019.

METHODS

We examined changes in daily rates of emergency department encounters and in-patient hospitalization encounters for all-causes, heat-related outcomes, renal disease, mental/behavioral disorders, cardiovascular disease, and respiratory disease. OLDW was the source of health data for insured individuals in California, and health data for the broader population were gathered from the California Department of Health Care Access and Information. We defined extreme heat exposure as any day in a group of 2 or more days with maximum temperatures exceeding the county-specific 97.5th percentile and used a space-time-stratified case-crossover design to assess and compare the impacts of heat on health.

RESULTS

Average incidence rates of medical encounters differed by dataset. However, rate ratios for emergency department encounters were similar across datasets for all causes [ratio of incidence rate ratios (rIRR) = 0.989; 95% confidence interval (CI) = 0.969, 1.009], heat-related causes (rIRR = 1.080; 95% CI = 0.999, 1.168), renal disease (rIRR = 0.963; 95% CI = 0.718, 1.292), and mental health disorders (rIRR = 1.098; 95% CI = 1.004, 1.201). Rate ratios for inpatient encounters were also similar.

CONCLUSIONS

This work presents evidence that OLDW can continue to be a resource for estimating the health impacts of extreme heat.

Unraveling the impact of the COVID-19 pandemic on the mortality trends in Belgium between 2020-2022

BACKGROUND

Over the past four years, the COVID-19 pandemic has exerted a profound impact on public health, including on mortality trends. This study investigates mortality patterns in Belgium by examining all-cause mortality, excess mortality, and cause-specific mortality.

METHODS

We retrieved all-cause mortality data from January 1, 2009, to December 31, 2022, stratified by age group and sex. A linear mixed model, informed by all-cause mortality from 2009 to 2019, was used to predict non-pandemic all-cause mortality rates in 2020-2022 and estimate excess mortality. Further, we also analyzed trends in cause-specific and premature mortality.

RESULTS

Different all-cause mortality patterns could be observed between the younger (<45 years) and older age groups. The impact of the COVID-19 pandemic was particularly evident among older age groups. The highest excess mortality occurred in 2020, while a reversal in this trend was evident in 2022. We observed a notable effect of COVID-19 on cause-specific and premature mortality patterns over the three-year period.

CONCLUSIONS

Despite a consistent decline in COVID-19 reported mortality over this three-year period, it remains imperative to meticulously monitor mortality trends in the years ahead.

Clinical Adjudication of Outpatient Complications Reported in the U.S. News and World Report's Urology Rankings

OBJECTIVE

To assess whether the US News and World Report (USNWR) Urology specialty ranking methodology accurately captures and classifies complications following elective outpatient urology procedures.

METHODS

We conducted electronic health record chart review of n = 80 elective, outpatient urology procedures with complications from 2019-2023 across 4 hospitals in our integrated US health system. We used the Solventum AM-PPC software and USNWR methodology to determine eligibility and measure complications. For each complication identified by the software, we assessed: (1) whether the procedure was performed by a urologist; (2) whether the adjudicator agreed with the complication type; and (3) whether the complication was a clinically related sequelae of the index procedure. We reported Clavien-Dindo severity of each complication.

RESULTS

Our adjudication agreed on complication type in 62/80 (78%) complications, and 64/80 (80%) complications were clinically related to the index urology procedure. Combined, 57/80 (71%) complications were concordant on both complication type and clinical relatedness. However, 38/80 (48%) index procedures were conducted by interventional radiologists, not urologists. Furthermore, 11/80 (13.8%) complications were false positive urinary tract infections (UTIs).

CONCLUSION

The USNWR methodology for elective outpatient urology procedural complications showed reasonable clinical validity but detected several false positive UTIs. Further, USNWR should clarify the extent to which procedures performed by interventional radiologists belong in urology rankings.

Impact of post-COVID-19 changes in outpatient chronic patients' healthcare-seeking behaviors on medical utilization and health outcomes

INTRODUCTION

This study comprehensively investigates the changes in healthcare utilization among chronic patients with regular outpatient visits to hospitals after the occurrence of Covid-19. The research examines whether patients altered their originally regular medical attendance frequencies due to the pandemic and explores potential negative impacts on the health conditions of those irregular attendees post-pandemic.

METHODS

Data for this study were sourced from a database at a medical center in Taiwan. The subjects were chronic patients with regular hospital outpatient visits before the Covid-19 outbreak. The study tracked medical utilization patterns from 2017 to 2022 for different patient characteristics and outpatient behaviors, employing statistical methods such as Repeated Measures ANOVA and Generalized Estimating Equation to analyze changes in healthcare utilization and health status during the post-pandemic period.

RESULTS

The results reveal that, compared to the regular group, chronic patients with irregular outpatient visits during the post-pandemic period exhibited a decrease of 5.85 annual outpatient visits, a reduction of NT$20,290.1 in annual medical expenses, and a significantly higher abnormality rate in average biochemical test results by 0.9%.

CONCLUSIONS

The findings contribute to understanding the impact of the Covid-19 pandemic on healthcare utilization and health conditions among outpatient chronic disease populations. In response to the new medical landscape in the post-pandemic era, proactive suggestions are made, including providing telemedicine outpatient services and referral-based medical care to meet the needs of the target population, ensuring a continuous and reassuring healthcare model for chronic patients, and mitigating the operational impacts of public health emergencies on hospitals.

Utilization of the Modified Brain Injury Guidelines by Neurosurgeons to Improve Traumatic Brain Injury Patient Throughput at a Level I Trauma Center: A Retrospective Observational Study

OBJECTIVE

The modified Brain Injury Guidelines (mBIG) were developed to improve care of patients with traumatic brain injury (TBI). This study aimed to assess if utilization of mBIG by neurosurgeons would improve TBI patient throughput at a Level I trauma center, particularly for patients meeting mBIG 1 criteria.

METHODS

This was a retrospective observational study at a Level I trauma center. The mBIG were adopted in November 2021. Outcome and safety data for patients ≥18 years old meeting mBIG 1 criteria treated 18 months before (pre-mBIG cohort) or after (post-mBIG cohort) implementation were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to mBIG, neurosurgery was involved in the care of all patients.

RESULTS

The study included 170 patients with traumatic brain injury (77 pre-mBIG, 93 post-mBIG). In the post-mBIG cohort, 53 patients (57%) were discharged from the emergency department after a period of observation versus 3 patients (4%) in the pre-mBIG cohort (P ≤ 0.01). Post-mBIG patients who were not discharged were most often admitted for care of other injuries (85%). Repeat neuroimaging was less frequent in post-mBIG patients (15% vs. 62%, P ≤ 0.01). No patients in either cohort needed operative neurosurgical interventions or medical therapy for intracranial hypertension or experienced neurological deterioration. No post-mBIG patients had radiographic injury progression. The rate of repeat emergency department presentation within 30 days was not different between cohorts (P = 0.14).

CONCLUSIONS

The mBIG 1 criteria were safe and improved low-risk TBI patient throughput at a Level I trauma center. Neurosurgical involvement may be beneficial to the mBIG while still facilitating significant resource savings.

Characterizing the impact of the Covid-19 pandemic on adults with autosomal dominant polycystic kidney disease: a cross-sectional study

BACKGROUND

The Covid-19 pandemic greatly affected those with chronic diseases, impacting healthcare access and healthcare seeking behaviors. The impact of the pandemic on adults with Autosomal Dominant Polycystic Kidney Disease (ADPKD) has not been investigated.

METHODS

Participants were recruited from a cohort of 239 ADPKD patients enrolled in a longitudinal study at the University of Maryland. Patients on renal replacement therapy were excluded. N = 66 patients participated in a phone questionnaire from June 2022-December 2022 about ADPKD-related complications, concern about contracting Covid-19, healthcare-seeking behaviors, and telehealth utilization before and after March 2020.

RESULTS

N = 34 (51.5%) of participants reported a positive Covid-19 test result. N = 29 (44%) expressed high concern of contracting Covid-19. Those who avoided medical care at least once (N = 17, 25.8%) had similar demographics and ADPKD severity to those who did not, but reported greater telehealth utilization (88.2% vs. 42.9%, p = 0.002), greater use of non-prescribed medication for Covid-19 treatment or prevention (35.3% vs. 8.2%, p = 0.01), and were more likely to contract Covid-19 (76.5% vs. 42.9%, p = 0.02). Among the N = 53 who reported very good or excellent ADPKD disease management pre-pandemic, N = 47(89%) reported no significant change during the pandemic.

CONCLUSIONS

In this highly educated, high-income cohort with a mean age of 46.1 years, most people reported well-managed ADPKD prior to the pandemic. This may explain why less than half of participants expressed high concern for contracting Covid-19. Overall, there was no significant pandemic-related decline in self-reported ADPKD management. This was likely due to this cohort's excellent access to, and uptake of, telehealth services. Notably, 1 in 4 participants reported healthcare avoidant behavior, the effect of which may only be seen years from now. Future studies should investigate potential impacts of avoidant behaviors, as well as expand investigation to a more diverse cohort whose care may not have been as easily transitioned to telehealth.

