Association Between Unmet Nonmedication Needs After Hospital Discharge and Readmission or Death Among Acute Respiratory Failure Survivors: A Multicenter Prospective Cohort Study.

OBJECTIVES: To characterize early unmet nonmedication discharge needs (UDNs), classified as durable medical equipment (DME), home health services (HHS), and follow-up medical appointments (FUAs) and explore their association with 90-day readmission and mortality among survivors of acute respiratory failure (ARF) who were discharged home. DESIGN: Prospective multicenter cohort study. SETTING: Six academic medical centers across United States. PARTICIPANTS: Adult survivors of ARF who required an ICU stay and were discharged home from hospital. INTERVENTIONS: None. Exposure of interest was the proportion of UDN for the following categories: DME, HHS, and FUA ascertained within 7-28 days after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Two hundred eligible patients were recruited between January 2019 and August 2020. One-hundred ninety-five patients were included in the analytic cohort: 118 were prescribed DME, 134 were prescribed HHS, and 189 needed at least one FUA according to discharge plans. 98.4% (192/195) had at least one identified nonmedication need at hospital discharge. Median (interquartile range) proportion of unmet needs across three categories were 0 (0-15%) for DME, 0 (0-50%) for HHS, and 0 (0-25%) for FUA, and overall was 0 (0-20%). Fifty-six patients (29%) had 90-day death or readmission. After adjusting for prespecified covariates, having greater than the median level of unmet needs was not associated with an increased risk of readmission or death within 90 days of discharge (risk ratio, 0.89; 0.51-1.57; p = 0.690). Age, hospital length of stay, Acute Physiology and Chronic Health Evaluation II severity of illness score, and Multidimensional Scale Perceived Social Support score were associated with UDN. CONCLUSIONS: UDN were common among survivors of ARF but not significantly associated a composite outcome of 90-day readmission or death. Our results highlight the substantial magnitude of UDN and identifies areas especially vulnerable to lapses in healthcare coordination.

Instruments Assessing Cognitive Impairment in Survivors of Critical Illness and Reporting of Race Norms: A Systematic Review.

To conduct a systematic review to summarize cognitive instruments being used in long-term outcome studies of survivors of adult critical illness, as well as evaluate whether these measures are reported as using patient demographic norms, specifically race norms. DATA SOURCES: A comprehensive search was conducted in PubMed (National Center for Biotechnology Information), Excerpta Medica dataBASE (Ovid), Psychological Information Database (ProQuest), and Web of Science (Clarivate) for English language studies published since 2002. STUDY SELECTION: Studies were eligible if the population included adult ICU survivors assessed for postdischarge cognitive outcomes. DATA EXTRACTION: Two independent reviewers screened abstracts, examined full text, and extracted data from all eligible articles. DATA SYNTHESIS: A total of 98 articles (55 unique cohorts: 22 general ICU, 14 Acute respiratory distress syndrome/Acute respiratory failure/Sepsis, 19 COVID-19 and other subpopulations) were eligible for data extraction and synthesis. Among general ICU survivors, the majority of studies (n = 15, 68%) assessed cognition using multiple instruments, of which the most common was the Mini-Mental State Examination. Only nine of the 22 studies (41%) explicitly reported using patient demographic norms for scoring neuropsychological cognitive tests. Of the nine, all reported using age as a norming characteristic, education was reported in eight (89%), sex/gender was reported in five (55%), and race/ethnicity was reported in three (33%). Among Acute respiratory distress syndrome/Acute respiratory failure/Sepsis survivors, norming characteristics were reported in only four (28%) of the 14 studies, of which all reported using age and none reported using race/ethnicity. CONCLUSIONS: Less than half of the studies measuring cognitive outcomes in ICU survivors reported the use of norming characteristics. There is substantial heterogeneity in how studies reported the use of cognitive instruments, and hence, the prevalence of the use of patient norms may be underestimated. These findings are important in the development of appropriate standards for use and reporting of neuropsychological tests among ICU survivors.

Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study

Introduction Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery. Methods and analysis In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors. Results We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need;the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months;10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25;95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7;95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13;95% CI 0.02–0.99). Discussion Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs. Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03848-3.

Stress and Fear: Clinical Implications for Providers and Patients (in the Time of COVID-19 and Beyond).

In light of the coronavirus disease 2019 pandemic, we explore the role of stress, fear, and the impact of positive and negative emotions on health and disease. We then introduce strategies to help mitigate stress within the health care team, and provide a rationale for their efficacy. Additionally, we identify strategies to optimize patient care and explain their heightened importance in today's environment.

