Remote Versus In-person Outpatient Clinic Visits and Antibiotic Use Among Children During the COVID-19 Pandemic

BACKGROUND

The proportion of remote clinic visits was expected to increase among children during the COVID-19 pandemic which might result in antibiotic overuse.

METHODS

In southern Israel, 2 ethnic groups, Jewish and Bedouin, live side-by-side. Computerized data on visits for children <18 years were examined from clinics with ≥50 insured children, active both pre-COVID-19 and during the COVID-19 pandemic. Visits were divided into in-person and remote. Monthly infectious diagnoses and dispensed antibiotic prescription rates were calculated by age (<5, 5-17 years) and ethnic groups. Mean monthly rates of 2 parallel seasons (pre-COVID-19 and COVID-19 periods) were compared.

RESULTS

Overall 2,120,253 outpatient clinic visits were recorded. Remote clinic visit rates (per 1000 children) increased from 97.04 and 33.86 in the pre-COVID-19 to 179.75 and 50.05 in the COVID-19 period in Jewish and Bedouin children, respectively ( P < 0.01) along with a reduction of in-person visit rates in both populations. Comparing pre-COVID-19 and COVID-19 periods, the rates of overall infectious diagnoses in remote visits increased. Nevertheless, dispensed antibiotic prescription rates in remote visits (per 1000 visits) remained unchanged (9.84 vs. 8.67, P = 0.70, in the Jewish population and 14.32 vs. 14.17, P = 1.00, in the Bedouin population in the pre-COVID-19 and COVID-19 periods, respectively) with a similar distribution of antibiotic categories.

CONCLUSIONS

COVID-19 pandemic resulted in an expansion of remote visits of children <18 years with an increase in infectious diagnoses. However, remote dispensed antibiotic prescription rates remained unchanged. These dynamics were more accentuated in Jewish children, characterized by higher socio-economic conditions, compared to Bedouin children.

Disproportionate reduction in respiratory vs. non-respiratory outpatient clinic visits and antibiotic use in children during the COVID-19 pandemic

Background

The COVID-19 pandemic led to improved hygiene and reduced social encounters. Near elimination of the activity of respiratory syncytial virus and influenza viruses were observed, worldwide. Therefore, we assessed the rates of pediatric outpatient clinic visits and medications prescribed at those visits during the coronavirus disease 2019 (COVID-19) pandemic and pre-COVID-19 period (2016–2019).

Methods

Monthly and annual incidence rates for respiratory and non-respiratory diagnoses and dispensed prescription rates were calculated. Acute gastroenteritis (AGE) visits were analyzed separately since the mode of transmission is influenced by hygiene and social distancing.

Results

Overall, 5,588,702 visits were recorded. Respiratory and AGE visits declined by 49.9% and 47.3% comparing the COVID-19 and pre-COVID-19 periods. The respective rate reductions for urinary tract infections, trauma, and skin and soft tissue infections were 18.2%, 19.9%, and 21.8%. Epilepsy visits increased by 8.2%. Overall visits rates declined by 21.6%. Dispensed prescription rates of antibiotics and non-antibiotics respiratory medications declined by 49.3% and 44.4%, respectively. The respective declines for non-respiratory antibiotics and non-antibiotics were 15.1% and 0.2%. Clinic visits and prescription rates reductions were highest in April–May, following the first lockdown in Israel.

Conclusions

COVID-19 pandemic resulted in a substantial reduction in respiratory outpatient clinic visits and dispensed respiratory drugs, with only a mild reduction seen for non-respiratory visits. These trends were probably driven by COVID-19 mitigation measures and by the profound disruption to non-SARS COV-2 respiratory virus activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03315-0.

The impact of a community-based heart failure multidisciplinary team clinic on healthcare utilization and costs

Aims

Multidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community‐based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs.

Methods and results

A retrospective cohort study was conducted among HF patients who visited at least once in a regional community‐based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow‐up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio‐economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow‐up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow‐up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20–2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow‐up after their first visit (RR = 0.66, 95% CI: 0.54–0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62–0.87, P < 0.001).