The Impact of COVID-19 on Substance Use and Related Consequences among Patients in Office-Based Opioid Use Disorder Treatment

OBJECTIVES

The COVID-19 pandemic led to increased substance-related morbidity and mortality and transformed care for opioid use disorder (OUD). We assessed the perceived impacts of the pandemic on substance use and related consequences among patients in office-based addiction treatment (OBAT).

METHODS

We recruited patients with OUD on buprenorphine from July 2021 to July 2022, with data collection at baseline and 6 months. Exposures of interest were the following 6 domains potentially impacted by COVID-19: personal or family infection, difficulty accessing healthcare/medication, economic stressors, worsening physical or mental health, social isolation, and conflicts/disruptions in the home. Outcomes were past 30-day alcohol and other substance use, increased use, and substance-related consequences at baseline and 6 months. Generalized estimating equations Poisson regression models quantified associations between increasing impact domain scores and relative risks of each outcome.

RESULTS

All participants (N = 150) reported at least one domain negatively impacted by COVID-19 at both time points. Higher "worsening physical or mental health" domain scores were associated with increased relative risk of recent alcohol or drug use (adjusted risk ratio [aRR] 1.04, 95% confidence interval [CI]: 1.01-1.07). Relative risks of experiencing substance-related consequences increased with higher scores in the domains of economic stressors (aRR 1.07, 95% CI: 1.02-1.13), difficulty accessing healthcare/medication (aRR 1.11, 95% CI: 1.04-1.19), and worsening physical or mental health (aRR 1.08, 95% CI: 1.04-1.12).

CONCLUSIONS

Among patients with OUD, stressors from COVID-19 were common. Three life domains impacted by COVID-19 appeared to be associated with consequential substance use, highlighting opportunities to address barriers to healthcare access and economic stressors.

Climate change and resilience for antimicrobial stewardship and infection prevention

PURPOSE OF REVIEW

This review covers recent research regarding the challenges posed by climate change within the areas of antimicrobial stewardship and infection prevention, and ways to build resiliency in these fields.

RECENT FINDINGS

Infectious disease patterns are changing as microbes adapt to climate change and changing environmental factors. Capacity for testing and treating infectious diseases is challenged by newly emerging diseases, which exacerbate challenges to antimicrobial stewardship and infection prevention.Antimicrobial resistance is accelerated due to environmental factors including air pollution, plastic pollution, and chemicals used in food systems, which are all impacted by climate change.Climate change places infection prevention practices at risk in many ways including from major weather events, increased risk of epidemics, and societal disruptions causing conditions that can overwhelm health systems. Researchers are building resilience by advancing rapid diagnostics and disease modeling, and identifying highly reliable versus low efficiency interventions.

SUMMARY

Climate change and associated major weather and socioeconomic events will place significant strain on healthcare facilities. Work being done to advance rapid diagnostics, build supply chain resilience, improve predictive disease modeling and surveillance, and identify high reliability versus low yield interventions will help build resiliency in antimicrobial stewardship and infection prevention for escalating challenges due to climate change.

The Neurologist's Guide to Drug Pricing in the United States

ABSTRACT

As newer, innovative neurology drugs enter the US health care system, neurologists should consider the cost of these treatments in addition to their efficacy, safety, and tolerability. To do so thoughtfully requires an understanding of how prescription drugs are priced in the United States. The process of drug pricing is linked to the distribution supply chain and the many stakeholders involved. Stakeholders include pharmaceutical manufacturers; wholesalers; pharmacies; pharmacy benefit managers; payers, including health insurers; hospital systems; neurologists and other clinicians; and patients. Drug pricing has taken center stage as the Inflation Reduction Act of 2022 has set maximum out-of-pocket expenses for Medicare beneficiaries for the first time in the program's history and limits drug price increases for a select group of Medicare Part D drugs. This article describes the US drug distribution supply chain and its stakeholders and introduces key drug pricing terms; a brief description of how rebates are generally estimated will also be discussed. Finally, as newer neurology outpatient drugs enter the market, the "value" of drugs will be described through cost-effectiveness terminology and their utility for the clinical neurologist.

Impact of the Early COVID-19 Pandemic on Incidence and Outcomes of Hepatocellular Carcinoma in the United States

INTRODUCTION

Access to hepatocellular carcinoma (HCC) surveillance and treatments were disrupted during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to characterize the impact of the pandemic on HCC incidence and mortality rates, treatment, and outcomes in the United States.

METHODS

Two nationwide databases, the United States Cancer Statistics and the National Vital Statistics System, were used to investigate HCC incidence and mortality between 2001 and 2020. Trends in age-adjusted incidence rate (aIR) and adjusted mortality rate (aMR) were assessed using joinpoint analysis. The 2020 aIR and aMR were projected based on the prepandemic data and compared with actual values to assess the extent of underdiagnosis. We assessed differences in HCC characteristics, treatment, and overall survival between 2020 and 2018-2019.

RESULTS

The aIR of HCC in 2020 was significantly reduced compared with 2019 (5.22 vs 6.03/100K person-years [PY]), representing a 12.2% decrease compared with the predicted aIR in 2020 (5.94/100K PY). The greatest extent of underdiagnosis was observed in Black (-14.87%) and Hispanic (-14.51%) individuals and those with localized HCC (-15.12%). Individuals staged as regional or distant HCC were also less likely to receive treatment in 2020. However, there was no significant difference in short-term overall survival in 2020 compared with 2018-2019, with HCC mortality rates remaining stable (aMR: 2.76 vs 2.73/100K PY in 2020 vs 2019).

DISCUSSION

The COVID-19 pandemic resulted in underdiagnosis of HCC, particularly early stage disease and racial ethnic minorities, and underuse of HCC-directed treatment. Longer follow-up is needed to determine the impact of the COVID-19 pandemic on HCC-related mortality.

Changes in Health Care and Prescription Medication Affordability in the US During the COVID-19 Pandemic

Importance

In the US, the COVID-19 pandemic led to a significant rise in unemployment and economic loss that disproportionately impacted low-income individuals. It is unknown how health care and prescription medication affordability changed among low-income adults during the COVID-19 pandemic overall and compared with their higher-income counterparts.

Objective

To evaluate changes in health care affordability and prescription medication affordability during the COVID-19 pandemic (2021 and 2022) compared with pre-COVID-19 pandemic levels (2019) and whether income-based inequities changed.

Design, Setting, and Participants

This retrospective cross-sectional study included adults 18 years and older participating in the National Health Interview Survey (NHIS) in 2019, 2021, and 2022. Low-income adults were defined as having a household income of 200% or less of the federal poverty level (FPL); middle-income adults, 201% to 400% of the FPL; and high-income adults, more than 400% of the FPL. Data were analyzed from June to November 2023.

Main Outcomes and Measures

Measures of health care affordability and prescription medication affordability.

Results

The study population included 89 130 US adults. Among the weighted population, 51.6% (95% CI, 51.2-52.0) were female, and the mean (SD) age was 48.0 (0.12) years. Compared with prepandemic levels, during the COVID-19 pandemic, low-income adults were less likely to delay medical care (2022: 11.2%; 95% CI, 10.3-12.1; 2019: 15.4%; 95% CI, 14.3-16.4; adjusted relative risk [aRR], 0.73; 95% CI, 0.66-0.81) or avoid care (2022: 10.7%; 95% CI, 9.7-11.6; 2019: 14.9%; 95% CI, 13.8-15.9; aRR, 0.72; 95% CI, 0.64-0.80) due to cost, while high-income adults experienced no change, resulting in a significant improvement in income-based disparities. Low-income and high-income adults were less likely to experience problems paying medical bills but experienced no change in worrying about medical bills during the COVID-19 pandemic compared with prepandemic levels. Across measures of prescription medication affordability, low-income adults were less likely to delay medications (2022: 9.4%; 95% CI, 8.4-10.4; 2019: 12.7%; 95% CI, 11.6-13.9; aRR, 0.74; 95% CI, 0.65-0.84), not fill medications (2022: 8.9%; 95% CI, 8.1-9.8; 2019: 12.0%; 95% CI, 11.1-12.9; aRR, 0.75; 95% CI, 0.66-0.83), skip medications (2022: 6.7%; 95% CI, 5.9-7.6; 2019: 10.1%; 95% CI, 9.1-11.1; aRR, 0.67; 95% CI, 0.57-0.77), or take less medications (2022: 7.3%; 95% CI, 6.4-8.1; 2019: 11.2%; 95% CI, 10.%-12.2; aRR, 0.65; 95% CI, 0.56-0.74) due to costs, and these patterns were largely similar among high-income adults. Improvements in measures of health care and prescription medication affordability persisted even after accounting for changes in health insurance coverage and health care use. These patterns were similar when comparing measures of affordability in 2021 with 2019.

