Rural-Urban Disparities in Hospital Admissions and Mortality Among Patients with COVID-19: Evidence from South Carolina from 2021 to 2022.

Although rural communities have been hard-hit by the COVID-19 pandemic, there is limited evidence on COVID-19 outcomes in rural America using up-to-date data. This study aimed to estimate the associations between hospital admissions and mortality and rurality among COVID-19 positive patients who sought hospital care in South Carolina. We used all-payer hospital claims, COVID-19 testing, and vaccination history data from January 2021 to January 2022 in South Carolina. We included 75,545 hospital encounters within 14 days after positive and confirmatory COVID-19 testing. Associations between hospital admissions and mortality and rurality were estimated using multivariable logistic regressions. About 42% of all encounters resulted in an inpatient hospital admission, while hospital-level mortality was 6.3%. Rural residents accounted for 31.0% of all encounters for COVID-19. After controlling for patient-level, hospital, and regional characteristics, rural residents had higher odds of overall hospital mortality (Adjusted Odds Ratio - AOR = 1.19, 95% Confidence Intervals - CI = 1.04-1.37), both as inpatients (AOR = 1.18, 95% CI = 1.05-1.34) and as outpatients (AOR = 1.63, 95% CI = 1.03-2.59). Sensitivity analyses using encounters with COVID-like illness as the primary diagnosis only and encounters from September 2021 and beyond - a period when the Delta variant was dominant and booster vaccination was available - yielded similar estimates. No significant differences were observed in inpatient hospitalizations (AOR = 1.00, 95% CI = 0.75-1.33) between rural and urban residents. Policymakers should consider community-based public health approaches to mitigate geographic disparities in health outcomes among disadvantaged population subgroups.

Broadband access within Medically Underserved Areas and its implication for telehealth utilization.

PURPOSE: There is little information as to how America's broadband infrastructure might impact recent efforts to expand access to virtual care for underserved communities. OBJECTIVE: To examine potential and realized access to broadband internet services within Medically Underserved Areas (MUAs) that rely on community health care service providers for primary care. METHODS: This cross-sectional study included 214,946 US Census Block Group estimates from the 2017 and 2019 American Community Survey and the corresponding Federal Communications Commission database. Changes in household broadband subscription rates and Healthy People 2020 access thresholds within MUAs were assessed. FINDINGS: In 2019, 24,304 MUA households (31.9%) met Healthy People 2020 targets for broadband subscription rates, compared to 64.4% of non-MUA households (n = 89,285). On average, 74.7% of MUA households had a broadband internet subscription compared to 85.2% of non-MUA households, whereas 61.1% (n = 46,635) of MUA households had access to broadband speeds of at least 25.0 Mbps, compared to 75.6% (n = 104,696) of non-MUA households. Within urban households, there was a 0.8 to 1.3 to 1.6 annual percentage point convergence in MUA versus non-MUA broadband disparities between across quintiles (P < .05). Rural MUA households showed little improvement in broadband access between 2017 and 2019. CONCLUSIONS: There has been an overall convergence of broadband access disparities between MUA and non-MUA households over time, but less improvements in access among the most rural households. Reimbursement for audio-only telehealth visits by state Medicaid agencies would help drive down barriers to virtual health care options for populations residing in MUAs.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States.

INTRODUCTION: The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based). METHODS: We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type. RESULTS: Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic. DISCUSSION: The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Trends in the availability of community-based home visiting services for oldest-old in China, 2005-2018.

