Association between distance to community health care facilities and COVID-19-related mortality across U.S. counties in the COVID-19-vaccine era.

OBJECTIVE: COVID-19 has caused tremendous damage to U.S. public health, but COVID vaccines can effectively reduce the risk of COVID-19 infections and related mortality. Our study aimed to quantify the association between proximity to a community healthcare facility and COVID-19 related mortality after COVID vaccines became publicly available and explore how this association varied across racial and ethnic groups. RESULTS: Residents living farther from a facility had higher COVID-19-related mortality across U.S. counties. This increased mortality incidence associated with longer distances was particularly pronounced in counties with higher proportions of Black and Hispanic populations.

Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and 10-Year Disease Risk in the US: National Health and Nutrition Examination Surveys, 2013 to March 2020.

Importance: The burden of atherosclerotic cardiovascular disease (ASCVD) in the US is higher among Black and Hispanic vs White adults. Inclusion of race in guidance for statin indication may lead to decreased disparities in statin use. Objective: To evaluate prevalence of primary prevention statin use by race and ethnicity according to 10-year ASCVD risk. Design, Setting, and Participants: This serial, cross-sectional analysis performed in May 2022 used data from the National Health and Nutrition Examination Survey, a nationally representative sample of health status in the US, from 2013 to March 2020 (limited cycle due to the COVID-19 pandemic), to evaluate statin use for primary prevention of ASCVD and to estimate 10-year ASCVD risk. Participants aged 40 to 75 years without ASCVD, diabetes, low-density lipoprotein cholesterol levels 190 mg/dL or greater, and with data on medication use were included. Exposures: Self-identified race and ethnicity (Asian, Black, Hispanic, and White) and 10-year ASCVD risk category (5%-<7.5%, 7.5%-<20%, ≥20%). Main Outcomes and Measures: Prevalence of statin use, defined as identification of statin use on pill bottle review. Results: A total of 3417 participants representing 39.4 million US adults after applying sampling weights (mean [SD] age, 61.8 [8.0] years; 1289 women [weighted percentage, 37.8%] and 2128 men [weighted percentage, 62.2%]; 329 Asian [weighted percentage, 4.2%], 1032 Black [weighted percentage, 12.7%], 786 Hispanic [weighted percentage, 10.1%], and 1270 White [weighted percentage, 73.0%]) were included. Compared with White participants, statin use was lower in Black and Hispanic participants and comparable among Asian participants in the overall cohort (Asian, 25.5%; Black, 20.0%; Hispanic, 15.4%; White, 27.9%) and within ASCVD risk strata. Within each race and ethnicity group, a graded increase in statin use was observed across increasing ASCVD risk strata. Statin use was low in the highest risk stratum overall with significantly lower rates of use among Black (23.8%; prevalence ratio [PR], 0.90; 95% CI, 0.82-0.98 vs White) and Hispanic participants (23.9%; PR, 0.90; 95% CI, 0.81-0.99 vs White). Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults. Prevalence of statin use did not meaningfully change over time by race and ethnicity or by ASCVD risk stratum. Conclusions and Relevance: In this study, statin use for primary prevention of ASCVD was low among all race and ethnicity groups regardless of ASCVD risk, with the lowest use occurring among Black and Hispanic adults. Improvements in access to care may promote equitable use of primary prevention statins in Black and Hispanic adults.

COVID-19 pandemic and trends in new diagnosis of atrial fibrillation: A nationwide analysis of claims data.