Conclusions and Relevance

Health care affordability improved for low-income adults during the COVID-19 pandemic, resulting in a narrowing of income-based disparities, while prescription medication affordability improved for all income groups. These findings suggest that the recent unwinding of COVID-19 pandemic-related safety-net policies may worsen health care affordability and widen existing income-based inequities.

Characterizing the Impact of the Covid-19 Pandemic on Adults with Autosomal Dominant Polycystic Kidney Disease: A Cross-Sectional Study

Background

The Covid-19 pandemic greatly affected those with chronic diseases, impacting healthcare access and healthcare seeking behaviors. The impact of the pandemic on adults with Autosomal Dominant Polycystic Kidney Disease (ADPKD) has not been investigated.

Methods

Participants were recruited from a cohort of 239 ADPKD patients enrolled in a longitudinal study at the University of Maryland. Patients on renal replacement therapy were excluded. N = 66 patients participated in a phone questionnaire from June 2022-December 2022 about ADPKD-related complications, concern about contracting Covid-19, healthcare-seeking behaviors, and telehealth utilization before and after March 2020.

Results

N = 34 (51.5%) of participants reported a positive Covid-19 test result and N = 29 (44%) expressed high concern of contracting Covid-19. Those who avoided medical care at least once (N = 17, 25.8%) had similar demographics and ADPKD severity to those who did not, but reported greater telehealth utilization (88.2% vs. 42.9%, p = 0.002), greater use of non-prescribed medication for Covid-19 treatment or prevention (35.3% vs. 8.2%, p = 0.01), and were more likely to contract Covid-19 (76.5% vs. 42.9%, p = 0.02). Among the N = 53 who reported very good or excellent ADPKD disease management pre-pandemic, N = 47(89%) reported no significant change during the pandemic.

Conclusions

In this highly educated, high-income cohort with a mean age of 46.1 years, most people reported well-managed ADPKD prior to the pandemic. This may explain why less than half of participants expressed high concern for contracting Covid-19. Overall, there was no significant pandemic-related decline in self-reported ADPKD management, like due to excellent access to, and uptake of, telehealth services. Notably, 1 in 4 participants reported healthcare avoidant behavior, the effect of which may only be seen years from now. Future studies should investigate potential impacts of avoidant behaviors, as well as expand investigation to a more diverse cohort whose care may not have been as easily transitioned to telehealth.

Prevalence and determinants of massage therapy use in the U.S.: Findings from the 2022 National Health Interview Survey

BACKGROUND

This study presents findings on the prevalence and determinants of past-year massage therapy use among U.S. adults from the 2022 round of the National Health Interview Survey (NHIS) (total available N = 27,651), an annual national population survey.

METHODS

The NHIS uses face-to-face interviews on a representative sample of the civilian, noninstitutionalized U.S. population drawn using a systematic, stratified, single-stage probability design. The analyses consist of logistically modeling the determinants of three outcome (dependent) measures: past year utilization of a practitioner of massage, past year utilization of massage for pain, and past-year utilization of massage to restore overall health. Exposure (independent) variables include numerous sociodemographic, health services, health-related, mental health and well-being, and behavioral indicators.

RESULTS

The past-year prevalence rate for visiting a massage therapist in the U.S. is 11.1 %. The past-year rate for massage visits for pain is 6.0 %, and for restoring overall health is 8.5 %. Significantly higher rates are found among females and socioeconomically advantaged individuals, among other categories, and the strongest net determinant of massage therapy utilization is use of complementary or integrative practitioners.

CONCLUSION

It is apparent that massage therapy is a commonly utilized therapeutic modality in the U.S. While use of complementary or integrative therapies is a significant determinant of massage utilization, it may not be fitting to consider massage therapy itself as an "alternative" therapy, but rather a widely used and increasingly mainstream therapeutic modality meriting wider integration into the community of healthcare professions.

Vasectomy incidence in the military health system after the reversal of Roe v. Wade

Dobbs v. Jackson Women's Health Organization (Dobbs decision) has already had profound impact on reproductive health care in the United States. Some studies have reported increased incidence of vasectomy after the Dobbs decision. The Military Health System (MHS) provides a unique opportunity to evaluate this relationship in a universally insured, geographically representative population. We conducted a retrospective cross-sectional study of vasectomies among all male beneficiaries in the MHS, ages 18 to 64, from 2018 to 2022. Beneficiaries receiving a vasectomy were identified via billing data extraction from the MHS Data Repository (MDR). Descriptive statistics of demographic factors of all those receiving a vasectomy in the study period were evaluated. Crude and multivariate logistic regression models were used to evaluate for differences in demographic variables in those receiving a vasectomy pre-Dobb's decision as compared to after the Dobb's decision. The total number of men receiving a vasectomy each month over the study period was analyzed, as were the numbers in a state immediately implementing abortion access restrictions (Texas), and one without any restrictions on abortion access (Virginia). Our analysis found that men receiving a vasectomy post-Dobbs decision were more likely to be younger, unmarried, and of junior military rank than prior to the Dobbs decision. In the months following the Dobbs decision in 2022 (June-December), there was a 22.1% increase in vasectomy utilization as compared to the averages of those months in 2018-2021. Further, it was found that the relative increase in vasectomy after the Dobbs decision was greater in Texas (29.3%) compared to Virginia (10.6%). Our findings highlight the impact of the Dobbs decision on reproductive health care utilization outside of abortion.

Association of COVID-19 Pandemic with Colorectal Cancer Screening: Impact of Race/Ethnicity and Social Vulnerability

BACKGROUND

The COVID-19 pandemic disrupted health care delivery, including cancer screening practices. This study sought to determine the impact of the COVID-19 pandemic lockdown on colorectal cancer (CRC) screening relative to social vulnerability.

METHODS

Using the Medicare Standard Analytic File, individuals 65 years old or older who were eligible for guideline-concordant CRC screening between 2019 and 2021 were identified. These data were merged with the Center for Disease Control Social Vulnerability Index (SVI) dataset. Changes in county-level monthly screening volumes relative to the start of the COVID-19 pandemic (March 2020) and easing of restrictions (March 2021) were assessed relative to SVI.

RESULTS

Among 10,503,180 individuals continuously enrolled in Medicare with no prior diagnosis of CRC, 1,362,457 (12.97%) underwent CRC screening between 2019 and 2021. With the COVID-19 pandemic, CRC screening decreased markedly across the United States (median monthly screening: pre-pandemic [n = 76,444] vs pandemic era [n = 60,826]; median Δn = 15,618; p < 0.001). The 1-year post-pandemic overall CRC screening utilization generally rebounded to pre-COVID-19 levels (monthly median screening volumes: pandemic era [n = 60,826] vs post-pandemic [n = 74,170]; median Δn = 13,344; p < 0.001). Individuals residing in counties with the highest SVI experienced a larger decline in CRC screening odds than individuals residing in low-SVI counties (reference, low SVI: pre-pandemic high SVI [OR, 0.85] vs pandemic high SVI [OR, 0.81] vs post-pandemic high SVI [OR, 0.85]; all p < 0.001).

CONCLUSIONS

The COVID-19 pandemic was associated with a decrease in CRC screening volumes. Patients who resided in high social vulnerability areas experienced the greatest pandemic-related decline.

Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018

BACKGROUND

Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity.

METHODS

The study evaluated data from the 1988-2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index-metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories-were calculated.

RESULTS

A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0-55.5 years; women, 51.9%-53.0%). From 1988-1994 to 2015-2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%-5.1%, P<0.05; PIR 3-4.99: 7.6%-6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%-8.7%). In 1988-1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015-2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%-7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health.

CONCLUSIONS

In this serial cross-sectional survey of US adults spanning 30 years, the population's mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.

Long-term Mammography Screening Trends and Predictors of Return to Screening after the COVID-19 Pandemic: Results from a Statewide Registry

Purpose To evaluate long-term trends in mammography screening rates and identify sociodemographic and breast cancer risk characteristics associated with return to screening after the COVID-19 pandemic. Materials and Methods In this retrospective study, statewide screening mammography data of 222 384 female individuals aged 40 years or older (mean age, 58.8 years ± 11.7 [SD]) from the Vermont Breast Cancer Surveillance System were evaluated to generate descriptive statistics and Joinpoint models to characterize screening patterns during 2000-2022. Log-binomial regression models estimated associations of sociodemographic and risk characteristics with post-COVID-19 pandemic return to screening. Results The proportion of female individuals in Vermont aged 50-74 years with a screening mammogram obtained in the previous 2 years declined from a prepandemic level of 61.3% (95% CI: 61.1%, 61.6%) in 2019 to 56.0% (95% CI: 55.7%, 56.3%) in 2021 before rebounding to 60.7% (95% CI: 60.4%, 61.0%) in 2022. Screening adherence in 2022 remained substantially lower than that observed during the 2007-2010 apex of screening adherence (66.1%-67.0%). Joinpoint models estimated an annual percent change of -1.1% (95% CI: -1.5%, -0.8%) during 2010-2022. Among the cohort of 95 644 individuals screened during January 2018-March 2020, the probability of returning to screening during 2020-2022 varied by age (eg, risk ratio [RR] = 0.94 [95% CI: 0.93, 0.95] for age 40-44 vs age 60-64 years), race and ethnicity (RR = 0.84 [95% CI: 0.78, 0.90] for Black vs White individuals), education (RR = 0.84 [95% CI: 0.81, 0.86] for less than high school degree vs college degree), and by 5-year breast cancer risk (RR = 1.06 [95% CI: 1.04, 1.08] for very high vs average risk). Conclusion Despite a rebound to near prepandemic levels, Vermont mammography screening rates have steadily declined since 2010, with certain sociodemographic groups less likely to return to screening after the pandemic. Keywords: Mammography, Breast, Health Policy and Practice, Neoplasms-Primary, Epidemiology, Screening Supplemental material is available for this article. © RSNA, 2024.