Global Economic Effects of COVID-19

From the Summary: Since the COVID-19 [coronavirus disease 2019] outbreak was first diagnosed, it has spread to over 190 countries and all U.S. states. The pandemic is having a noticeable impact on global economic growth. Estimates so far indicate the virus could trim global economic growth by as much as 2.0% per month if current conditions persist and raise the risks of a global economic recession similar in magnitude to that experienced during the Great Depression of the 1930s. Global trade could also fall by 13% to 32%, depending on the depth and extent of the global economic downturn. The full impact will not be known until the effects of the pandemic peak. This report provides an overview of the global economic costs to date and the response by governments and international institutions to address these effects.COVID-19 (Disease);Epidemics;Economy

Fiscal and Monetary Policy Initiatives by Major Economies to Address COVID-19

In response to the pandemic-related collapse in global economic growth in the first half of 2020, national governments, central banks, and international organizations adopted unprecedented fiscal, monetary, and other measures to stabilize financial markets and stimulate growth. The policy responses directed at the initial liquidity crisis in the financial sector have also significantly raised government debt levels, pushed unemployment rates to their highest levels in a generation, and reduced global economic growth by an estimated 3.0% to 6.0%. The human costs in terms of lives lost could permanently affect global economic output in addition to the cost of rising poverty levels, lives upended, shuttered businesses, and increased social unrest. Given the evolving nature of the health crisis, the economic crisis may persist longer than most forecasters previously have assumed. [...] The challenge for policymakers is one of implementing targeted policies that address what had been expected to be short-term problems without creating distortions in economies that could outlast the impact of the virus. Many policymakers, however, have been overwhelmed by the quickly changing nature of the health crisis that has turned into a global trade and economic crisis.

Effective community screening for asymptomatic and symptomatic COVID-19 with a fast and extremely low cost COVID-Anosmia Checker tool (preprint)

Background: Covid-19 curve can be flattened by adopting mass screening protocols with aggressive testing and isolating infected populations. The current approach largely depends on RT-PCR/rapid antigen tests that require expert personnel resulting in higher costs and reduced testing frequency. Loss of smell is reported as a major symptom of Covid-19, however, a precise olfactory testing tool to identify Covid-19 patient is still lacking. Methods: To quantitatively check for the loss of smell, we developed an odor strip, COVID-Anosmia checker, spotted with gradients of coffee and lemon grass oil. We validated its efficiency in healthy and COVID-19 positive subjects. A trial screening to identify SARS-CoV-2 infected persons was also carried out to check the sensitivity and specificity of our screening tool. Results: It was observed that COVID positive participants were hyposmic instead of being anosmic when they were subjected to smelling higher odor concentration. Our tool identified 97% of symptomatic and 94% of asymptomatic COVID-19 positive subjects after excluding most confounding factors like concurrent chronic sinusitis. Further, it was possible to reliably predict COVID-19 infection by calculating a loss of smell score with 100% specificity. We coupled this tool with a mobile application, which takes the input response from the user, and can readily categorize the user in the appropriate risk groups. Conclusion: Loss of smell can be used as a reliable marker for screening for Covid-19. Our tool can rapidly quantitate anosmia, hyposmia, parosmia, and can be used as a first-line screening tool to trace out Covid-19 infection effectively.

Global Economic Effects of COVID-19 [Updated July 21, 2020]

From the Summary: Since the COVID-19 [coronavirus disease 2019] outbreak was first diagnosed, it has spread to over 200 countries and all U.S. states. The pandemic is negatively affecting global economic growth beyond anything experienced in nearly a century. Estimates so far indicate the virus could trim global economic growth by 3.0% to 6.0% in 2020, with a partial recovery in 2021, assuming there is not a second wave of infections. The economic fallout from the pandemic raises the risks of a global economic recession with levels of unemployment not experienced since the Great Depression of the 1930s. The human costs in terms of lives lost will permanently affect global economic growth in addition to the cost of rising levels of poverty, lives upended, careers derailed, and increased social unrest. Global trade could also fall by 13% to 32%, depending on the depth and extent of the global economic downturn, exacting an especially heavy economic toll on trade-dependent developing and emerging economies. The full impact will not be known until the effects of the pandemic peak. This report provides an overview of the global economic costs to date and the response by governments and international institutions to address these effects.COVID-19 (Disease);Public health;Economics