ABSTRACT
Introduction: Timely treatment of ST elevation myocardial infarction [STEMI] requires ongoing coordinated care between emergency departments, paramedics, and primary percutaneous coronary (PCI) intervention facilities. Method(s): To provide a current view and a national benchmark, we examined 121,576 patient records submitted by 648 hospitals participating the GWTG-CAD registry from Q2 2018 through Q3 2021 [median age 63, women 29%, Black 11%, Hispanic 8%, admission cardiac arrest 5%, shock 7%, heart failure 7%, Covid 0.2%, presentation EMS 47%, walk in 27%, transfer 22%] Results: Reperfusion method for all patients included primary PCI 87%, fibrinolysis 5%, and no reperfusion 8% [increasing from 7 to 9% during the study period]. Median time from symptom onset to reperfusion was shortest for EMS patients 148 minutes, followed by walk-in 195 minutes, ground transferred 238 minutes, and air transferred 247 minutes. Process times did not improve during the study period. First medical contact to device times increased by 5 minutes for EMS and ground transferred patients in Q2 2020 corresponding with the pandemic onset, and adjusted mortality was significantly higher in the final 3 quarters compared to Q2 2018 [OR, 95% CI 1.28(1.07-1.53);1.35(1.13-1.61);1.23(1.03-1.48)]. Patients treated within guideline goals had significantly lower mortality [Figure]. Conclusion(s): These data reaffirm the association between process times and lower mortality for STEMI patients. They also identify concerning trends and opportunities for improved care. Increasing delays in treatment, particularly for hospital transfer, greater numbers of untreated patients, and increased risk-adjusted in-hospital mortality all provide strong impetus for renewed focus on STEMI systems. Regional collaborative efforts led by coordinators and informed by a common data system have the potential to reverse these trends and improve survival.
ABSTRACT
Purpose/Background: The COVID-19 pandemic required strict prioritization of health care resources, which resulted in a partial to total shutdown of endoscopy in many healthcare centers worldwide. This study aims to quantify the impact of colonoscopy shutdown on colorectal cancer detection and screening. Methods/Interventions: After institutional ethics board approval, the endoscopy database at an academic tertiary-care center was queried for all colonoscopies performed from March-June 2020, corresponding to the first wave of the pandemic, and colonoscopies performed in March-June 2019, the non-pandemic period. The indications, cancer and adenoma detection rates, as well as the prioritization of urgent procedures were compared between the two periods. Multivariable logistic regressions were used to study the association of the pandemic period with the outcomes of interest. Results/Outcomes: In the non-pandemic period, 2,515 colonoscopes were performed while only 462 were performed during the pandemic period, representing an absolute reduction by 82%. Surveillance colonoscopies in high-risk patients was reduced from 848 to 114 colonoscopies, representing an 87% absolute reduction. For screening colonoscopies in high-risk patients, only 17 patients were screened compared to 303 in 2019, a 94% reduction. Overall, screening and surveillance were reduced from 60.8% to 47.3% (p < 0.0001) of colonoscopies performed. Emergency access to colonoscopy was preserved with a median time to endoscopy of <1 day (IQR 0,1). An increase in proportion of colonoscopies performed in the pandemic period urgent indications (4.7 vs 27.1% (p < 0.001)) and as inpatient procedure (0.5% vs. 13.6%, (p < 0.0001)). In the non-pandemic period, 44 (1.7%) patients were diagnosed with cancers and adenomas were removed in 766 patients (30.5%);whereas during the pandemic period, 18 (3.9%) cancers were diagnosed and 142 patients (30.7%) had adenomas removed, resulting in an absolute reduction of 26 cancers and adenomas in 624 patients. On multivariate regression, the pandemic era remained independently associated with increased cancer detection (OR 2.12, 95% CI 1.18-3.80), an urgent colonoscopy (OR 6.58, 95% CI 4.81-9.09) but was not associated with adenoma detection (OR 1.06, 95% CI 0.84, 1.35). Conclusion/Discussion: The restriction of access to colonoscopy has resulted in a significant reduction in screening and surveillance even in high-risk patients. While prioritization has increased the rate of cancers detected, there remains a significant reduction in cancer detection resulting in a delay in the diagnosis for these patients. Future studies will determine the ramifications of the decrease in surveillance and adenoma detection on patients whose colonoscopies were delayed because of the pandemic.