Risk of Potentially Preventable Hospitalizations After SARS-CoV-2 Infection

Importance

Research demonstrates that SARS-CoV-2 infection is associated with increased risk of all-cause hospitalization. However, no prior studies have assessed the association between SARS-CoV-2 and potentially preventable hospitalizations-that is, hospitalizations for conditions that can usually be effectively managed in ambulatory care settings.

Objective

To examine whether SARS-CoV-2 is associated with potentially preventable hospitalization in a nationwide cohort of US veterans.

Design, Setting, and Participants

This cohort study used an emulated target randomized trial design with monthly sequential trials to compare risk of a potentially preventable hospitalization among veterans with SARS-CoV-2 and matched comparators without SARS-CoV-2. A total of 189 136 US veterans enrolled in the Veterans Health Administration (VHA) who were diagnosed with SARS-CoV-2 between March 1, 2020, and April 30, 2021, and 943 084 matched comparators were included in the analysis. Data were analyzed from May 10, 2023, to January 26, 2024.

Exposure

SARS-CoV-2 infection.

Main Outcomes and Measures

The primary outcome was a first potentially preventable hospitalization in VHA facilities, VHA-purchased community care, or Medicare fee-for-service care. Extended Cox models were used to examine adjusted hazard ratios (AHRs) of potentially preventable hospitalization among veterans with SARS-CoV-2 and comparators during follow-up periods of 0 to 30, 0 to 90, 0 to 180, and 0 to 365 days. The start of follow-up was defined as the date of each veteran's first positive SARS-CoV-2 diagnosis, with the same index date applied to their matched comparators.

Results

The 1 132 220 participants were predominantly men (89.06%), with a mean (SD) age of 60.3 (16.4) years. Most veterans were of Black (23.44%) or White (69.37%) race. Veterans with SARS-CoV-2 and comparators were well-balanced (standardized mean differences, all <0.100) on observable baseline clinical and sociodemographic characteristics. Overall, 3.10% of veterans (3.81% of those with SARS-CoV-2 and 2.96% of comparators) had a potentially preventable hospitalization during 1-year follow-up. Risk of a potentially preventable hospitalization was greater among veterans with SARS-CoV-2 than comparators in 4 follow-up periods: 0- to 30-day AHR of 3.26 (95% CI, 3.06-3.46); 0- to 90-day AHR of 2.12 (95% CI, 2.03-2.21); 0- to 180-day AHR of 1.69 (95% CI, 1.63-1.75); and 0- to 365-day AHR of 1.44 (95% CI, 1.40-1.48).

Conclusions and Relevance

In this cohort study, an increased risk of preventable hospitalization in veterans with SARS-CoV-2, which persisted for at least 1 year after initial infection, highlights the need for research on ways in which SARS-CoV-2 shapes postinfection care needs and engagement with the health system. Solutions are needed to mitigate preventable hospitalization after SARS-CoV-2.

Integration of Telemedicine Consultation Into a Tertiary Radiation Oncology Department: Predictors of Use, Treatment Yield, and Effects on Patient Population

PURPOSE

The COVID-19 pandemic led to rapid expansion of telemedicine. The implications of telemedicine have not been rigorously studied in radiation oncology, a procedural specialty. This study aimed to evaluate the characteristics of in-person patients (IPPs) and virtual patients (VPs) who presented to a large cancer center before and during the pandemic and to understand variables affecting likelihood of receiving radiotherapy (yield) at our institution.

METHODS

A total of 17,915 patients presenting for new consultation between 2019 and 2021 were included, stratified by prepandemic and pandemic periods starting March 24, 2020. Telemedicine visits included video and telephone calls. Area deprivation indices (ADIs) were also compared.

RESULTS

The overall population was 56% male and 93% White with mean age of 63 years. During the pandemic, VPs accounted for 21% of visits, were on average younger than their in-person (IP) counterparts (63.3 years IP v 62.4 VP), and lived further away from clinic (215 miles IP v 402 VP). Among treated VPs, living closer to clinic was associated with higher yield (odds ratio [OR], 0.95; P < .001). This was also seen among IPPs who received treatment (OR, 0.96; P < .001); however, the average distance from clinic was significantly lower for IPPs than VPs (205 miles IP v 349 VP). Specialized radiotherapy (proton and brachytherapy) was used more in VPs. IPPs had higher ADI than VPs. Among VPs, those treated had higher ADI (P < .001).

CONCLUSION

Patient characteristics and yield were significantly different between IPPs and VPs. Telemedicine increased reach to patients further away from clinic, including from rural or health care-deprived areas, allowing access to specialized radiation oncology care. Telemedicine has the potential to increase the reach of other technical and procedural specialties.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020

OBJECTIVE

We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic.

METHODS

We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth.

RESULTS

Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020.

CONCLUSIONS

Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

The Impact of the COVID-19 Pandemic on Diabetes Self-Management in Saudi Arabia

The COVID-19 pandemic disrupted healthcare worldwide, potentially impacting disease management. The objective of this study was to assess the self-management behaviors of Saudi patients with diabetes during and after the COVID pandemic period using the Arabic version of the Diabetes Self-Management Questionnaire (DSMQ). A cross-sectional study was conducted in patients aged ≥18 years diagnosed with type 2 diabetes mellitus who had at least one ambulatory clinic visit in each of the specified time frames (Pre-COVID-19: 1 January 2019-21 March 2020; COVID-19 Time frame: 22 March 2020 to 30 April 2021) utilizing the DSMQ questionnaire, with an additional three questions specifically related to their diabetes care during the COVID pandemic. A total of 341 patients participated in the study. The study results revealed that the surveyed patients showed moderately high self-care activities post-COVID-19. Total DSMQ scores were significantly higher in patients aged >60 years versus younger groups (p < 0.05). Scores were significantly lower in patients diagnosed for 1-5 years versus longer durations (p < 0.05). Patients on insulin had higher glucose management sub-scores than oral medication users (p < 0.05). Overall, DSMQ scores were higher than the pre-pandemic Saudi population and Turkish post-pandemic findings. DSMQ results suggest that, while COVID-19 negatively impacted some self-management domains, the Saudi patients surveyed in this study upheld relatively good diabetes control during the pandemic. Further research is warranted on specific barriers to optimize diabetes care during public health crises.

Impact of the COVID-19 Pandemic on Health Care Utilization in the Vaccine Safety Datalink: Retrospective Cohort Study

BACKGROUND

Understanding the long-term impact of the COVID-19 pandemic on health care utilization is important to health care organizations and policy makers for strategic planning, as well as to researchers when designing studies that use observational electronic health record data during the pandemic period.

OBJECTIVE

This study aimed to evaluate the changes in health care utilization across all care settings among a large, diverse, and insured population in the United States during the COVID-19 pandemic.

METHODS

We conducted a retrospective cohort study within 8 health care organizations participating in the Vaccine Safety Datalink Project using electronic health record data from members of all ages from January 1, 2017, to December 31, 2021. The visit rates per person-year were calculated monthly during the study period for 4 health care settings combined as well as by inpatient, emergency department (ED), outpatient, and telehealth settings, both among all members and members without COVID-19. Difference-in-difference analysis and interrupted time series analysis were performed to assess the changes in visit rates from the prepandemic period (January 2017 to February 2020) to the early pandemic period (April-December 2020) and the later pandemic period (July-December 2021), respectively. An exploratory analysis was also conducted to assess trends through June 2023 at one of the largest sites, Kaiser Permanente Southern California.

RESULTS

The study included more than 11 million members from 2017 to 2021. Compared with the prepandemic period, we found reductions in visit rates during the early pandemic period for all in-person care settings. During the later pandemic period, overall use reached 8.36 visits per person-year, exceeding the prepandemic level of 7.49 visits per person-year in 2019 (adjusted percent change 5.1%, 95% CI 0.6%-9.9%); inpatient and ED visits returned to prepandemic levels among all members, although they remained low at 0.095 and 0.241 visits per person-year, indicating a 7.5% and 8% decrease compared to pre-pandemic levels among members without COVID-19, respectively. Telehealth visits, which were approximately 42% of the volume of outpatient visits during the later pandemic period, were increased by 97.5% (95% CI 86.0%-109.7%) from 0.865 visits per person-year in 2019 to 2.35 visits per person-year in the later pandemic period. The trends in Kaiser Permanente Southern California were similar to those of the entire study population. Visit rates from January 2022 to June 2023 were stable and appeared to be a continuation of the use levels observed at the end of 2021.