BACKGROUND: Atrial fibrillation (AF) is associated with a five-fold increased risk of stroke and a two-fold increased risk of death. We aimed to quantify changes in new diagnoses of AF following the onset of the COVID-19 pandemic. Investigating changes in new diagnoses of AF is of relevance because delayed diagnosis interferes with timely treatment to prevent stroke, heart failure, and death. METHODS: Using De-identified Optum's Clinformatics® Data Mart, we identified 19,500,401 beneficiaries continuously enrolled for 12 months in 2016-Q3 2020 with no history of AF. The primary outcome was new AF diagnoses per 30-day interval. Secondary outcomes included AF diagnosis in the inpatient setting, AF diagnosis in the outpatient setting, and ischemic stroke as initial manifestation of AF. We constructed seasonal autoregressive integrated moving average models to quantify changes in new AF diagnoses after the onset of the COVID-19 pandemic (3/11/2020, date of pandemic declaration). We tested whether changes in the new AF diagnoses differed by race and ethnicity. RESULTS: The average age of study participants was 51.0±18.5 years, and 52% of the sample was female. During the study period, 2.7% of the study sample had newly-diagnosed AF. New AF diagnoses decreased by 35% (95% CI, 21%-48%) after the onset of the COVID-19 pandemic, from 1.14 per 1000 individuals (95% CI, 1.05-1.24) to 0.74 per 1000 (95% CI, 0.64 to 0.83, p-value<0.001). New AF diagnoses decreased by 37% (95% CI, 13%- 55%) in the outpatient setting and by 29% (95% CI, 14%-43%) in the inpatient setting. The decrease in new AF diagnoses was similar across racial and ethnic subgroups. CONCLUSION: In a nationwide cohort of 19.5 million individuals, new diagnoses of AF decreased substantially following the onset of the COVID-19 pandemic. Our findings evidence pandemic disruptions in access to care for AF, which are concerning because delayed diagnosis interferes with timely treatment to prevent complications.

COVID-19 and adherence to biologic therapies for psoriasis: An analysis of nationwide pharmacy claims data.

BACKGROUND: Early after the onset of the COVID-19 pandemic, concerns were raised that the use of psoriasis treatments, particularly biologic therapies because of their immunosuppressant effects, could be associated with a poor prognosis in the case of COVID-19 infection. OBJECTIVE: To examine changes in adherence to systematic biologic therapies for psoriasis after the onset of the COVID-19 pandemic. METHODS: Using IQVIA medical and pharmacy claims data from January 1, 2018, to October 31, 2020, we identified patients aged 18 years or older who had a diagnosis of plaque psoriasis in 2018 and who received systemic biologic therapies for psoriasis, including both provider-administered and pharmacy-dispensed therapies. We calculated the incidence of 14-day gaps without therapy per 1,000 study participants for each 30-day interval. We constructed interrupted time series analyses to test changes in the incidence of outcomes after the pandemic declaration. RESULTS: The sample included 15,890 study participants: 45.4% were female and 15.2% were aged 65 years or older. For patients using biologic therapies dispensed from the pharmacy, there was a 13.1% decrease in the incidence of 14-day gaps without biologic therapy immediately after pandemic declaration, from 92.4 gaps per 1,000 patients to 80.2 gaps per 1,000 patients, but this decrease was not statistically significant. However, for patients using provider-administered therapies, the incidence of 14-day gaps without biologic therapy increased by 55.1% after pandemic declaration, from 29.0 gaps per 1,000 patients to 44.9 gaps per 1,000 patients (P < 0.01). CONCLUSIONS: Following the onset of the COVID-19 pandemic, we found an increased incidence of gaps in biologic therapy for psoriasis among users of provider-administered treatments but not among users of pharmacy-dispensed therapies. DISCLOSURES: Dr Hernandez reports personal fees from Bristol Myers Squibb and personal fees from Pfizer outside the submitted work. Dr Hernandez is funded by the National Heart, Lung and Blood Institute (grant K01HL142847). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The statements, findings, conclusions, views, and opinions expressed in this publication are based on data obtained under license from IQVIA as part of the IQVIA Institute's Human Data Science Research Collaborative.

Disparities in distribution of COVID-19 vaccines across US counties: A geographic information system-based cross-sectional study.

