Telemedicine and the Utilization of Outpatient Mental Health Services By Patients with Incident Major Depressive Disorder during the COVID-19 Pandemic

Objectives: To examine the role of telemedicine in providing access to outpatient psychotherapy for children and young adults with incident major depressive disorder (MDD) before and during the COVID-19 pandemic, overall and by race and ethnicity. Method(s): Medical claims from a large, national insurer were retrospectively analyzed to identify two cohorts of individuals aged 10-26 years old, based on incident diagnosis ("index") date of MDD (pre-COVID: March-December 2018, COVID: March-December 2020). We tracked health care utilization, utilization by site of care, modality of care, and psychotherapy Results: The majority of patients in the two cohorts (pre-COVID: N=7,758, COVID: N=8,517) were White (78.9% and 78.8%, respectively), followed by Hispanic (11.5% and 10.9%), Black (6.6% and 7.1%), and Asian (3.0% and 3.2%). While pre-index utilization was similar between cohorts, the COVID cohort had 919 psychotherapy visits per 1,000 patients compared to 735 for the pre-COVID cohort in the month post-index. The increase in visits is largely attributable to an increase in telemedicine visits for the COVID cohort. Similarly, psychotherapy visits increased for all racial and ethnic groups in the COVID cohort compared to the pre-COVID cohort in the month post-index: 22.3% for Whites (931 visits per 1,000 patients in COVID cohort vs. 759 in pre-COVID cohort), 45.0% for Asians (951 vs. 656), 20.5% for Blacks (792 vs. 657) and 46.5% for Hispanics (860 vs. 587). Conclusion(s): Telemedicine increased access to mental health services during the pandemic across races and ethnicities, but racial and ethnic disparities persisted. Health systems should capitalize on the telehealth infrastructure developed during the pandemic to sustain this increased access to care while continuing work to reduce disparities.Copyright © 2023

Increased risk of diabetic ketoacidosis in an Urban, United States, safety-net emergency department in the COVID-19 era

Aims: The incidence of diabetic ketoacidosis (DKA) increased during the COVID-19 pandemic but estimates from low-resource settings are limited. We examined the odds of DKA among emergency department (ED) visits in the Los Angeles County Department of Health Services (DHS) (1) during the COVID-19 pandemic compared to the pre-COVID era, ( 2) without active COVID infections, and (3) stratified by effect modifiers to identify impacted sub-groups. Methods: We estimated the odds of DKA from 400,187 ED visits pre-COVID era (March 2019-Feb 2020) and 320,920 ED visits during the COVID era (March 2020-Feb 2021). Our base model estimated the odds of DKA based on the COVID era. Additional specifications stratified by effect modifiers, controlled for confounders, and limited to visits without confirmed COVID-19 disease. Results: After adjusting for triage acuity and interaction terms for upper respiratory infections and payor, the odds of DKA during the COVID era were 27% higher compared to the pre-COVID era (95%CI 14-41%, p < 0.001). In stratified analyses, visits with private payors had a 112% increased odds and visits with Medicaid had a 20% increased odds of DKA during the COVID era (95%CI 7-36%, p = 0.003). Conclusions: We identified increased odds of DKA during the COVID pandemic, robust to a variety of specifications. We found differential effects by the payor;with increased odds during COVID for privately-insured patients.

Trends Of Diabetic Ketoacidosis During COVID-19 Pandemic In Large Urban Public Emergency Department

Study Objectives: Diabetic ketoacidosis (DKA) is a common and serious endocrine emergency. Common triggers for diabetic ketoacidosis include infection, cardiovascular events, drug use, medication non-adherence, and new onset diabetes. Early evidence suggests a correlation between COVID-19 infection and DKA. Based on the limited data, it is unclear at this time if increases in DKA are triggered by acute COVID-19 infection, or secondary factors from the pandemic such as lack of access to care or acute stress. In this study, we examine trends in DKA prevalence among patients at an underserved urban public ED within the context of the COVID-19 pandemic. Methods: This is a retrospective study using administrative report data of all ED encounters. Cases of DKA, found using top 5 ICD10 ED diagnoses, were identified from 2019 and 2020. COVID-19 infection was pulled from laboratory data and merged to create one data set. Poisson regression was utilized to compare incidence rates of DKA (1) between 2019 and 2020 and (2) among COVID positive and COVID negative patients with DKA for the year of 2020. Yearly trends were examined month by month. Results: There were 180,158 patient visits in 2019 and 138,012 in 2020. Compared to 2019, incidence rates of DKA increased by 23% in 2020 (95% CI 4% to 42%, p=0.017). Among all those tested for COVID in 2020 (n=25,867), patients with positive COVID-19 tests trended to higher DKA rate (37% higher (95% CI -6% to 81% increase, p=0.098) than patients with negative COVID-19 tests. The increase was most prominent from April 2020 onward, with the largest increase in December 2020, correlating with the COVID surge at our hospital. (Figure 1). In December 2019, 20 out of 14,324 visits (0.14%) were coded as DKA, while in December 2020, 37 out of 10,942 visits (0.34%) were coded DKA. In December 2020, 11 DKA cases were COVID-19 positive and 26 were COVID-19 negative. When excluding the 11 cases of DKA with positive COVID-19 tests, the rate of DKA in 12/2020 would be 0.24%. Conclusions: We found the incidence rate ratio of DKA in 2020 increased compared to 2019, with an almost doubling of DKA rates in the month of December, the peak months of our pandemic surge. Our findings suggest a correlation between COVID-19 positivity and DKA, but is limited by small numbers at a single site. There is also limited data to suggest secondary factors may also play a role in increased rates. When removing COVID positive DKA cases in December 2020, the prevalence that month continued to 0.10% higher than in December 2019. While small numbers prevent firm conclusions, itis possible factors outside of COVID infection are attributing to higher rates. Various studies have shown reduced access to care for conditions managed in ambulatory settings during the COVID pandemic. Given this, decreased access to care for medication refill and titration may also be contributing to the rise in DKA rates. As more data becomes available, further research is required to establish the role of access to care versus inflammation from COVID-19 infection in triggering DKA. [Formula presented]