CONCLUSIONS

Telehealth services became a mainstay of the health care system during the late COVID-19 pandemic period. Inpatient and ED visits returned to prepandemic levels, although they remained low among members without evidence of COVID-19. Our findings provide valuable information for strategic resource allocation for postpandemic patient care and for designing observational studies involving the pandemic period.

Prevalence of lifestyle-related behavioral information in claims data in the U.S

OBJECTIVE

Given their association with varying health risks, lifestyle-related behaviors are essential to consider in population-level disease prevention. Health insurance claims are a key source of information for population health analytics, but the availability of lifestyle information within claims data is unknown. Our goal was to assess the availability and prevalence of data items that describe lifestyle behaviors across several domains within a large U.S. claims database.

METHODS

We conducted a retrospective, descriptive analysis to determine the availability of the following claims-derived lifestyle domains: nutrition, eating habits, physical activity, weight status, emotional wellness, sleep, tobacco use, and substance use. To define these domains, we applied a serial review process with three physicians to identify relevant diagnosis and procedure codes within claims for each domain. We used enrollment files and medical claims from a large national U.S. health plan to identify lifestyle relevant codes filed between 2016 and 2020. We calculated the annual prevalence of each claims-derived lifestyle domain and the proportion of patients by count within each domain.

RESULTS

Approximately half of all members within the sample had claims information that identified at least one lifestyle domain (2016 = 41.9%; 2017 = 46.1%; 2018 = 49.6%; 2019 = 52.5%; 2020 = 50.6% of patients). Most commonly identified domains were weight status (19.9-30.7% across years), nutrition (13.3-17.8%), and tobacco use (7.9-9.8%).

CONCLUSION

Our study demonstrates the feasibility of using claims data to identify key lifestyle behaviors. Additional research is needed to confirm the accuracy and validity of our approach and determine its use in population-level disease prevention.

Impact of Private Payer Policies on the Transition to Telemental Health Care Among Privately Insured Patients with Mental Health Disorders

Introduction: Mental health patients in states without private payer telehealth reimbursement policies before the public health emergency (PHE) may have experienced reduced access to telemental health (TMH). We estimate the association between private payer telehealth policy status in 2019 and the transition to TMH in 2020. Methods: Retrospective cohort study of privately insured individuals 2-64 years old with a mental health disorder and without TMH use in 2019. We examined new telemental use in 2020 by three categories of policy reimbursement status in 2019 (partial parity, full parity vs. no policy), overall (any telemental), and by modality (live video, audio-only, and online assessments) using logistic regression models clustered by state. Results: Among the 34,612 enrollees, 54.7% received TMH for the first time. Relative to no policy states, enrollees in partial or full parity states were equally likely to receive TMH in 2020. However, enrollees in states with a private payer telehealth policy were less likely to receive audio-only (partial parity: odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.39-0.90; full parity: OR: 0.38, 95% CI: 0.26-0.55), but more likely to receive online assessments (full parity: OR: 2.28, 95% CI: 1.4-4.59). Conclusions: Privately insured enrollees similarly transitioned to TMH across states suggesting a broad impact of the PHE policies on access to this care. The differences in audio-only and online assessments suggest that providers were possibly better prepared to implement TMH care via live video or patient portals in states with telehealth policies.

Encounter Appropriateness Score for You Model: Development and Pilot Implementation of a Predictive Model to Identify Visits Appropriate for Telehealth in Rheumatology

OBJECTIVE

We aimed to develop a decision-making tool to predict telehealth appropriateness for future rheumatology visits and expand telehealth care access.

METHODS

The model was developed using the Encounter Appropriateness Score for You (EASY) and electronic health record data at a single academic rheumatology practice from January 1, 2021, to December 31, 2021. The EASY model is a logistic regression model that includes encounter characteristics, patient sociodemographic and clinical characteristics, and provider characteristics. The goal of pilot implementation was to determine if model recommendations align with provider preferences and influence telehealth scheduling. Four providers were presented with future encounters that the model identified as candidates for a change in encounter modality (true changes), along with an equal number of artificial (false) recommendations. Providers and patients could accept or reject proposed changes.

RESULTS

The model performs well, with an area under the curve from 0.831 to 0.855 in 21,679 encounters across multiple validation sets. Covariates that contributed most to model performance were provider preference for and frequency of telehealth encounters. Other significant contributors included encounter characteristics (current scheduled encounter modality) and patient factors (age, Routine Assessment of Patient Index Data 3 scores, diagnoses, and medications). The pilot included 201 encounters. Providers were more likely to agree with true versus artificial recommendations (Cohen's κ = 0.45, P < 0.001), and the model increased the number of appropriate telehealth visits.

CONCLUSION

The EASY model accurately identifies future visits that are appropriate for telehealth. This tool can support shared decision-making between patients and providers in deciding the most appropriate follow-up encounter modality.

Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US

BACKGROUND

Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions.

METHODS

A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing.

RESULTS

Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases.

CONCLUSIONS

We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Long- and Short-Term Trends in Outpatient Attendance by Speciality in Japan: A Joinpoint Regression Analysis in the Context of the COVID-19 Pandemic

The COVID-19 pandemic resulted in a decline in outpatient attendance. Therefore, this study aimed to clarify long- and short-term clinic attendance trends by speciality in Japan between 2009 and 2021. A retrospective observational study of Japan's claims between 2009 and 2021 was conducted using the Estimated Medical Expenses Database. The number of monthly outpatient claims in clinics was used as a proxy indicator for monthly outpatient attendance, and specialities were categorised into internal medicine, paediatrics, surgery, orthopaedics, dermatology, obstetrics and gynaecology, ophthalmology, otolaryngology, and dentistry. The annually summarised age-standardised proportions and the percentage of change were calculated. Joinpoint regression analysis was used to evaluate long-term secular trends. The data set included 4,975,464,894 outpatient claims. A long-term statistically significant decrease was observed in outpatient attendance in internal medicine, paediatrics, surgery, ophthalmology, and otolaryngology during the pandemic. From March 2020 to December 2021, which includes the COVID-19 pandemic period, outpatient attendance in paediatrics, surgery, and otolaryngology decreased in all months compared with that of the corresponding months in 2019. For some specialities, the impact of the pandemic was substantial, even in the context of long-term trends. Speciality-specific preparedness is required to ensure essential outpatient services in future public health emergencies.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019)

STUDY OBJECTIVE

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.

RESULTS

In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.

CONCLUSION

Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Statewide Trends in Buprenorphine Prescribing in Rural and Nonrural Vermont: Analysis of Population-based Patient Pharmacy Claims

IMPORTANCE

Opioid-related mortality rates have risen dramatically over the past decade, and office-based opioid treatment using buprenorphine offers hope for combatting this trend. Vermont's policymakers, health care systems, and treatment providers have worked to expand access to treatment throughout the rural state.

OBJECTIVE

The objective of the current study was to characterize the trends in the number of buprenorphine prescribers and the number of patients per prescriber in Vermont over the past decade (2010-2020).

METHODS

We used Vermont's all-payer claims database to identify patients with buprenorphine claims between 2010 and 2020 and their prescribers. We conducted analyses of trends in the number of prescribers treating different numbers of patients, the number of patients treated by prescribers in those categories, and the number of rural (vs nonrural) patients filling buprenorphine prescriptions. We used Z tests to determine if there were statistical differences between trends.

RESULTS

The number of buprenorphine prescribers treating 10+ patients grew more rapidly than other prescriber groups ( P < 0.001). Nearly half of Vermont patients in 2020 were treated by 33 high-volume prescribers who treated 100 or more patients with buprenorphine. The number of patients filling buprenorphine prescriptions in Vermont increased by 98% between 2010 and 2020, with greater increases seen among rural than nonrural residents (107% vs 72%; P = 0.008).

CONCLUSIONS AND RELEVANCE

Since 2010, Vermont has increased utilization of its office-based opioid treatment capacity, particularly in rural counties.

North Carolina's Medicaid Transformation: the Early Enrollee Experience

INTRODUCTION

On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs.

METHODS

Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition.

RESULTS

Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees.

CONCLUSIONS

Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.

Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic

PURPOSE

To examine whether cancer screening prevalence in the United States during 2021 has returned to prepandemic levels using nationally representative data.

METHODS

Information on receipt of age-eligible screening for breast (women age 50-74 years), cervical (women without a hysterectomy age 21-65 years), prostate (men age 55-69 years), and colorectal cancer (men and women age 50-75 years) according to the US Preventive Services Task Force recommendations was obtained from the 2019 and 2021 National Health Interview Survey. Past-year screening prevalence in 2019 and 2021 and adjusted prevalence ratios (aPRs), 2021 versus 2019, with their 95% CIs were calculated using complex survey logistic regression models.

