The impact of broadening COVID-19 testing eligibility on communities of color - A lesson for overcoming structural barriers to health care.

CDC guidelines for COVID-19 testing in March 2020 did not prioritize underserved communities. We present the effect that expanding COVID-19 testing had for residents of the predominantly Hispanic city of Chelsea, MA, which had the highest case rate in the state. Results were compared to another city with similar demographics, Lynn, MA, where testing eligibility remained unchanged. Institutional data were used to identify outpatient visits for influenza-like illness or COVID-19 exposure, COVID-19 tests, and hospitalizations for confirmed COVID-19 between 3/30/2020-4/28/2020. Multivariable logistic regressions were used to compare outcomes before and after the change in testing eligibility occurred on 4/13/2020. A total of 3,060 patients were included, 1,374 Chelsea residents and 1,686 Lynn residents. After guidelines changed, Chelsea residents were more likely to present as outpatients (adjusted odds ratio [AOR] 4.2, p < 0.001) and less likely to be hospitalized (AOR 0.2, p < 0.001). They were more likely to be tested (AOR 8.8, p < 0.001), but less likely to test positive (AOR 0.6, p = 0.05). Lynn residents were also more likely to be tested after 4/13/2020 (AOR 1.9, p < 0.001), but no significant differences in visit acuity or test positivity were observed. This study demonstrates how broadening testing eligibility for one highly affected, predominantly Hispanic community was associated with an increase in outpatient presentations and a concomitant decrease in test positivity and hospitalizations. These results highlight the impact of improved access to care on utilization of services among underserved communities, a lesson that is especially crucial as we continue to grapple with the COVID pandemic.

Addressing virtual care disparities for patients with limited English proficiency.

During a surge of COVID-19 cases, the majority of care delivery at a large academic medical center moved to virtual care. Due to COVID-19-associated regulatory changes, virtual care is now delivered through telephone and videoconferencing platforms. Although virtual platforms allow patients to access care while socially distancing, patients with limited English proficiency (LEP) face structural barriers to these platforms, including lack of access to technology, need for medical interpreters, unfriendly patient portals, and increased privacy concerns. Strategies for increasing access to virtual platforms and technology for patients with LEP included offering patient education in multiple languages, reducing barriers to patient portal enrollment, and addressing the technology literacy gap through the use of tablets and bilingual interns. Strategies for addressing privacy concerns for patients with LEP included developing a low-literacy script and other actions that address patient concerns about Immigration and Customs Enforcement and mitigate perceived risk, as well as identifying a virtual platform that meets privacy regulations and does not require a patient to download an application to their phone or computer to join. Strategies for integrating medical interpreters into virtual visits included assessing existing virtual platforms for the ability to host a third party, changing the electronic health record software (Epic) interface, and convening directors of interpreter departments at each site to ensure comprehensive system rollout. Health care organizations that rely heavily on virtual visits to provide patient care will need to take all these challenges into consideration for patients with LEP.

Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic forced health systems to offer video and telephone visits as in-person visit alternatives. Although video visits offer some benefits compared with telephone visits, they require complex setup, which may disadvantage some patients due to the "digital divide." Our objective was to determine patient and neighborhood characteristics associated with visit modality. STUDY DESIGN: This was a cross-sectional study across 1652 primary care and specialty care practices of adult patients at an integrated health system from April 23 to June 1, 2020. METHODS: We used electronic health record and administrative data. Our primary outcome was visit modality (in-person, video, or telephone), which was captured using billing codes. We assessed predictors of using video vs telephone using multivariable logistic regression. We used hierarchical logistic regression to determine the contribution of patient-, physician-, and practice-level components of variance in the choice of video or telephone visits. RESULTS: We analyzed 231,596 visits by 162,102 patients. Sixty-five percent of the visits were virtual (31.7% telephone, 33.5% video). Patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and from areas with low broadband access (AOR, 0.93; 95% CI, 0.88-0.98) were less likely to use video visits. Practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%). CONCLUSIONS: Telemedicine access differences may compound disparities in chronic disease and COVID-19 outcomes. Institutions should monitor video visit use across demographics and equip patients, clinicians, and practices to promote telemedicine equity.

High Seroprevalence of Anti-SARS-CoV-2 Antibodies in Chelsea, Massachusetts.

SARS-CoV-2 antibody testing allows quantitative determination of disease prevalence, which is especially important in high-risk communities. We performed anonymized convenience sampling of 200 currently asymptomatic residents of Chelsea, the epicenter of COVID-19 illness in Massachusetts, by BioMedomics SARS-CoV-2 combined IgM-IgG point-of-care lateral flow immunoassay. The seroprevalence was 31.5% (17.5% IgM+IgG+, 9.0% IgM+IgG-, and 5.0% IgM-IgG+). Of the 200 participants, 50.5% reported no symptoms in the preceding 4 weeks, of which 24.8% (25/101) were seropositive, and 60% of these were IgM+IgG-. These data are the highest seroprevalence rates observed to date and highlight the significant burden of asymptomatic infection.

Racial and Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed Coronavirus Disease 2019: A Retrospective Cohort Study.

Background Disease severity on chest radiographs has been associated with higher risk of disease progression and adverse outcomes from coronavirus disease 2019 (COVID-19). Few studies have evaluated COVID-19-related racial and/or ethnic disparities in radiology. Purpose To evaluate whether non-White minority patients hospitalized with confirmed COVID-19 infection presented with increased severity on admission chest radiographs compared with White or non-Hispanic patients. Materials and Methods This single-institution retrospective cohort study was approved by the institutional review board. Patients hospitalized with confirmed COVID-19 infection between March 17, 2020, and April 10, 2020, were identified by using the electronic medical record (n = 326; mean age, 59 years ±17 [standard deviation]; male-to-female ratio: 188:138). The primary outcome was the severity of lung disease on admission chest radiographs, measured by using the modified Radiographic Assessment of Lung Edema (mRALE) score. The secondary outcome was a composite adverse clinical outcome of intubation, intensive care unit admission, or death. The primary exposure was the racial and/or ethnic category: White or non-Hispanic versus non-White (ie, Hispanic, Black, Asian, or other). Multivariable linear regression analyses were performed to evaluate the association between mRALE scores and race and/or ethnicity. Results Non-White patients had significantly higher mRALE scores (median score, 6.1; 95% confidence interval [CI]: 5.4, 6.7) compared with White or non-Hispanic patients (median score, 4.2; 95% CI: 3.6, 4.9) (unadjusted average difference, 1.8; 95% CI: 0.9, 2.8; P < .01). For both White (adjusted hazard ratio, 1.3; 95% CI: 1.2, 1.4; P < .001) and non-White (adjusted hazard ratio, 1.2; 95% CI: 1.1, 1.3; P < .001) patients, increasing mRALE scores were associated with a higher likelihood of experiencing composite adverse outcome with no evidence of interaction (P = .16). Multivariable linear regression analyses demonstrated that non-White patients presented with higher mRALE scores at admission chest radiography compared with White or non-Hispanic patients (adjusted average difference, 1.6; 95% CI: 0.5, 2.7; P < .01). Adjustment for hypothesized mediators revealed that the association between race and/or ethnicity and mRALE scores was mediated by limited English proficiency (P < .01). Conclusion Non-White patients hospitalized with coronavirus disease 2019 infection were more likely to have a higher severity of disease on admission chest radiographs than White or non-Hispanic patients, and increased severity was associated with worse outcomes for all patients. © RSNA, 2020 Online supplemental material is available for this article.