OBJECTIVES: This study aims to examine trends in neighbourhood availability of community-based home visiting services (CHVS) (ie, coverage by local primary healthcare providers) over time and disparities in service availability according to individual characteristics using nationwide data of oldest-old individuals (age >80) in China. DESIGN: Repeated, cross-sectional study. SETTING: This study derived nationally representative data from the 2005-2018 Chinese Longitudinal Health Longevity Survey. PARTICIPANTS: A final analytical sample of 38 032 oldest-old individuals. PRIMARY OUTCOME MEASURES: Availability of CHVS was defined as having home visiting services in one's neighbourhood. Cochran-Armitage tests were used to test linear trends in the proportions of oldest-old with service availability. Weighted logistic regression models were used to examine variations in service availability across individual characteristics. RESULTS: Of 38 032 oldest-old individuals, availability of CHVS decreased from 9.7% in 2005 to 7.8% in 2008/2009, followed by continual increases to 33.7% in 2017/2018. These changes were similar between rural and urban oldest-old. After accounting for individual characteristics, in 2017/2018, compared with their counterparts, urban residents who had white-collar jobs before retirement and those residing in Western and Northeast China were less likely to have service availability. Oldest-old with disabilities, those living alone and those with low incomes did not report having greater availability of CHVS in either 2005 or 2017/2018. CONCLUSIONS: Despite the increasing service availability over the past 13 years, persistent geographical disparities in the availability of CHVS remain. As of 2017/2018, only one in three oldest-old in China reported having service availability, which raises concerns regarding continuity of care across different settings of services for those most in need, especially those living alone or with disabilities. National policies and targeting efforts are necessary to improve the availability of CHVS and reduce inequity in service availability for optimal long-term care to the oldest-old population in China.

Trends in the availability of community-based psychological counselling services for oldest-old in China, 2005 to 2018.

BACKGROUND: Community-based psychological counselling services (CPCS) is crucial for the oldest-old who often faces challenges or are reluctant to seek care at the healthcare settings. This study aims to examine trends in availability of CPCS over time and rural-urban disparities in service availability among nationwide oldest-old in China. METHODS: Multiple cross-sectional data were derived from the 2005-2018 Chinese Longitudinal Health Longevity Survey. Service availability was reported by each oldest-old participant or their next-of-kins as having CPCS in one's neighborhood. We used Cochran-Armitage tests to estimate service availability trends and applied sample-weighted logistic regression models to examine its rural-urban disparities. RESULTS: Of 38,032 oldest-old, CPCS availability decreased from 6.7 % in 2005 to 4.8 % in 2008/2009, followed by continual increases to 13.6 % in 2017/2018. In 2017/2018, rural oldest-old's neighborhoods had no greater service availability. Oldest-old residing in the Central (6.7 %), Western (13.4 %) and Northeast China (8.1 %) were less likely to report having services locally than their Eastern counterparts (17.8 %). Oldest-old having any disability or living in the nursing homes reported having greater service availability than those without disability or living at home. LIMITATION: Service availability might have been disrupted during the COVID-19 pandemic. CONCLUSIONS: Despite the increasing service availability, as of 2017/2018, only 13.6 % oldest-old in China had reported CPCS availability. It raises concerns on the disproportionate access to and continuity of mental health care, especially for those living the Central, Western China and those living at home. Policy efforts are needed to incentivize service expansion and eliminate disparities in the service availability.

Risk for stillbirth among pregnant individuals with SARS-CoV-2 infection varied by gestational age.

BACKGROUND: Despite previous research findings on higher risks of stillbirth among pregnant individuals with SARS-CoV-2 infection, it is unclear whether the gestational timing of viral infection modulates this risk. OBJECTIVE: This study aimed to examine the association between timing of SARS-CoV-2 infection during pregnancy and risk of stillbirth. STUDY DESIGN: This retrospective cohort study used multilevel logistic regression analyses of nationwide electronic health records in the United States. Data were from 75 healthcare systems and institutes across 50 states. A total of 191,403 pregnancies of 190,738 individuals of reproductive age (15-49 years) who had childbirth between March 1, 2020 and May 31, 2021 were identified and included. The main outcome was stillbirth at ≥20 weeks of gestation. Exposures were the timing of SARS-CoV-2 infection: early pregnancy (<20 weeks), midpregnancy (21-27 weeks), the third trimester (28-43 weeks), any time before delivery, and never infected (reference). RESULTS: We identified 2342 (1.3%) pregnancies with COVID-19 in early pregnancy, 2075 (1.2%) in midpregnancy, and 12,697 (6.9%) in the third trimester. After adjusting for maternal and clinical characteristics, increased odds of stillbirth were observed among pregnant individuals with SARS-CoV-2 infection only in early pregnancy (odds ratio, 1.75, 95% confidence interval, 1.25-2.46) and midpregnancy (odds ratio, 2.09; 95% confidence interval, 1.49-2.93), as opposed to pregnant individuals who were never infected. Older age, Black race, hypertension, acute respiratory distress syndrome or acute respiratory failure, and placental abruption were found to be consistently associated with stillbirth across different trimesters. CONCLUSION: Increased risk of stillbirth was associated with COVID-19 only when pregnant individuals were infected during early and midpregnancy, and not at any time before the delivery or during the third trimester, suggesting the potential vulnerability of the fetus to SARS-CoV-2 infection in early pregnancy. Our findings underscore the importance of proactive COVID-19 prevention and timely medical intervention for individuals infected with SARS-CoV-2 during early and midpregnancy.