RESULTS

Between 2019 and 2021, past-year screening in the United States decreased from 59.9% to 57.1% (aPR, 0.94; 95% CI, 0.91 to 0.97) for breast cancer, from 45.3% to 39.0% (aPR, 0.85; 95% CI, 0.82 to 0.89) for cervical cancer, and from 39.5% to 36.3% (aPR, 0.9; 95% CI, 0.84 to 0.97) for prostate cancer. Declines were most notable for non-Hispanic Asian persons. Colorectal cancer screening prevalence remained unchanged because an increase in past-year stool testing (from 7.0% to 10.3%; aPR, 1.44; 95% CI, 1.31 to 1.58) offset a decline in colonoscopy (from 15.5% to 13.8%; aPR, 0.88; 95% CI, 0.83 to 0.95). The increase in stool testing was most pronounced in non-Hispanic Black and Hispanic populations and in persons with low socioeconomic status.

CONCLUSION

Past-year screening prevalence for breast, cervical, and prostate cancer among age-eligible adults in the United States continued to be lower than prepandemic levels in the second year of the COVID-19 pandemic, reinforcing the importance of return to screening health system outreach and media campaigns. The large increase in stool testing emphasizes the role of home-based screening during health care system disruptions.

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Transformation to a patient-centred medical home led and delivered by an urban Aboriginal and Torres Strait Islander community, and association with engagement and quality-of-care: quantitative findings from a pilot study

BACKGROUND

The patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019-2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here.

METHODS

De-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes.

RESULTS

The number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services' catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16-17% versus 10-11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes.

CONCLUSIONS

The increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

Racial, Ethnic, and Socioeconomic Differences in Primary Care No-Show Risk with Telemedicine During the COVID-19 Pandemic

BACKGROUND

The coronavirus 2019 (COVID-19) pandemic resulted in rapid implementation of telemedicine. Little is known about the impact of telemedicine on both no-show rates and healthcare disparities on the general primary care population during the pandemic.

OBJECTIVE

To compare no-show rates between telemedicine and office visits in the primary care setting, while controlling for the burden of COVID-19 cases, with focus on underserved populations.

DESIGN

Retrospective cohort study.

SETTING

Multi-center urban network of primary care clinics between April 2021 and December 2021.

PARTICIPANTS

A total of 311,517 completed primary care physician visits across 164,647 patients.

MAIN MEASURES

The primary outcome was risk ratio of no-show incidences (i.e., no-show rates) between telemedicine and office visits across demographic sub-groups including age, ethnicity, race, and payor type.

RESULTS

Compared to in-office visits, the overall risk of no-showing favored telemedicine, adjusted risk ratio of 0.68 (95% CI 0.65 to 0.71), absolute risk reduction (ARR) 4.0%. This favorability was most profound in several cohorts with racial/ethnic and socioeconomic differences with risk ratios in Black/African American 0.47 (95% CI 0.41 to 0.53), ARR 9.0%; Hispanic/Latino 0.63 (95% CI 0.58 to 0.68), ARR 4.6%; Medicaid 0.58 (95% CI 0.54 to 0.62) ARR 7.3%; Self-Pay 0.64 (95% CI 0.58 to 0.70) ARR 11.3%.

LIMITATION

The analysis was limited to physician-only visits in a single setting and did not examine the reasons for visits.

CONCLUSION

As compared to office visits, patients using telemedicine have a lower risk of no-showing to primary care appointments. This is one step towards improved access to care.

The 2020 US cancer screening deficit and the timing of adults' most recent screen: a population-based cross-sectional study

OBJECTIVE

In 2020, cancer screenings declined, resulting in a cancer screening deficit. The significance of this deficit, however, has yet to be quantified from a population health perspective. Our study addresses this evidence gap by examining how the pandemic changed the timing of American adults' most recent cancer screen.

METHODOLOGY

We obtained population-based, cancer screening data from the Behavioural Risk Factor Surveillance System (BRFSS) (2010, 2012, 2014, 2016, 2018, 2020). Mammograms, pap smears and colonoscopies were each specified as a variable of mutually exclusive categories to indicate the timing since the most recent screening (never, 0-1 years, 1-2 years, 3+ years). Our cross-sectional, quasi-experimental design restricts the sample to adults surveyed in January, February or March. We then leverage a quirk in the BRFSS implementation and consider adults surveyed in the second year of the 2020 survey wave as exposed to the COVID-19 pandemic. Respondents surveyed in January 2020-March 2020 were considered unexposed. To estimate the impact of exposure to the COVID-19 pandemic on the timing of recent cancer screenings, we constructed linear and logistic regression models which control for sociodemographic characteristics associated with screening patterns, and state fixed effects and temporal trend fixed effects to control for confounding.

RESULTS

In 2020, the cancer screening deficit was largely due to a 1 year delay among adults who receive annual screening, as the proportion of adults reporting a cancer screen in the past year declined by a nearly identical proportion of adults reporting their most recent cancer screen 1-2 years ago (3%-4% points). However, the relative change was higher for mammograms and pap smears (17%) than colonoscopies (4%). We also found some evidence that the proportion of women reporting never having completed a mammogram declined in 2020, but the mechanisms for this finding should be further explored with the release of future data.

CONCLUSION

Our estimates for the pandemic's effect on cancer screening rates are smaller than prior studies. Because we account for temporal trends, we believe prior studies overestimated the effect of the pandemic and underestimated the overall downward trend in cancer screenings across the country leading up to 2020.

Long term risk of death and readmission after hospital admission with covid-19 among older adults: retrospective cohort study

OBJECTIVES

To characterize the long term risk of death and hospital readmission after an index admission with covid-19 among Medicare fee-for-service beneficiaries, and to compare these outcomes with historical control patients admitted to hospital with influenza.

DESIGN

Retrospective cohort study.

SETTING

United States.

PARTICIPANTS

883 394 Medicare fee-for-service beneficiaries age ≥65 years discharged alive after an index hospital admission with covid-19 between 1 March 2020 and 31 August 2022, compared with 56 409 historical controls discharged alive after a hospital admission with influenza between 1 March 2018 and 31 August 2019. Weighting methods were used to account for differences in observed characteristics.

MAIN OUTCOME MEASURES

All cause death within 180 days of discharge. Secondary outcomes included first all cause readmission and a composite of death or readmission within 180 days.

RESULTS

The covid-19 cohort compared with the influenza cohort was younger (77.9 v 78.9 years, standardized mean difference -0.12) and had a lower proportion of women (51.7% v 57.3%, -0.11). Both groups had a similar proportion of black beneficiaries (10.3% v 8.1%, 0.07) and beneficiaries with dual Medicaid-Medicare eligibility status (20.1% v 19.2%; 0.02). The covid-19 cohort had a lower comorbidity burden, including atrial fibrillation (24.3% v 29.5%, -0.12), heart failure (43.4% v 49.9%, -0.13), and chronic obstructive pulmonary disease (39.2% v 52.9%, -0.27). After weighting, the covid-19 cohort had a higher risk (ie, cumulative incidence) of all cause death at 30 days (10.9% v 3.9%; standardized risk difference 7.0%, 95% confidence interval 6.8% to 7.2%), 90 days (15.5% v 7.1%; 8.4%, 8.2% to 8.7%), and 180 days (19.1% v 10.5%; 8.6%, 8.3% to 8.9%) compared with the influenza cohort. The covid-19 cohort also experienced a higher risk of hospital readmission at 30 days (16.0% v 11.2%; 4.9%, 4.6% to 5.1%) and 90 days (24.1% v 21.3%; 2.8%, 2.5% to 3.2%) but a similar risk at 180 days (30.6% v 30.6%;-0.1%, -0.5% to 0.3%). Over the study period, the 30 day risk of death for patients discharged after a covid-19 admission decreased from 17.9% to 7.2%.

CONCLUSIONS

Medicare beneficiaries who were discharged alive after a covid-19 hospital admission had a higher post-discharge risk of death compared with historical influenza controls; this difference, however, was concentrated in the early post-discharge period. The risk of death for patients discharged after a covid-19 related hospital admission substantially declined over the course of the pandemic.

Telemedicine Visits in US Skilled Nursing Facilities

Importance

Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.

Objective

To describe patterns of telemedicine use in SNFs.

Design, Setting, and Participants

This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.

Exposure

Telemedicine adoption at SNF after 2020.

Main Outcomes and Measures

Number and proportion of telemedicine SNF and outpatient visits.

Results

Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%).

Conclusions and Relevance

In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015

BACKGROUND

While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers.

METHODS

Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance.

RESULTS

We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009).

CONCLUSIONS

Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.

Persistent Disparities in Pediatric Health Care Engagement During the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic has disrupted traditional health care, including pediatric health care. We described the impact of the pandemic on disparities in pediatric health care engagement.

METHODS

Using a population-based cross-sectional time-series design, we compared monthly ambulatory care visit volume and completion rates (completed vs no-show and cancelled visits) among pediatric patients aged 0-21 years in 4 states in the mid-Atlantic United States during the first year of the COVID-19 pandemic (March 2020-February 2021) with the same period before the pandemic (March 2019-February 2020). We used unadjusted odds ratios, stratified by visit type (telehealth or in-person) and sociodemographic characteristics (child race and ethnicity, caregiver primary language, geocoded Child Opportunity Index, and rurality).