Conclusions

Intensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations.

Treating patients with advanced heart failure in a community-based multidisciplinary team clinic is associated with significant reduction of healthcare utilization and costs

Background/Introduction

Heart failure (HF) care imposes a major economic burden, accounting for 1–3% of healthcare expenditure in developed countries. The greatest proportion of this cost (60%-70%) is accounted for by hospitalizations. A multidisciplinary team (MDT) approach in HF management is a key recommendation in international guidelines, to reduce mortality and HF hospitalization.

Purpose

To investigate whether a community-based MDT in an HF unit (HFU) had an impact on patients' healthcare utilization (HCU), and their associated costs.

Methods

A retrospective cohort study was conducted among members of the country's largest HMO, who visited at least once in a regional community-based HFU, established to provide ambulatory specialist care for patients with advanced HF, emphasizing patients in NYHA functional class III and IV, especially those with recurrent hospitalizations. HCU data were obtained from the HMO's claims data for 12 months before and after first HFU visit.

Results

Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up, and 119 (12.4%) died during the 12 months following their first HFU visit. Both groups were comparable with regard to sex, socioeconomic status, Charlson comorbidity index, prevalence of IHD and/or carotid artery disease, AF, obesity, and chronic pulmonary disease. Those who died within 12 months were older, had more hypertension, hyperlipidaemia, diabetes, chronic renal disease and malignancy but were less likely to be smokers or to have supplementary health insurance coverage. There was a significant reduction in the total average HCU costs of the entire study population 12 months after the first HFU visit ($12,675 after vs. $13,188 before, p=0.014). However, while a reduction in these costs was observed among patients who completed 12 months of follow-up ($11,955 after vs. $13,112 before, p&lt;0.001), an increase in these costs was observed among patients who died during follow-up ($17,774 after vs. $13,728 before, p=0.015). These opposite trends stem from a decrease ($3,540 after vs. $4,941 before, p&lt;0.001) versus increase ($10,932 after vs. $6,733 before, p=0.002) in hospitalization costs of these groups, respectively, and an increase ($1,272 after vs. $928 before, p&lt;0.001) versus decrease ($799 after vs. $1,116 before, p&lt;0.001) in medication costs of these subgroups, respectively.

Conclusion(s)

Intensification of therapy by a dedicated MDT significantly reduced costs of HCU, predominantly because of a decrease in hospitalizations. This saving was noted even when including patients who died within a year of commencing treatment in our HFU (a group in whom healthcare costs are known to be excessive). A widespread establishment of dedicated community-based units, should be encouraged.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Usefulness of the hematopoietic cell transplantation-specific comorbidity index (HCT-CI) in predicting outcomes for adolescents and young adults (AYAs) with hematologic malignancies (HM) undergoing allogeneic stem cell transplant (alloSCT)

7034

Background: The HCT-CI was developed to help predict overall survival (OS) and non-relapse mortality (NRM) in pts undergoing alloSCT, a procedure with significant toxicity. AYAs with cancer (ages 16–40) have been identified by the NCI as a high-risk group, but it is not known whether the HCT-CI is a useful predictor of outcomes in this relatively healthy population. Methods: All pts ages 16–39 at the time of alloSCT from 1992–2008 were included. HCT-CI was retrospectively calculated for pts with complete data available. Univariable Cox regression models were used to examine the association between covariates and OS and NRM. Results: 62 evaluable pts included 38 males and 24 females. 50 (81%) were Caucasian, 9 (15%) African American, and 3 (5%) other. Diseases included AML (23), CML (14), ALL (14), and other (11). All comorbidities had a frequency of <5% in this population except for pulmonary dysfunction (69%), hepatic dysfunction (27%), infection (19%), and psychiatric disturbance (10%). When dichotomized into categories of 0–2 (32) and >3 (30), the HCT-CI was significantly associated with OS (p = 0.0006) and marginally with NRM (p = 0.07). Because pulmonary dysfunction appeared to be the most important contributor to the HCT-CI, the diffusing capacity adjusted for hemoglobin and alveolar volume (DLCO/VA adj) was examined independently. When dichotomized into categories of <80% and >80% of normal, the DLCO/VA adj alone was also significantly associated with OS (p = 0.008), but not with NRM (p = 0.2). Conclusions: AYAs with HM undergoing alloSCT have a limited number of comorbidities in the HCT-CI. Pulmonary dysfunction is most prevalent, and the DLCO/VA adj alone appears to be nearly as predictive for OS as the HCT-CI. The discrepancy between the predictiveness for OS and NRM may reflect pre-treatment or disease status of this population at the time of transplant.