Pre-pandemic geographic access to hospital-based telehealth for cancer care in the United States.

IMPORTANCE: Little is known about US hospitals' capacity to ensure equitable provision of cancer care through telehealth. OBJECTIVE: To conduct a national analysis of hospitals' provision of telehealth and oncologic services prior to the SARS-CoV-2 pandemic, along with geographic and sociodemographic correlates of access. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional analysis with Geographic Information Systems mapping of 1) 2019 American Hospital Association (AHA) Annual Hospital Survey and IT Supplement, 2) 2013 Urban Influence Codes (UIC) from the United States Department of Agriculture, 3) 2018 Area Health Resources Files from the Health Services and Resources Administration (HRSA). INTERVENTIONS: Hospitals were categorized by telehealth and oncology services availability. Counties were classified as low-, moderate-, or high-access based on availability of hospital-based oncology and telehealth within their boundaries. MAIN OUTCOMES AND MEASURES: Geospatial mapping of access to hospital-based telehealth for cancer care. Generalized logistic mixed effects models identified associations between sociodemographic factors and county- and hospital-level access to telehealth and oncology care. RESULTS: 2,054 out of 4,540 hospitals (45.2%) reported both telehealth and oncology services. 272 hospitals (6.0%) offered oncology without telehealth, 1,369 (30.2%) offered telehealth without oncology, and 845 (18.6%) hospitals offered neither. 1,288 out of 3,152 counties with 26.6 million residents across 41 states had no hospital-based access to either oncology or telehealth. After adjustment, rural hospitals were less likely than urban hospitals to offer telehealth alongside existing oncology care (OR 0.27; 95% CI 0.14-0.55; p < .001). No county-level factors were significantly associated with telehealth availability among hospitals with oncology. CONCLUSIONS AND RELEVANCE: Hospital-based cancer care and telehealth are widely available across the US; however, 8.4% of patients are at risk for geographic barriers to cancer care. Advocacy for adoption of telehealth is critical to ensuring equitable access to high-quality cancer care, ultimately reducing place-based outcomes disparities. Detailed, prospective, data collection on telehealth utilization for cancer care is also needed to ensure improvement in geographic access inequities.

Temporal Events Detector for Pregnancy Care (TED-PC): A rule-based algorithm to infer gestational age and delivery date from electronic health records of pregnant women with and without COVID-19.

OBJECTIVE: Identifying the time of SARS-CoV-2 viral infection relative to specific gestational weeks is critical for delineating the role of viral infection timing in adverse pregnancy outcomes. However, this task is difficult when it comes to Electronic Health Records (EHR). In combating the COVID-19 pandemic for maternal health, we sought to develop and validate a clinical information extraction algorithm to detect the time of clinical events relative to gestational weeks. MATERIALS AND METHODS: We used EHR from the National COVID Cohort Collaborative (N3C), in which the EHR are normalized by the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). We performed EHR phenotyping, resulting in 270,897 pregnant women (June 1st, 2018 to May 31st, 2021). We developed a rule-based algorithm and performed a multi-level evaluation to test content validity and clinical validity, and extreme length of gestation (<150 or >300). RESULTS: The algorithm identified 296,194 pregnancies (16,659 COVID-19, 174,744 without COVID-19) in 270,897 pregnant women. For inferring gestational age, 95% cases (n = 40) have moderate-high accuracy (Cohen's Kappa = 0.62); 100% cases (n = 40) have moderate-high granularity of temporal information (Cohen's Kappa = 1). For inferring delivery dates, the accuracy is 100% (Cohen's Kappa = 1). The accuracy of gestational age detection for the extreme length of gestation is 93.3% (Cohen's Kappa = 1). Mothers with COVID-19 showed higher prevalence in obesity or overweight (35.1% vs. 29.5%), diabetes (17.8% vs. 17.0%), chronic obstructive pulmonary disease (0.2% vs. 0.1%), respiratory distress syndrome or acute respiratory failure (1.8% vs. 0.2%). DISCUSSION: We explored the characteristics of pregnant women by different gestational weeks of SARS-CoV-2 infection with our algorithm. TED-PC is the first to infer the exact gestational week linked with every clinical event from EHR and detect the timing of SARS-CoV-2 infection in pregnant women. CONCLUSION: The algorithm shows excellent clinical validity in inferring gestational age and delivery dates, which supports multiple EHR cohorts on N3C studying the impact of COVID-19 on pregnancy.