RESULTS

We examined 1 556 548 scheduled ambulatory care visits for a diverse pediatric patient population. Visit volume and completion rates (mean, 70.1%) decreased during the first months of the pandemic but returned to prepandemic levels by June 2020. Disparities in in-person visit completion rates among non-Hispanic Black versus non-Hispanic White patients (64.9% vs 74.3%), patients from socioeconomically disadvantaged versus advantaged communities as measured by Child Opportunity Index (65.8% vs 76.4%), and patients in rural versus urban neighborhoods (66.0% vs 70.8%) were the same during the remainder of the first year of the pandemic as compared with the previous year. Concurrent with large increases in telehealth (0.5% prepandemic, 19.0% during the pandemic), telehealth completion rates increased.

CONCLUSIONS

Disparities in pediatric visit completion rates that existed before the pandemic persisted during the pandemic. These findings underscore the need for culturally tailored practices to reduce disparities in pediatric health care engagement.

A "sludge audit" for health system colorectal cancer screening services

OBJECTIVES

"Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services.

STUDY DESIGN

Mixed methods sludge audit.

METHODS

We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes.

RESULTS

Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients.

CONCLUSIONS

Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Impact of the COVID-19 Pandemic on Cancer Screening Delays

PURPOSE

To examine delays in cancer screenings during the COVID-19 pandemic.

METHODS

Participants from previous studies (N = 32,989) with permissions to be recontacted were invited to complete a survey between June and November 2020. Participants (n = 7,115) who met the age range for cancer screenings were included. Participants were asked if they planned to have and then if they postponed a scheduled mammogram, Pap test, stool blood test, colonoscopy, or human papillomavirus (HPV) test. Logistic regression was used to determine the factors associated with cancer screening delays for each planned test.

RESULTS

The average age was 57.3 years, 75% were female, 89% were non-Hispanic White, 14% had public insurance, and 34% lived in rural counties. Those who planned cancer screenings (n = 4,266, 60%) were younger, more likely to be female, with higher education, had private insurance, and lived in rural counties. Specifically, 24% delayed a mammogram (n = 732/2,986), 27% delayed a Pap test (n = 448/1,651), 27% delayed an HPV test (n = 59/220), 11% delayed a stool blood test (n = 44/388), and 36% delayed a colonoscopy (n = 304/840). Age, race/ethnicity, education, and health insurance were associated with delays in cancer screenings (all P < .05). Compared with non-Hispanic White women, non-Hispanic Black women had lower odds of delaying a mammogram (odds ratio [OR], 0.60; 95% CI, 0.39 to 0.94), Hispanic women had higher odds of delaying Pap test (OR, 2.46; 95% CI, 1.34 to 4.55), and women with other race/ethnicity had higher odds of delaying both Pap test (OR, 2.38; 95% CI, 1.41 to 4.02) and HPV test (OR, 5.37; 95% CI, 1.44 to 19.97).

CONCLUSION

Our findings highlighted the urgency for health care providers to address the significant delays in cancer screenings in those most likely to delay. Strategies and resources are needed to help those with barriers to receiving guideline-appropriate cancer screening.

Disruptions to in-person medical visits across the United States during the COVID-19 pandemic: evolving disparities by medical specialty and socio-economic status

OBJECTIVES

This study aimed to investigate how people's health-seeking behaviors evolve in the COVID-19 pandemic by community and medical service category.

STUDY DESIGN

This is a longitudinal study using mobility data from 19 million mobile devices of visits to all types of health facility locations for all US states.

METHODS

We examine the variations in weekly in-person medical visits across county, neighborhood, and specialty levels. Different regression models are used for each level to investigate factors that influence the disparities in medical visits. County-level analysis explores associations between county medical visit patterns, political orientation, and COVID-19 infection rate. Neighborhood-level analysis focuses on neighborhood socio-economic compositions as potential determinants of medical visit levels. Specialty-level analysis compares the evolution of visit disruptions in different specialties.

RESULTS

A more left-leaning political orientation and a higher local infection rate were associated with larger decreases in in-person medical visits, and these associations became stronger, moving from the initial period of stay-at-home orders into the post-lockdown period. Initial reactions were strongest for seniors and those of high socio-economic status, but this reversed in post-lockdown period where socio-economically disadvantaged communities stabilized at a lower level of medical visits. Neighborhoods with more female and young people exhibited larger decreases in in-person medical visits throughout the initial and post-lockdown periods. The evolution of disruptions diverges across medical specialties, from only short-term disruption in specialties such as dentistry to increasing disruption, as in cardiology.

CONCLUSIONS

Given distinct patterns in visit between communities, medical service categories, and between different periods in the pandemic, policy makers, and providers should concentrate on monitoring patients in disrupted specialties who overlap with the at-risk contexts and socio-economic factors in future health emergencies.

The COVID-19 Pandemic and In-Person Visit Rate Disruptions Among Patients With Hematologic Neoplasms in the US in 2020 to 2021

Importance

The COVID-19 pandemic has led to a reduction in routine in-person medical care; however, it is unknown whether there have been any changes in visit rates among patients with hematologic neoplasms.

Objective

To examine associations between the COVID-19 pandemic and in-person visits and telemedicine use among patients undergoing active treatment for hematologic neoplasms.

Design, Setting, and Participants

Data for this retrospective observational cohort study were obtained from a nationwide electronic health record-derived, deidentified database. Data for patients with hematologic neoplasms who had received at least 1 systemic line of therapy between March 1, 2016, and February 28, 2021, were included. Treatments were categorized into 3 types: oral therapy, outpatient infusions, and inpatient infusions. The data cutoff date was April 30, 2021, when study analyses were conducted.

Main Outcomes and Measures

Monthly visit rates were calculated as the number of documented visits (telemedicine or in-person) per active patient per 30-day period. We used time-series forecasting methods on prepandemic data (March 2016 to February 2020) to estimate expected rates between March 1, 2020, and February 28, 2021 (if the pandemic had not occurred).

Results

This study included data for 24 261 patients, with a median age of 68 years (IQR, 60-75 years). A total of 6737 patients received oral therapy, 15 314 received outpatient infusions, and 8316 received inpatient infusions. More than half of patients were men (14 370 [58%]) and non-Hispanic White (16 309 [66%]). Early pandemic months (March to May 2020) demonstrated a significant 21% reduction (95% prediction interval [PI], 12%-27%) in in-person visit rates averaged across oral therapy and outpatient infusions. Reductions in in-person visit rates were also significant for all treatment types for multiple myeloma (oral therapy: 29% reduction; 95% PI, 21%-36%; P = .001; outpatient infusions: 11% reduction; 95% PI, 4%-17%; P = .002; inpatient infusions: 55% reduction; 95% PI, 27%-67%; P = .005), for oral therapy for chronic lymphocytic leukemia (28% reduction; 95% PI, 12%-39%; P = .003), and for outpatient infusions for mantle cell lymphoma (38% reduction; 95% PI, 6%-54%; P = .003) and chronic lymphocytic leukemia (20% reduction; 95% PI, 6%-31%; P = .002). Telemedicine visit rates were highest for patients receiving oral therapy, with greater use in the early pandemic months and a subsequent decrease in later months.

Conclusions and Relevance

In this cohort study of patients with hematologic neoplasms, documented in-person visit rates for those receiving oral therapy and outpatient infusions significantly decreased during the early pandemic months but returned to close to projected rates in the later half of 2020. There were no statistically significant reductions in the overall in-person visit rate for patients receiving inpatient infusions. There was higher telemedicine use in the early pandemic months, followed by a decline, but use was persistent in the later half of 2020. Further studies are needed to ascertain associations between the COVID-19 pandemic and subsequent cancer outcomes and the evolution of telemedicine use for care delivery.

Changes in health care utilization among Medicare beneficiaries with diabetes two years into the COVID-19 pandemic

IMPORTANCE

The coronavirus 2019 (COVID-19) pandemic abruptly impacted health care service delivery and utilization. However, the impact on older adults with diabetes in the United States is unclear.

OBJECTIVE

To estimate changes in health care utilization among older adults with diabetes during the initial 2 years of the COVID-19 pandemic compared to the 2 years before, and to examine the variation in utilization changes by demographic and socioeconomic characteristics.

DESIGN SETTING AND PARTICIPANTS

In this study, we analyzed changes in utilization, measured by the average use of health care services per 1,000 persons with diabetes, using medical claims for Medicare fee-for-service beneficiaries aged 67 years and above. Utilization changes by setting (acute inpatient, emergency room [ER], hospital outpatient, physician office, and ambulatory surgery center [ASC]) and by media (telehealth and in-person) were examined for 22 months of the pandemic (03/2020-12/2021) compared with pre-pandemic period (03/2018-12/2019). We also estimated utilization changes by beneficiaries' age group, sex, race/ethnicity, and residential urbanicity.