No significant financial relationships to disclose.

Lipid levels among African and Middle-Eastern Bedouin populations

BACKGROUND

Previous studies observed higher high-density lipoprotein (HDL) levels and lower triglycerides levels among people of African ancestry. The goal of this study was to characterize lipid levels in Bedouins of African vs. Middle-Eastern ethnicity.

MATERIAL/METHODS

A cross-sectional study was conducted in a Bedouin primary care clinic in southern Israel, with 4470 listed individuals over the age of 21, of whom 402 (9%) were of African origin. A stratified random sample was included in the analysis. Associations between ethnicity, age, gender and lipid levels were assessed. Multiple linear regression and logistic regression models were used for multivariate analysis.

RESULTS

The study included 261 African Bedouins and 406 Middle-Eastern Bedouins. (median age: 37 years, 58.6% females). The average total cholesterol and low-density lipoprotein (LDL) levels were 10 mg/dl lower among African Bedouins as compared to Middle-Eastern Bedouins (total cholesterol: 168.6 vs. 179.6 mg/dl, p<0.001; LDL: 99.5 vs. 109.0 mg/dl, respectively, p<0.001). Average triglycerides levels were 36 mg/dl lower among African Bedouins as compared to Middle-Eastern Bedouins (102.8 vs. 138.9 mg/dl, respectively, p<0.001). Average HDL levels were 3 mg/dl higher among African Bedouins as compared to Middle-Eastern Bedouins (48.3 vs. 44.6 mg/dl, respectively, p<0.001).

CONCLUSIONS

A lower prevalence of dyslipidemia was found in African Bedouins, as compared with Middle-Eastern Bedouins.

Utilization of emergency department services by the Bedouin population in southern Israel

Excessive use of the emergency department (ED) is associated with increased costs and workload in the ED, patients' inconvenience and disruption of the continuity of care. The study's goal was to describe trends in ED utilization among Bedouins living in southern Israel. A retrospective cross-sectional study was conducted in primary care clinics in southern Israel. Patients included Bedouin and Jewish patients insured by Clalit Health Services. Data was retrieved from a central database. The number of visits to the ED and age-adjusted rates of ED visits during 2000-2003 were determined in the Bedouin vs. Jewish population. All visits that ended in hospitalization were excluded. Data was stratified according to patients' residence (semi-nomadic vs. urban Bedouins) and referral origin. Age-adjusted rates of ED visits decreased from 42.9/1000 patients/month in 2000 to 38.3/1000 patients/month in 2003. There were more ED visits in the Bedouin as compared to Jewish population (38.3/1000 vs. 21.8/1000 patients/month). The decrease in ED utilization was more prominent among adult semi-nomadic Bedouins (from 60.8/1000 to 40.3/1000 patients/month). The proportion of referrals by the family physician to ED significantly decreased (among urban Bedouins: from 54.3% to 43.2%, p<0.001; among semi-nomadic Bedouins: from 53.9% to 39.9%, p<0.001), while the proportion of self-referrals and referrals from physicians other than the family physician increased. A decrease in ED utilization by the Bedouin population during the last years was demonstrated. Utilization of ED services is still increased as compared to the non-Bedouin population. Interventions to control excessive use of ED services in the Bedouin population are currently underway.