The Opioid Epidemic Meets the Coronavirus Pandemic: Rates and Patient Characteristics of Emergency Department Visits for Opiate Use Disorder During the COVID-19 Pandemic in the Los Angeles County Public Hospital System

Study Objective: The COVID-19 pandemic led to profound challenges for health systems and disruptions in care for society’s most vulnerable patients, in particular people with opiate use disorders (OUD). The closure of outpatient addiction clinics, cessation of harm-reduction services, and lack of access to support groups have all been attributed to worsening outcomes for patients with OUD during the COVID-19 pandemic. Most concerningly, emerging evidence points to accelerated rates of overdose deaths. In Los Angeles, a city disproportionately affected by high rates of COVID-19, chronic housing insecurity, and substance use disorder, the Department of Public Health reported a 48% increase in accidental drug overdose deaths during the first five months of the pandemic. In March of 2020, a state of emergency was declared for COVID-19 and stay-at-home orders were issued. These events were associated with a sharp reduction in total ED visits. However, with the profound disruption in usual sources of care and support for people with substance use disorders, emergency departments (EDs) remained a critical access point for these patients. Methods: We examined all visits to public safety-net hospital EDs in Los Angeles County. We considered OUD-related ED visits as those which included any of the following: visits with a discharge diagnosis related to OUD, patients who received buprenorphine or naloxone while in the ED, and visits where a prescription for buprenorphine or naloxone was given on discharge. We performed a logistic regression to examine patient characteristics of opiate use disorder-related visits from April 2019-Feb 2020 compared with April 2020-Feb 2021. Results: Overall, there was a 22% increased odds of an ED visit being related to OUD when we compared pre- and post- COVID shutdown periods in Los Angeles. Visit acuity levels increased across all ESI scores. There was a statistically significant increase in the predicted probability of OUD visits for black and Hispanic patients of 17% and 25% respectively compared to pre-COVID levels. Patients were more likely to present for OUD-related encounters if they were publicly insured, uninsured, or brought in by ambulance. Admitted patients were four times more likely to have an OUD-related ED visit on presentation. Conclusions: Rates of OUD-related ED visits increased during COVID-related shutdowns. These increases were most pronounced among black and Hispanic patients and those with no insurance or publicly funded insurance plans. Patients admitted to the hospital had higher odds of OUD-related complaints. This reinforces the importance of the emergency department as a safety net resource for the most vulnerable patients suffering from OUD during the pandemic and highlights the opportunity to address these disparities with ED-based interventions.

84 The Opioid Epidemic Meets the Coronavirus Pandemic: Rates of Emergency Department Visits for Opiate Use Disorder during COVID-19

Study Objectives: There is growing evidence that medication assisted therapy (MAT) which includes buprenorphine can lead to improved outcomes for patients with opiate use disorder (OUD), increased follow up with addiction treatment programs, as well as reduced illicit drug use and medical system costs for drug related emergency department (ED) visits. Emergency providers may serve to provide an induction to MAT and referrals to outpatient MAT providers. However, there continue to be barriers to utilization of buprenorphine from the ED including fears of precipitating withdrawal, fears of diversion or overdose, and beliefs that additional licenses are needed to offer treatment. The novel coronavirus epidemic threatens to pose even greater barriers to treatment access. EDs continue to serve patients throughout this crisis and may provide a critical role in continuing to link patients to MAT and provide care to patients with OUD. Methods: Our institution had planned to study the impact of an X-waiver training program for residents in our large, urban residency program. Closures during the coronavirus decreased patient volumes for many health care settings, especially outpatient clinics where much of MAT is delivered. We hypothesized that the “safer at home” order would have minimal impact on the percentage of patients presenting with OUD related complaints, as this would be coupled with less access to community resources that had previously provided support. We considered OUD-related ED visits as those which included any of the following: visits with a discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a prescription for buprenorphine or naloxone was given on discharge. We analyzed these visit rates compared with all ED visits per month. Results: The number of ED visits in January 2020 and February 2020 were 13,933 and 12,639 with rates of OUD-related visits 24 and 32 per 10,000, respectively. Social distancing guidelines were announced in Los Angeles on March 11, and stay at home orders began March 19, 2020. In April and May, there were 6,649 and 8,385 ED visits, however, rates of OUD-related visits were 59 and 35 per 10,000. Conclusion: Restrictive requirements on MAT dispensation already limits access to office-based treatment;during the coronavirus, the closure of clinics and other ancillary services to support persons with OUD threaten those most at risk of relapse. The COVID-19 pandemic and the changes in response to it have exacerbated disparities for marginalized populations. In order to combat these disparities, we need to recognize and bolster the systems of care serving these patient groups. Our ED continued to see steady rates of OUD-related visits, reinforcing the importance of continuing efforts to provide MAT from our social safety net. ED MAT programming represents an important portal to care, especially as a stop gap when other access points are destabilized. [Formula presented]