Analysis of Residential Segregation and Racial and Ethnic Disparities in Severe Maternal Morbidity Before and During the COVID-19 Pandemic.

Importance: Persistent racial and ethnic disparities in severe maternal morbidity (SMM) in the US remain a public health concern. Structural racism leaves women of color in a disadvantaged situation especially during COVID-19, leading to disproportionate pandemic afflictions among racial and ethnic minority women. Objective: To examine racial and ethnic disparities in SMM rates before and during the COVID-19 pandemic and whether the disparities varied with level of Black residential segregation. Design, Setting, and Participants: A statewide population-based retrospective cohort study used birth certificates linked to all-payer childbirth claims data in South Carolina. Participants included women who gave birth between January 2018 and June 2021. Data were analyzed from December 2021 to February 2022. Exposures: Exposures were (1) period when women gave birth, either before the pandemic (January 2018 to February 2020) or during the pandemic (March 2020 to June 2021) and (2) Black-White residential segregation (isolation index), categorizing US Census tracts in a county as low (<40%), medium (40%-59%), and high (≥60%). Main Outcomes and Measures: SMM was identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes developed by the US Centers for Disease Control and Prevention. Multilevel logistic regressions with an interrupted approach were used, adjusting for maternal-level and facility-level factors, accounting for residential county-level random effects. Results: Of 166 791 women, 95 098 (57.0%) lived in low-segregated counties (mean [SD] age, 28.1 [5.7] years; 5126 [5.4%] Hispanic; 20 523 [21.6%] non-Hispanic Black; 62 690 [65.9%] White), and 23 521 (14.1%) women (mean [SD] age, 28.1 [5.8] years; 782 [3.3%] Hispanic; 12 880 [54.8%] non-Hispanic Black; 7988 [34.0%] White) lived in high-segregated areas. Prepandemic SMM rates were decreasing, followed by monthly increasing trends after March 2020. On average, living in high-segregated communities was associated with higher odds of SMM (adjusted odds ratio [aOR], 1.61; 95% CI, 1.06-2.34). Black women regardless of residential segregation had higher odds of SMM than White women (aOR, 1.47; 95% CI, 1.11-1.96 for low-segregation; 2.12; 95% CI, 1.38-3.26 for high-segregation). Hispanic women living in low-segregated communities had lower odds of SMM (aOR, 0.48; 95% CI, 0.25-0.90) but those living in high-segregated communities had nearly twice the odds of SMM (aOR, 1.91; 95% CI, 1.07-4.17) as their White counterparts. Conclusions and Relevance: Living in high-segregated Black communities in South Carolina was associated with racial and ethnic SMM disparities. During the COVID-19 pandemic, Black vs White disparities persisted with no signs of widening gaps, whereas Hispanic vs White disparities were exacerbated. Policy reforms on reducing residential segregation or combating the corresponding structural racism are warranted to help improve maternal health.

Racial and Ethnic Disparities in Postpartum Care in the Greater Boston Area During the COVID-19 Pandemic.

