Stage-1 Hybrid Palliation for High-Risk 2-Ventricle Patients with Ductal-Dependent Systemic Circulation in the Era of High Prenatal Detection.

OBJECTIVE: We reviewed our center's prenatal detection and surgical experience with high-risk, 2-ventricle patients, with complex congenital heart disease that underwent stage-1 hybrid palliation. METHODS: We retrospectively identified those born between March 2008 and March 2021 with 2-ventricle hearts, complex congenital cardiovascular malformations, and ductal-dependent systemic circulation that underwent stage-1 hybrid palliation consisting of surgical bilateral pulmonary artery banding and interventional catheterization placed ductus arteriosus stents. RESULTS: We identified 30 patients. Of the 30, 19 (63%) were male. For the 30, median gestational age was 35 weeks (29-39 weeks), and median birth weight was 2.2 kg (0.6-4.5 kg). Of the 30, 1 was transferred from an adjacent state, and 29 were born in Nevada. Of the 29 born in Nevada, overall statewide prenatal detection was 18 of 29 (62%); however, for 2008 to 2011 the prenatal detection rate was 3 of 10 (30%) and 15 of 19 (79%) for 2012 to 2021, P = .03. For the last 5 years, prenatal detection for Nevada-born patients was 8 of 8 (100%). Two full-term newborns, without a prenatal diagnosis, presented postnatally in extremis. For the 30 patients, there were 0 stage-1 hybrid palliation mortalities, 1 subsequent repair mortality, and 3 late nonsurgical deaths. CONCLUSIONS: Stage-1 hybrid palliation may result in excellent surgical outcomes for high-risk, 2-ventricle patients. Additionally, high rates of population-wide prenatal detection are possible for high-risk congenital heart disease, allowing prenatal planning and possibly reducing postnatal extremis presentations.

Nursing home quality, COVID-19 deaths, and excess mortality.

The COVID-19 pandemic in the US has been particularly devastating for nursing home residents. A key question is how have some nursing homes been able to effectively protect their residents, while others have not? Using data on the universe of US nursing homes, we examine whether establishment quality is predictive of COVID-19 mortality. Higher-quality nursing homes, as measured by CMS overall five-star rating, have substantially lower COVID-19 mortality through September of 2020. Quality does not predict the ability to prevent any COVID-19 resident or staff cases, but higher-quality establishments prevent the spread of resident infections conditional on having one. Preventing COVID-19 cases and deaths may come at some cost, as high-quality homes have substantially higher non-COVID deaths. The positive correlation between establishment quality and non-COVID mortality is strong enough that high-quality homes also have more total deaths than their low-quality counterparts and this relationship has grown with time. As of late April 2021, five-star homes have experienced 8.4 percent more total deaths than one-star homes.

Private Precaution and Public Restrictions: What Drives Social Distancing and Industry Foot Traffic in the COVID-19 Era?

We examine the role of state and local policies to encourage social distancing, including stay at home orders, public school closures, and restrictions on restaurants, entertainment, and large social gatherings. Outcomes come from cell phone records and include foot traffic in six industries (essential and nonessential retail, entertainment, hotel, restaurant, and business services) plus the fraction of cell phones that are home all day. Structural break models show mobility series at the national and state levels start to change dramatically in a short window from March 8-14, well before state or local restrictions of note are in place. In difference-in-difference models, declarations of state of emergency reduce foot traffic and increase social distancing. Stay at home restrictions explain a modest fraction of the change in behavior across outcomes. Industry-specific restrictions have large impacts. For example, restrictions on dining in restaurants reduce traffic in restaurants, hotels, and nonessential retail. Private, self-regulating behavior explains more than three-quarters of the decline in foot traffic in most industries. Restrictive regulation explains half the decline in foot traffic in essential retail and 75 percent of the increase in the fraction home all day. In this latter result, public school closings have a substantial effect.

Nursing Home Quality, COVID-19 Deaths, and Excess Mortality

The COVID-19 pandemic in the US has been particularly devastating for nursing home residents. A key question is how have some nursing homes been able to effectively protect their residents, while others have not? Using data on the universe of US nursing homes, we examine whether establishment quality is predictive of COVID-19 mortality. Higher-quality nursing homes, as measured by inspection ratings, have substantially lower COVID-19 mortality. Quality does not predict the ability to prevent any COVID-19 resident or staff cases, but higher-quality establishments prevent the spread of resident infections conditional on having one. Preventing COVID-19 cases and deaths may come at some cost, as high-quality homes have substantially higher non-COVID deaths, a result consistent with high excess non-COVID mortality among the elderly since March. The positive correlation between establishment quality and non-COVID mortality is driven entirely by nursing homes located in counties with below-median COVID-19 case rates. As a result, high-quality homes in these counties have significantly more total deaths than their low-quality counterparts. The concentration of excess death in low-risk areas suggests that future suffering could be avoided with more nuanced guidelines, such as those recently suggested by CMS that outline a role for in-person visits in lower-risk areas.

Excess mortality from COVID and non-COVID causes in minority populations.

The 2020 US mortality totaled 2.8 million after early March, which is 17.3% higher than age-population-weighted mortality over the same time interval in 2017 to 2019, for a total excess death count of 413,592. We use data on weekly death counts by cause, as well as life tables, to quantify excess mortality and life years lost from both COVID-19 and non-COVID-19 causes by race/ethnicity, age, and gender/sex. Excess mortality from non-COVID-19 causes is substantial and much more heavily concentrated among males and minorities, especially Black, non-Hispanic males, than COVID-19 deaths. Thirty-four percent of the excess life years lost for males is from non-COVID-19 causes. While minorities represent 36% of COVID-19 deaths, they represent 70% of non-COVID-19 related excess deaths and 58% of non-COVID-19 excess life years lost. Black, non-Hispanic males represent only 6.9% of the population, but they are responsible for 8.9% of COVID-19 deaths and 28% of 2020 excess deaths from non-COVID-19 causes. For this group, nearly half of the excess life years lost in 2020 are due to non-COVID-19 causes.

Total shutdowns, targeted restrictions, or individual responsibility: How to promote social distancing in the COVID-19 Era?

We examine the impact of early state and local COVID-19 policies to encourage social distancing. Outcomes are daily foot traffic at establishments spanning ten key industries, across which transmission risk varies substantially. Policies include state of emergency declarations, blunt general restrictions such as stay-at-home (SAH) orders, and targeted rules such as restrictions on bars, restaurants, entertainment venues, and schools. Exploiting variation in the timing of policies in difference-in-difference models, we show that much of the decline in foot traffic early in the pandemic was due to private precautionary behavior. SAH orders explain almost none of the foot traffic decline in industries with high risk of virus transmission, but they do explain a substantial share of the decline in moderate- to low-risk industries such as outdoor sports and visits to parks. Targeted restrictions tend to impact intended industries, as well as complementary ones. We show that the impact of targeted restrictions is largest in counties with no SAH restrictions, suggesting that better targeting of public restrictions can have important efficiency gains.