ABSTRACT
The COVID-19 pandemic devastated the cruise sector with an initial global shutdown and ongoing patchy resumption, widespread reporting of virus transmission onboard and billions of dollars in economic losses. This study explores how COVID-19 has impacted Australian and UK consumers' risk perceptions, revealing cruises are no longer considered "safe". Consumers are more negative about, and less willing to, cruise. Cluster and Leximancer analyses identified five distinct market segments differentiated by the extent of travel risk they perceived. Specific risk reduction strategies are identified and include risk mitigation, use of risk relievers, and risk avoidance.
ABSTRACT
Background: Cancer patients face an increased risk of developing acute complications from COVID-19. Remote monitoring can help with the critical need for early detection of symptoms among those diagnosed with COVID-19, enabling timely symptom management that can mitigate clinical deterioration. In response to this need, Memorial Sloan Kettering Cancer Center fast-tracked a program to monitor patients with COVID-19 from home, using an electronic symptom-tracking questionnaire and digital pulse oximeter to track patients' status and alert care teams to intervene if symptoms worsened. A multi-disciplinary group composed of Oncology providers, advanced practice providers, nursing, nursing informatics and biomedical informatics formed to manage the program. Methods: Memorial Sloan Kettering launched a remote monitoring program for patients diagnosed with COVID-19 on March 25, 2020. All patients testing positive for COVID-19 were enrolled in the program and asked to complete a daily symptom tracking questionnaire accessed through their patient portal or administered verbally over the phone. A subset of high risk patients were also provided with a digital pulse oximeter linked to their patient portal and capable of transmitting readings directly to the care team. Clinicians received alerts for patients reporting symptoms or an oxygen saturation below 92%. Alerts resulted in an immediate response from the care team to determine if the patient needed additional care. We retrospectively evaluated the program usage, outcomes and learnings from March 25, 2020 to December 22, 2020. Results: In total, 1,721 patients were enrolled in the program from March 25, 2020 to December 22, 2020. Among these, 210 were deemed high risk patients who received a pulse oximeter in addition the daily symptom questionnaire. Over this period, 27% of patients triggered an alert from an electronic symptom questionnaire, and 63% of patients with a pulse oximeter triggered an alert from their device. Among patients who triggered an alert of any kind, 3% were triaged to a higher level of care. Patients reported that the program was highly valued and alleviated anxiety about their care. Iterative improvements were made to the program over time in response to the evolving knowledge about care for patients with COVID-19. Conclusions: Memorial Sloan Kettering was able to quickly implement a program to detect and triage symptoms among patients with COVID-19 and cancer. Refinements were made over time to many aspects of the program in response to learnings about care related to COVID-19, including to clinical eligibility, alert criteria, monitoring duration and workflows. The program also demonstrated value for patients who felt more comfortable with their care while being monitored remotely. This program established a successful model for remote monitoring of patients with COVID-19 with the potential to be scaled to other institutions or clinical areas.
ABSTRACT
Background: Oncology patients are particularly vulnerable to adverse outcomes from COVID-19 and require careful monitoring to identify early deterioration and render higher level care when indicated. Several institutions launched remote patient monitoring programs (RPMPs) to care for patients with COVID-19. We describe patients' perspectives on a COVID-19 RPMP at a National Comprehensive Cancer Center. Methods: Adult patients who had either tested positive for COVID-19 on an outpatient microbiology test or were discharged after hospitalization for the virus were eligible. Patients enrolled in the RPMP received a daily 10-question electronic patient-reported outcome assessment of COVID-19 symptoms and their responses generated alerts to a centralized monitoring team for new or worsening symptoms. A subset of high-risk patients also received a pulse oximeter which alerted when blood oxygen levels dropped below 93%. RPM was discontinued 14 days after a patient's positive test result and following 3 days without worsening symptoms or fever. Patients who exited the program and had completed at least one assessment were sent a patient engagement survey. The objective of the survey was to evaluate the patient's experience with digital monitoring and symptom management for COVID-19. The assessment was structured with objective response questions, including a net promoter score, and free text questions to elicit patient perspectives on RPM value. Free text responses were analyzed using grounded theory to identify primary themes regarding perceived value. Results: The survey was distributed to 452 patients;241 responded as of June 10, 2020 (53% completion rate). The net promoter score was 91%. The table provides responses to objective questions. Qualitative analysis of free text responses identified the primary themes regarding patient perceived value which included: 1) Security: patients appreciated that the RPMP provided a clinical safety net;2) Connection: patients appreciated the link to their clinical team during a period of isolation;3) Empowerment: patients appreciated that the RPMP provided education on the virus and symptom management. Conclusions: RPMPs are perceived to be of value to oncology patients with COVID-19. A key barrier to maintaining these programs is cost. Policymakers should consider how these programs can be reimbursed in the future so that they can continue to provide care to vulnerable patients and keep them at home out of the acute care setting.