Importance: Racial and ethnic disparities in postpartum care access have been well identified in the United States. Such disparities could be exacerbated by the COVID-19 pandemic because of amplified economic distress and compromised social capital among pregnant women who belong to racial or ethnic minority groups. Objective: To examine whether the COVID-19 pandemic is associated with an increase in the existing racial and ethnic disparity in postpartum care access. Design, Setting, and Participants: This was a retrospective cohort study using electronic health records data. Multinomial logistic regressions in an interrupted time series approach were used to assess monthly changes in postpartum care access across Asian, Hispanic, non-Hispanic Black (hereafter, Black), non-Hispanic White (hereafter, White) women, and women of other racial groups, controlling for maternal demographic and clinical characteristics. Eligible participants were women who gave live birth at 8 hospitals in the greater Boston, Massachusetts, area from January 1, 2019, to November 30, 2021, allowing for tracking 90-day postpartum access until March 1, 2022. Exposures: Delivery period: prepandemic (January to December 2019), early pandemic (January to March 2020), and late pandemic (April 2020 to November 2021). Main Outcomes and Measures: Postpartum care within 90 days after childbirth was categorized into 3 groups: attended, canceled, and nonscheduled. Results: A total of 45 588 women were included. Participants were racially and ethnically diverse (4735 [10.4%] Asian women, 3399 [7.5%] Black women, 6950 [15.2%] Hispanic women, 28 529 [62.6%] White women, and 1269 [2.8%] women of other race or ethnicity). The majority were between 25 and 34 years of age and married and had a full-term pregnancy, vaginal delivery, and no clinical conditions. In the prepandemic period, the overall postpartum care attendance rate was 75.2%, dropping to 41.7% during the early pandemic period, and rebounding back to 60.9% in the late pandemic period. During the months in the late pandemic, the probability of not scheduling postpartum care among Black (average marginal effect [AME], 1.1; 95% CI, 0.6-1.6) and Hispanic women (AME, 1.3; 95% CI, 0.9-1.6) increased more than among their White counterparts. Conclusions and Relevance: In this cohort study of postpartum care access before and during the COVID-19 pandemic, racial and ethnic disparities in postpartum care were exacerbated following the onset of the COVID-19 pandemic, when postpartum care access recovered more slowly among Black and Hispanic women than White women. These disparities require swift attention and amelioration to address barriers for these women to obtain much needed postpartum care during this pandemic.

Multilevel determinants of racial/ethnic disparities in severe maternal morbidity and mortality in the context of the COVID-19 pandemic in the USA: protocol for a concurrent triangulation, mixed-methods study.

INTRODUCTION: The COVID-19 pandemic has affected communities of colour the hardest. Non-Hispanic black and Hispanic pregnant women appear to have disproportionate SARS-CoV-2 infection and death rates. METHODS AND ANALYSIS: We will use the socioecological framework and employ a concurrent triangulation, mixed-methods study design to achieve three specific aims: (1) examine the impacts of the COVID-19 pandemic on racial/ethnic disparities in severe maternal morbidity and mortality (SMMM); (2) explore how social contexts (eg, racial/ethnic residential segregation) have contributed to the widening of racial/ethnic disparities in SMMM during the pandemic and identify distinct mediating pathways through maternity care and mental health; and (3) determine the role of social contextual factors on racial/ethnic disparities in pregnancy-related morbidities using machine learning algorithms. We will leverage an existing South Carolina COVID-19 Cohort by creating a pregnancy cohort that links COVID-19 testing data, electronic health records (EHRs), vital records data, healthcare utilisation data and billing data for all births in South Carolina (SC) between 2018 and 2021 (>200 000 births). We will also conduct similar analyses using EHR data from the National COVID-19 Cohort Collaborative including >270 000 women who had a childbirth between 2018 and 2021 in the USA. We will use a convergent parallel design which includes a quantitative analysis of data from the 2018-2021 SC Pregnancy Risk Assessment and Monitoring System (unweighted n>2000) and in-depth interviews of 40 postpartum women and 10 maternal care providers to identify distinct mediating pathways. ETHICS AND DISSEMINATION: The study was approved by institutional review boards at the University of SC (Pro00115169) and the SC Department of Health and Environmental Control (DHEC IRB.21-030). Informed consent will be provided by the participants in the in-depth interviews. Study findings will be disseminated with key stakeholders including patients, presented at academic conferences and published in peer-reviewed journals.

Mental health among pregnant women with COVID-19-related stressors and worries in the United States.

