Interrupted Time Series Analysis: Patient Characteristics and Rates of Opioid-Use-Disorder-Related Emergency Department Visits in the Los Angeles County Public Hospital System during COVID-19.

The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82-6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged from the Emergency Department with Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Quantification of Severe Acute Respiratory Syndrome Coronavirus 2 Binding Antibody Levels To Assess Infection and Vaccine-Induced Immunity Using WHO Standards.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binding antibody (Ab) levels following vaccination or natural infection could be used as a surrogate for immune protection if results of serological assays were standardized to yield quantitative results using an international standard. Using a bead-based serological assay (Luminex xMAP), anti-receptor binding domain (anti-RBD) Ab levels were determined for 1,450 participants enrolled in the Los Angeles Pandemic Surveillance Cohort (LAPSC) study. For 123 participants, SARS-CoV-2 binding antibody unit (BAU) levels were also quantified using WHO standards and then compared to the semiquantitative results. Samples were chosen to represent the range of results and time from vaccination. Antibody levels and decay rates were then compared using unadjusted and adjusted linear regression models. The linear range of the assay used in this study was determined to be 300 to 5,000 mean fluorescence intensity units (MFI). Among the fully vaccinated groups (vaccinated only and vaccinated with past infection), 84.8% had anti-RBD MFI values above the linear range of >5,000 MFI, and 33.8% had values of >15,000 MFI. Among vaccinated participants with past infection (hybrid immunity), 97% had anti-RBD values of >5,000 MFI and 70% (120/171) had anti-RBD values of >15,000 MFI. In the subgroup quantified using the WHO control, BAU levels were significantly higher than the semiquantitative MFI results. In vaccinated participants, Ab decay levels were similar between infected and noninfected groups (P = 0.337). These results demonstrate that accurate quantitation is possible if standardized with an international standard. BAU can then be compared over time or between subjects and would be useful in clinical decision making. IMPORTANCE Accurate quantification of SARS-CoV-2-specific antibodies can be achieved using a universal standard with sample dilution within the linear range. With hybrid immunity being now common, it is critical to use protocols adapted to high Ab levels to standardize serological results. We validated this approach with the Los Angeles Pandemic Surveillance Cohort by comparing the antibody decay rates in vaccinated participants and vaccinated infected participants.

Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic.

In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.

Factors associated with parents' willingness to vaccinate their children against COVID-19: The LA pandemic surveillance cohort study.

Background: Children age 5-11 became eligible for COVID-19 vaccination in November 2021 in the United States, but vaccine uptake in this age group remains low. Understanding reasons why parents are hesitant to vaccinate their children may provide critical insights to help protect children from COVID-19 infection. This study examines factors associated with parents' willingness to vaccinate their children. Methods: We conducted a cross-sectional survey focusing on the Los Angeles County adult residents between March and June 2021. Our analytic sample focused on a subgroup of participants who self-report having a child. Predictors included parents' vaccination status and beliefs about COVID-19. We used multivariable logistic regression analysis and calculated the predicted probabilities of parents' willingness to vaccinate their children. Results: Parents (n = 401) who worried about catching the virus, had trust in vaccine development and the COVID-19 vaccine approval process, and vaccinated against COVID-19 were more likely to be willing to vaccinate their children. Socio-economic, racial and ethnic differences were no longer statistically significant in the adjusted model. Predicted probabilities of parents who were willing to vaccine their children were 55% among the vaccinated and 36% among the unvaccinated. Conclusions: Parents' intent to vaccinate their children is influenced by their perceived severity of the pandemic, trust in the vaccine development process, and their vaccination status, which can be the potential drivers of hesitancy to vaccinate their children.

Did prioritizing essential workers help to achieve racial/ethnic equity in early COVID-19 vaccine distribution? The LA pandemic surveillance cohort study.