BACKGROUND: The US Centers for Disease Control and Prevention has repeatedly called for Coronavirus Disease 2019 (COVID-19) vaccine equity. The objective our study was to measure equity in the early distribution of COVID-19 vaccines to healthcare facilities across the US. Specifically, we tested whether the likelihood of a healthcare facility administering COVID-19 vaccines in May 2021 differed by county-level racial composition and degree of urbanicity. METHODS AND FINDINGS: The outcome was whether an eligible vaccination facility actually administered COVID-19 vaccines as of May 2021, and was defined by spatially matching locations of eligible and actual COVID-19 vaccine administration locations. The outcome was regressed against county-level measures for racial/ethnic composition, urbanicity, income, social vulnerability index, COVID-19 mortality, 2020 election results, and availability of nontraditional vaccination locations using generalized estimating equations. Across the US, 61.4% of eligible healthcare facilities and 76.0% of eligible pharmacies provided COVID-19 vaccinations as of May 2021. Facilities in counties with >42.2% non-Hispanic Black population (i.e., > 95th county percentile of Black race composition) were less likely to serve as COVID-19 vaccine administration locations compared to facilities in counties with <12.5% non-Hispanic Black population (i.e., lower than US average), with OR 0.83; 95% CI, 0.70 to 0.98, p = 0.030. Location of a facility in a rural county (OR 0.82; 95% CI, 0.75 to 0.90, p < 0.001, versus metropolitan county) or in a county in the top quintile of COVID-19 mortality (OR 0.83; 95% CI, 0.75 to 0.93, p = 0.001, versus bottom 4 quintiles) was associated with decreased odds of serving as a COVID-19 vaccine administration location. There was a significant interaction of urbanicity and racial/ethnic composition: In metropolitan counties, facilities in counties with >42.2% non-Hispanic Black population (i.e., >95th county percentile of Black race composition) had 32% (95% CI 14% to 47%, p = 0.001) lower odds of serving as COVID administration facility compared to facilities in counties with below US average Black population. This association between Black composition and odds of a facility serving as vaccine administration facility was not observed in rural or suburban counties. In rural counties, facilities in counties with above US average Hispanic population had 26% (95% CI 11% to 38%, p = 0.002) lower odds of serving as vaccine administration facility compared to facilities in counties with below US average Hispanic population. This association between Hispanic ethnicity and odds of a facility serving as vaccine administration facility was not observed in metropolitan or suburban counties. Our analyses did not include nontraditional vaccination sites and are based on data as of May 2021, thus they represent the early distribution of COVID-19 vaccines. Our results based on this cross-sectional analysis may not be generalizable to later phases of the COVID-19 vaccine distribution process. CONCLUSIONS: Healthcare facilities in counties with higher Black composition, in rural areas, and in hardest-hit communities were less likely to serve as COVID-19 vaccine administration locations in May 2021. The lower uptake of COVID-19 vaccinations among minority populations and rural areas has been attributed to vaccine hesitancy; however, decreased access to vaccination sites may be an additional overlooked barrier.

Effect of the COVID-19 pandemic on adversity in individuals receiving anticoagulation for atrial fibrillation: A nationally representative administrative health claims analysis.

BACKGROUND: Atrial fibrillation (AF) is strongly associated with clinical adversity, including increased hospitalization and bleeding and stroke events. We examined the effect of the SARS-2 Coronavirus 2019 (COVID-19) pandemic on such events in individuals with AF receiving oral anticoagulation. METHODS: We employed medical and pharmacy claims spanning 2018-2020 from a nationally representative U.S. database (IQVIA Longitudinal Prescription, Medical Claims, and Institutional Claims). We selected individuals receiving oral anticoagulation in 2018 for AF and followed them from 1/1/2019-7/8/2020 for clinical events. We constructed interrupted time-series analyses across 30-day intervals with Poisson regression models to determine the effect of the COVID-19 pandemic on clinical events. RESULTS: The dataset included 1,439,145 individuals (half with age ≥75 years; 47.6% women) receiving oral anticoagulation. We determined a 19% decrease in emergency room visits following the pandemic declaration and 8% decrease in inpatient admissions. In contrast admissions for stroke and bleeding were not affected by the declaration of the pandemic. DISCUSSION: These results describe the temporal effect of the COVID-19 pandemic on clinical adversity - hospitalizations, strokes, and bleeding events - in individuals receiving oral anticoagulation for AF. Our analysis quantifies the decrease in clinical adversity accompanying COVID-19 in a large, highly representative U.S. health claims database.

The global impact of COVID-19 on drug purchases: A cross-sectional time series analysis.