BACKGROUND: Few studies have evaluated whether pandemic-related stressors, worries, and social distancing have affected the mental health of pregnant women during the COVID-19 pandemic. METHODS: Data came from an online survey of United States pregnant women (n = 715), conducted in May 2020. The Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder Scale were used to assess depressive symptoms, thoughts of self-harm, and moderate or severe anxiety. Multiple logistic regressions were used to examine the associations of COVID-19 experiences with mental health outcomes. RESULTS: Participants were racially diverse. The prevalence of adverse mental health outcomes was 36% for probable depression, 20% for thoughts of self-harm, and 22% for anxiety. Women who reported family members dying from COVID-19 had four times higher odds of having thoughts of self-harm than women who did not experience family death. Depression was more prevalent among women who canceled or reduced medical appointments. Women were more likely to have worse mental health outcomes if they expressed worry about getting financial or emotional/social support, about their pregnancy, or about family or friends. Strict social distancing was positively associated with depression. A higher proportion of adults working from home was inversely associated with depression and thoughts of self-harm. CONCLUSION: High percentages of pregnant women had symptoms of depression or anxiety, suggesting an urgent need to screen and treat mental health conditions among pregnant women during the pandemic. Pandemic-related risks and protective factors are relevant to developing tailored interventions to address the mental health of pregnant women during pandemic circumstances.

Telepsychiatry adoption across hospitals in the United States: a cross-sectional study.

BACKGROUND: Access to psychiatric care is critical for patients discharged from hospital psychiatric units to ensure continuity of care. When face-to-face follow-up is unavailable or undesirable, telepsychiatry becomes a promising alternative. This study aimed to investigate hospital- and county-level characteristics associated with telepsychiatry adoption. METHODS: Cross-sectional national data of 3475 acute care hospitals were derived from the 2017 American Hospital Association Annual Survey. Generalized linear regression models were used to identify characteristics associated with telepsychiatry adoption. RESULTS: About one-sixth (548 [15.8%]) of hospitals reported having telepsychiatry with a wide variation across states. Rural noncore hospitals were less likely to adopt telepsychiatry (8.3%) than hospitals in rural micropolitan (13.6%) and urban counties (19.4%). Hospitals with both outpatient and inpatient psychiatric care services (marginal difference [95% CI]: 16.0% [12.1% to 19.9%]) and hospitals only with outpatient psychiatric services (6.5% [3.7% to 9.4%]) were more likely to have telepsychiatry than hospitals with neither psychiatric services. Federal hospitals (48.9% [32.5 to 65.3%]), system-affiliated hospitals (3.9% [1.2% to 6.6%]), hospitals with larger bed size (Quartile IV vs. I: 6.2% [0.7% to 11.6%]), and hospitals with greater ratio of Medicaid inpatient days to total inpatient days (Quartile IV vs. I: 4.9% [0.3% to 9.4%]) were more likely to have telepsychiatry than their counterparts. Private non-profit hospitals (- 6.9% [- 11.7% to - 2.0%]) and hospitals in counties designated as whole mental health professional shortage areas (- 6.6% [- 12.7% to - 0.5%]) were less likely to have telepsychiatry. CONCLUSIONS: Prior to the Covid-19 pandemic, telepsychiatry adoption in US hospitals was low with substantial variations by urban and rural status and by state in 2017. This raises concerns about access to psychiatric services and continuity of care for patients discharged from hospitals.

Variations in health behaviors among pregnant women during the COVID-19 pandemic.

PURPOSE: To examine changes in lifestyle behaviors early in the COVID-19 pandemic among pregnant women. MATERIALS AND METHODS: A cross-sectional internet-based survey was completed by 706 pregnant women (mean age 29.6 years ± 3.2) residing in the United States in May 2020 to assess self-reported changes in diet, physical activity, and sleep during the COVID-19 pandemic. Logistic regression analyses examined whether sociodemographic, clinical, and pandemic-related characteristics were associated with health behavior changes. RESULTS: Approximately 17% of women reported their diets worsened during the COVID-19 pandemic, 42% reported improvements, and 41% reported no change. For physical activity, 22% reported they stopped being active, 2% reported they became active, and 76% reported no change. Nearly one-third of participants reported getting less sleep. The factors consistently associated with adverse lifestyle changes (worse diet, stopped being active, and reduced sleep) were experiences of pregnancy complications, loss of income due to COVID-19, and changes in social connections due to COVID-19. CONCLUSIONS: A substantial proportion of pregnant women reported adverse lifestyle changes during the COVID-19 pandemic. Interventions during the pandemic to optimize health behaviors in pregnant women, especially among those with pregnancy complications, should address economic disadvantages and social support.