BACKGROUND: Most US states and counties prioritized essential workers for early access to COVID-19 vaccines due to their heightened occupational risk. Racial/ethnic groups most impacted by COVID-19 are overrepresented among essential workers. This study estimates the effects of prioritizing essential workers on racial/ethnic equity in COVID-19 vaccination. METHODS: Survey data were collected from 5500 Los Angeles County adult residents in March and April 2021. Multivariate regression models were used to assess marginal changes in probabilities of vaccination attributable to essential worker status by race/ethnicity. These probabilities were multiplied by population proportions of essential workers in each racial/ethnic group to estimate the effects of prioritizing essential workers on vaccine equity in the population. RESULTS: While Latinos (24.9%), Blacks (22.4%), and Asians (21.4%) were more likely to be prioritized essential workers than Whites (14.3%), their marginal gains in vaccine uptake due to their essential worker status did not significantly differ from that of Whites. At the population-level, prioritizing vaccines for essential workers increased the probabilities of vaccination by small and similar amounts among Asians (5.3%; 95% confidence interval [CI]: 3.3%, 7.5%), Blacks (4.0%; 95% CI: 1.7%, 6.5%), Latinos (3.7%; 95% CI: 2.3%, 5.1%), and Whites (2.9%; 95% CI :1.9%, 3.9%). CONCLUSIONS: Prioritizing essential workers did not provide proportionally greater early vaccine uptake benefits to racial/ethnic groups that were disproportionately affected by COVID-19. Early prioritization of essential workers during vaccine campaigns is an important but insufficient strategy for reducing racial/ethnic disparities in early vaccine uptake. Additional strategies addressing access and trust are needed to achieve greater equity in vaccine distribution.

Relationship between mask wearing, testing, and vaccine willingness among Los Angeles County adults during the peak of the COVID-19 pandemic.

BACKGROUND: Mask wearing mitigates the spread of COVID-19; however, many individuals have not adopted the protective behavior. PURPOSE: We examine mask wearing behavior during the height of the pandemic in Los Angeles County, and its association with COVID-19 testing and willingness to get vaccinated. METHODS: We conducted a cross-sectional survey using representative sampling between December 2020 and January 2021, through an online platform targeting Los Angeles County residents. Survey items include demographic characteristics, health conditions, access to health care, mask wearing, COVID-19 testing, exposure risk factors, and willingness to receive COVID-19 vaccine. We performed logistic regression models to examine factors associated with always mask wearing. RESULTS: Of the analytic sample (n = 1,984), 75.3% reported always wearing a face mask when leaving home. Being a female, Asian or African American, or non-Republican resident, or having higher education, having poor or fair health, having a regular doctor, knowing someone hospitalized for COVID-19, and being willing to receive the COVID-19 vaccine were associated with always wearing a mask. Residents who were younger, had a highest risk health condition, and had ≥2 COVID-19 tests had lower odds of always mask wearing. CONCLUSION: Mask wearing guidelines are easing; however, as vaccination rates plateau and new virus variants emerge, mask wearing remains an important tool to protect vulnerable populations. Encouraging protective measures among younger adults, those with less education, republicans, men, and White residents-groups that are least likely to be vaccinated or wear a mask-may be critical to reducing transmission.

Who Stayed Home Under Safer-at-Home? Impacts of COVID-19 on Volume and Patient-Mix at an Emergency Department.

INTRODUCTION: To describe the impact of COVID-19 on a large, urban emergency department (ED) in Los Angeles, California, we sought to estimate the effect of the novel coronavirus 2019 (COVID-19) and "safer-at-home" declaration on ED visits, patient demographics, and diagnosis-mix compared to prior years. METHODS: We used descriptive statistics to compare ED volume and rates of admission for patients presenting to the ED between January and early May of 2018, 2019, and 2020. RESULTS: Immediately after California's "safer-at-home" declaration, ED utilization dropped by 11,000 visits (37%) compared to the same nine weeks in prior years. The drop affected patients regardless of acuity, demographics, or diagnosis. Reductions were observed in the number of patients reporting symptoms often associated with COVID-19 and all other complaints. After the declaration, higher acuity, older, male, Black, uninsured or non-Medicaid, publicly insured, accounted for a disproportionate share of utilization. CONCLUSION: We show an abrupt, discontinuous impact of COVID-19 on ED utilization with a slow return as safer-at-home orders have lifted. It is imperative to determine how this reduction will impact patient outcomes, disease control, and the health of the community in the medium and long terms.