BACKGROUND: The drug supply chain is global and at risk of disruption and subsequent drug shortages, especially during unanticipated events. OBJECTIVE: Our objective was to determine the impact of coronavirus disease 2019 (COVID-19) on drug purchases overall, by class, and for specific countries. METHODS: A cross-sectional time series analysis of country-level drug purchase data from August 2014 to August 2020 from IQVIA MIDAS was conducted. Standardized units per 100 population and percentage increase in units purchased were assessed from 68 countries and jurisdictions in March 2020 (when the World Health Organization declared COVID-19 a pandemic). Analyses were compared by United Nations development status and drug class. Autoregressive integrated moving average models tested the significance of changes in purchasing trends. RESULTS: Before COVID-19, standardized medication units per 100 population ranged from 3990 to 4760 monthly. In March 2020, there was a global 15% increase in units of drugs purchased to 5309.3 units per 100 population compared with the previous year; the increase was greater in developed countries (18.5%; P < 0.001) than in developing countries (12.8%; P < 0.0001). After the increase in March 2020, there was a correction in the global purchase rate decreasing by 4.7% (April to August 2020 rate, 21,334.6/100 population; P < 0.001). Globally, we observed high purchasing rates and large changes for respiratory medicines such as inhalers and systemic adrenergic drugs (March 2020 rate, 892.7/100 population; change from 2019, 28.5%; P < 0.001). Purchases for topical dermatologic products also increased substantially (42.2%), although at lower absolute rates (610.0/100 population in March 2020; P < 0.0001). Interestingly, purchases for systemic anti-infective agents (including antiviral drugs) increased in developing countries (11.3%; P < 0.001), but decreased in developed countries (1.0%; P = 0.06). CONCLUSION: We observed evidence of global drug stockpiling in the early months of the COVID-19 pandemic, especially among developed countries. Actions toward equitable distribution of medicines through a resilient drug supply chain should be taken to increase global response to future unanticipated events, such as pandemics.

COVID-19 and Anticoagulation for Atrial Fibrillation: An Analysis of US Nationwide Pharmacy Claims Data.

Background Adherence to oral anticoagulation (OAC) is critical for stroke prevention in atrial fibrillation. However, the COVID-19 pandemic may have disrupted access to such therapy. We hypothesized that our analysis of a US nationally representative pharmacy claims database would identify increased incidence of lapses in OAC refills during the COVID-19 pandemic. Methods and Results We identified individuals with atrial fibrillation prescribed OAC in 2018. We used pharmacy dispensing records to determine the incidence of 7-day OAC gaps and 15-day excess supply for each 30-day interval from January 1, 2019 to July 8, 2020. We constructed interrupted time series analyses to test changes in gaps and supply around the pandemic declaration by the World Health Organization (March 11, 2020), and whether such changes differed by medication (warfarin or direct OAC), prescription payment type, or prescriber specialty. We identified 1 301 074 individuals (47.5% women; 54% age ≥75 years). Immediately following the COVID-19 pandemic declaration, we observed a 14% decrease in 7-day OAC gaps and 56% increase in 15-day excess supply (both P<0.001). The increase in 15-day excess supply was more marked for direct OAC (69% increase) than warfarin users (35%; P<0.001); Medicare beneficiaries (62%) than those with commercial insurance (43%; P<0.001); and those prescribed OAC by a cardiologist (64%) rather than a primary care provider (48%; P<0.001). Conclusions Our analysis of nationwide claims data demonstrated increased OAC possession after the onset of the COVID-19 pandemic. Our findings may have been driven by waivers of early refill limits and patients' tendency to stockpile medications in the first weeks of the pandemic.

Association between opioid dose escalation and time to death in a comfort measures only population.

PURPOSE: Opioids are crucial to the relief of pain and dyspnea experienced by patients dying in the hospital setting; however, there are concerns about the association of opioid dosage with hastened death via opioid-induced respiratory depression, and there is little published evidence regarding the association between opioid dose escalation and time to death in the inpatient comfort measures only (CMO) population. METHODS: The medical records of adult patients admitted to 2 hospitals who had an active CMO order at the time of death and received opioid dose escalations after CMO pronouncement were assessed in a retrospective cohort study. Patients were categorized into higher and lower opioid dose escalation groups according to an institutional palliative care symptom guide. A Cox proportional hazards model was constructed to test the associations between dose escalation group, patient sex, opioid naivety, palliative care consultation, and opioid dosage after CMO pronouncement (independent variables) and time to death (dependent variable). RESULTS: In the 71-patient cohort, 39 patients (54.9%) were male and 32 (45.1%) were female. The mean (SD) age of patients was 67.2 (16.6) years. Higher dose escalation (n = 46, 64.8%) was associated with a nonsignificant decrease in survival time compared to lower dose escalation (n = 25, 35.2%), with a mean difference in time to death of 19.8 hours (hazard ratio [HR], 1.67; 95% confidence interval [CI], 0.94-2.97). Receipt of a palliative care consult (n = 56, 78.9%) during the final hospital visit was associated with increased survival time (mean difference, 20.1 hours; HR, 0.32; 95% CI, 0.16-0.63). CONCLUSION: Time to death in an inpatient CMO population was not significantly associated with the degree of opioid dose escalation.