RESULTS

The study sample consisted of approximately 6 million beneficiaries with diabetes each month. In the first 2 years of the pandemic, the average use of health care services by setting was 5-17% lower than the pre-pandemic level for all types of services. Phase 1 (03/2020-05/2020) had the largest decrease in utilization: physician office visits changed by -51.2% (95% CI, -55.0% to -47.5%), ASC procedures by -45.1% (95% CI, -49.8% to -40.4%), ER visits by -36.9% (95% CI, -39.0% to -34.7%), acute inpatient stays by -31.5% (95% CI, -33.6% to -29.3%), and hospital outpatient visits by -27% (95% CI, -29.3% to -24.8%). The reduction in utilization varied by sociodemographic subgroup. During the pandemic, the use of telehealth visits increased by 511.1% (95% CI, 502.2% to 520.0%) compared to the pre-pandemic period. The increase was smaller among rural residents.

CONCLUSIONS AND RELEVANCE

Medicare beneficiaries with diabetes experienced a reduction in the use of health care services during the COVID-19 pandemic, some of which persisted through two years into the pandemic. Telehealth visits increased, but not enough to overcome decreases in in-person visits. Understanding these patterns may help to optimize the use of health care resources for diabetes management in the post-pandemic era and during future emergencies.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits

BACKGROUND

Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care.

METHODS

A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends.

RESULTS

Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%).

CONCLUSIONS

Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

Disruption in Blood Pressure Control With the COVID-19 Pandemic: The PCORnet Blood Pressure Control Laboratory

OBJECTIVE

To explore trends in blood pressure (BP) control before and during the COVID-19 pandemic.

PATIENTS AND METHODS

Health systems participating in the National Patient-Centered Clinical Research Network (PCORnet) Blood Pressure Control Laboratory Surveillance System responded to data queries, producing 9 BP control metrics. Averages of the BP control metrics (weighted by numbers of observations in each health system) were calculated and compared between two 1-year measurement periods (January 1, 2019, through December 31, 2019, and January 1, 2020, through December 31, 2020).

RESULTS

Among 1,770,547 hypertensive persons in 2019, BP control to <140/<90 mm Hg varied across 24 health systems (range, 46%-74%). Reduced BP control occurred in most health systems with onset of the COVID-19 pandemic; the weighted average BP control was 60.5% in 2019 and 53.3% in 2020. Reductions were also evident for BP control to <130/<80 mm Hg (29.9% in 2019 and 25.4% in 2020) and improvement in BP (reduction of 10 mm Hg in systolic BP or achievement of systolic BP <140 mm Hg; 29.7% in 2019 and 23.8% in 2020). Two BP control process metrics exhibited pandemic-associated disruption: repeat visit in 4 weeks after a visit with uncontrolled hypertension (36.7% in 2019 and 31.7% in 2020) and prescription of fixed-dose combination medications among those with 2 or more drug classes (24.6% in 2019 and 21.5% in 2020).

CONCLUSION

BP control decreased substantially during the COVID-19 pandemic, with a corresponding reduction in follow-up health care visits among persons with uncontrolled hypertension. It is unclear whether the observed decline in BP control during the pandemic will contribute to future cardiovascular events.

Impact of COVID-19 on Trends in Outpatient Clinic Utilization: A Tale of 2 Departments

BACKGROUND

The COVID-19 pandemic forced many US health care organizations to shift from mostly in-person care to a hybrid of virtual visits (VV) and in-person visits (IPV). While there was an expected and immediate shift to virtual care (VC) early in the pandemic, little is known about trends in VC use after restrictions eased.

METHODS

This is a retrospective study using data from 3 health care systems. All completed visits from adult primary care (APC) and behavioral health (BH) were extracted from the electronic health record of adults aged 19 years and older from January 1, 2019 to June 30, 2021. Standardized weekly visit rates were calculated by department and site and analyzed using time series analysis.

RESULTS

There was an immediate decrease in APC visits following the onset of the pandemic. IPV were quickly replaced by VV such that VV accounted for most APC visits early in the pandemic. By 2021, VV rates declined, and VC visits accounted for <50% of all APC visits. By Spring 2021, all 3 health care systems saw a resumption of APC visits as rates neared or returned to prepandemic levels. In contrast, BH visit rates remained constant or slightly increased. By April 2020, almost all BH visits were being delivered virtually at each of the 3 sites and continue to do so without changes to utilization.

CONCLUSIONS

VC use peaked during the early pandemic period. While rates of VC are higher than prepandemic levels, IPV are the predominant visit type in APC. In contrast, VC use has sustained in BH, even after restrictions eased.

An Infrastructure to Provide Safer, Higher-Quality, and More Equitable Telehealth

The rapid expansion and prompt widescale adoption of telehealth during the COVID-19 pandemic resulted in telehealth practice variations across health care settings and has implications for patient safety, health equity, and quality of care. Telehealth is part of the public health infrastructure, and health care stakeholders have an opportunity to strategically plan for telehealth expansion and sustainability in organizations as the pandemic wanes. A framework to guide organizational telehealth integration is needed that can support safe, accessible, and high-quality telehealth to patients regardless of social and/or economic status. The purpose of this article is to propose an innovative telehealth model, supported by systems theory, to address the complexity of telehealth implementation in health care organizations. A Donabedian approach is used to address quality. The telehealth model is an organizational infrastructure that outlines how policy and authority requirements, organization factors, provider competencies, and patient determinants of health influence safer, more equitable, higher-quality telehealth. The framework can guide leaders in building, redesigning, and measuring the impact of telehealth programs as health care shifts into a revolutionary technology era to meet the needs of diverse organizations and populations.

TikTok Influence on Rates of Tonsillectomies for Tonsil Stones

INTRODUCTION

Tonsillectomy is one of the most common otolaryngologic surgeries and is increasingly being performed for the management of tonsil stones or tonsilloliths. Incidentally, over the years, tonsilloliths have become a popular topic on the social media platform TikTok (ByteDance, Beijing, China) and we propose that this may be influencing the trends of tonsillectomies for tonsil stones.  Objectives: We aim to assess rates of outpatient visits and tonsillectomies for tonsil stones at our institution as well as analyze videos on TikTok regarding tonsil stones.

METHODS

A retrospective chart query was performed. Data including the number of patient encounters per month with a diagnosis code of tonsilloliths were collected from July 2016 to December 2021. The number of TikTok videos under the search result "tonsil stones" and the content of these videos were reviewed.

RESULTS

There were 126 patients seeking evaluation for tonsil stones with an average age of 33.4 years, and 76% were females. The number of patients who underwent a tonsillectomy for tonsil stones increased from two in the first full year of collection in 2017 to 13 in 2021. Similarly, the average number of patients presenting for tonsil stone evaluation per month increased steadily from 1.0 in 2017 to 3.3 in 2021. TikTok video content under the search result "tonsil stones" varied and the number of videos on this topic has increased in recent years.

CONCLUSION

Rates of patients seeking tonsillectomy for tonsil stones increased from 2016 to 2021 in conjunction with the rising popularity of TikTok. Given the numerous TikTok videos featuring tonsil stones, we believe that this social media platform may be influencing the number of patients seeking evaluation for tonsil stones. This data may be used to understand future influence patterns of social media posts on healthcare consumer behavior and patient care practices.

Genetic Testing Among Patients with High-Risk Breast, Ovarian, Pancreatic, and Prostate Cancers

BACKGROUND

The National Comprehensive Cancer Network recommends genetic testing in patients with potentially hereditary breast, ovarian, pancreatic, and prostate cancers (HBOPP). Knowledge of genetic mutations impacts decisions about screening and treatment.

METHODS

A retrospective cohort study of 28,586 HBOPP patients diagnosed from 2013 to 2019 was conducted using a linked administrative-cancer database in the Seattle-Puget Sound SEER area. Guideline-concordant testing (GCT) was assessed annually according to guideline updates. Frequency of testing according to patient/cancer characteristics was evaluated using chi-squared tests, and factors associated with receipt of genetic testing were identified using multivariable logistic regression.

RESULTS

Testing occurred in 17% of HBOPP patients, increasing from 9% in 2013 to 21% in 2019 (p < 0.001). Ovarian cancer had the highest testing (40%) and prostate cancer the lowest (4%). Age < 50, female sex, non-Hispanic White race, commercial insurance, urban location, family history of HBOPP, and triple negative breast cancer (TNBC) were associated with increased testing (all p < 0.05). GCT increased from 38% in 2013 to 44% in 2019, and was highest for early age at breast cancer diagnosis, TNBC, male breast cancer, and breast cancer with family history of HBOPP (all > 70% in 2019), and lowest for metastatic prostate cancer (6%).

CONCLUSIONS

The frequency of genetic testing for HBOPP cancer has increased over time. Though GCT is high for breast cancer, there are gaps in concordance among patients with other cancers. Increasing provider and patient education, genetic counseling, and insurance coverage for testing among HBOPP patients may improve guideline adherence.