Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery.

BACKGROUND: Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown. OBJECTIVE: To examine pandemic CKD care and identify factors associated with a high care deficit. DESIGN: Retrospective observational study PARTICIPANTS: 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3-G4 CKD in 2018 MAIN MEASURES: Predicted (based on the pre-pandemic period of January 1, 2019-February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020-June 30, 2020), pre-vaccine (July 1, 2020-December 31, 2020), and late (January 2021-August 2021) periods and overall. KEY RESULTS: In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9-20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8-43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall. CONCLUSIONS: The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.

Behavioral Health Needs of a Commercially Insured Adult Population with Type 2 Diabetes

Background: There is an increasing appreciation of the interconnection between chronic illnesses such as type-2 diabetes and behavioral health conditions such as depression and anxiety, as well as more serious behavioral health conditions. The separation of practice and payment for medical and behavioral conditions is ripe for disruption. This is of particular importance for risk-bearing entities. Methods: Level2 is a virtual accountable care organization taking total cost-of-care risk for a commercially insured population. Using a de-identified administrative claims research database, we estimated the behavioral health profile of our enrolled population by examining the prescribing of common behavioral health medications. Results: In our enrolled population of 7,361 members, the average age was 54.4 years, and the M:F ratio was 53:47. Prescriptions for behavioral health medications were demonstrated in 26.2% of the population. Medications for depression and anxiety were most common (20.0% and 8.0% respectively) , while antipsychotics were prescribed in 0.1% of attributed members. Twenty-four months of enrollment (November 2019- November 2021) showed stable prescribing patterns. Conclusion: The movement towards provider risk bearing, and a more sophisticated understanding of the relationship between physical and behavioral health, necessitate a more comprehensive and integrated approach to care for patients. While this intersection may be evident to providers in their daily activities, the analysis of a population of nearly 7,400 members gives a broader insight into this challenge and calls for clinical service redesign, the application of new methodologies and measurements, and over time, new payment models. Of note, the prescribing data spans the COVID and pre-COVID periods and was stable over time, so the high use of behavioral health medications is not COVID-attributable.

Contribution of the elevated thrombosis risk of males to the excess male mortality observed in COVID-19: an observational study.

BACKGROUND: The mortality rate of COVID-19 is elevated in males compared with females. OBJECTIVE: Determine the extent that the elevated thrombotic risk in males relative to females contributes to excess COVID-19 mortality in males. DESIGN: Observational study. SETTING: Data sourced from electronic medical records from over 200 US hospital systems. PARTICIPANTS: 60 877 patients aged 18 years and older hospitalised with COVID-19. EXPOSURE: Exposure variable: biological sex; key variable of interest: thrombosis. PRIMARY OUTCOME MEASURES: Primary outcome was COVID-19 mortality. We measured: (1) mortality rate of males relative to females, (2) rate of thrombotic diagnoses occurring during hospitalisation for COVID-19 in both sexes and (3) mortality rate when evidence of thrombosis was present. RESULTS: The COVID-19 mortality rate of males was 29.9% higher than that of females. Males had a 35.8% higher rate of receiving a thrombotic diagnosis compared with females. The mortality rate of all patients with a thrombotic diagnosis was 40.0%-over twice that of patients with COVID-19 without a thrombotic diagnosis (adjusted OR 2.50 (2.37 to 2.64), p<0.001). When defining thrombosis as either a documented thrombotic diagnosis or a D-dimer level ≥3.0 µg/mL, 16.4% of the excess mortality in male patients could be explained by increased thrombotic risk. CONCLUSIONS: Our findings suggest the higher COVID-19 mortality rate in males may be significantly accounted for by the elevated risk of thrombosis among males. Understanding the mechanisms that underlie increased male thrombotic risk may allow for the advancement of effective anticoagulation strategies that reduce COVID-19 mortality in males.

Objective Measures of Physical Distancing in the Hospital During the COVID-19 Pandemic.

During the COVID-19 pandemic, hospitals published physical-distancing guidance and created dedicated respiratory isolation units (RIUs) for patients with COVID-19. The degree to which such distancing occurred between clinicians and patients is unknown. In this study, heat sensors from an existing hospital hand-hygiene monitoring system objectively tracked room entries as a proxy for physical distancing in both RIUs and general medicine units before and during the pandemic. The RIUs saw a 60.6% reduction in entries per room per day (from 85.7 to 33.8). General medicine units that cared for patients under investigation for COVID-19 and other patients experienced a 14.7% reduction in entries per room per day (from 76.9 to 65.1). While gradual extinction was observed in both units as COVID-19 cases declined, the RIUs had a higher degree of physical distancing. Although the optimal level of physical distancing is unknown, sustaining physical distancing in the hospital may require re-education and real-time monitoring.

The impact of the COVID-19 pandemic on nighttime room entries and sleep disruptions for pediatric patients.

OBJECTIVES/BACKGROUND: Sleep is critical to recovery, but inpatient sleep is often disrupted. During the COVID-19 pandemic, social distancing efforts to minimize spread may have improved hospitalized children's sleep by decreasing unnecessary overnight disruptions. This study aimed to describe the impact of these efforts on pediatric inpatient sleep using objective and subjective metrics. METHODS: Sleep disruptions for pediatric inpatients admitted prior to and during the COVID-19 pandemic were compared. Hand hygiene sensors tracking room entries were utilized to measure objective overnight disruptions for 69 nights pre-pandemic and 154 pandemic nights. Caregiver surveys of overnight disruptions, sleep quantity, and caregiver mood were adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. RESULTS: Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p < 0.001), then returned towards baseline, mirroring the COVID-19 hospital census. However, surveyed caregivers (n_pre = 293, n_post = 154) reported more disrupted sleep (p < 0.001) due to tests (21% vs. 38%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 fewer minutes (95% CI: -12 min, -110 min, p < 0.001). Caregivers self-reported feeling more sad, weary, and worse overall (p < 0.001 for all). CONCLUSIONS: Despite a decrease in objective room entries during the pandemic, caregivers reported their children were disrupted more and slept less. Caregivers also self-reported worse mood. This highlights the effects of the COVID-19 pandemic on subjective experiences of hospitalized children and their caregivers. Future work targeting stress and anxiety could improve pediatric inpatient sleep.