Veterans’ Ambulatory Care Experience During COVID-19: Veterans’ Access to and Satisfaction with Primary Care Early in the Pandemic (preprint)

Background The COVID-19 pandemic caused widespread practice changes to healthcare in all settings, but little is known about veterans’ experience with primary care during the early phase of the pandemic.Objective To characterize how COVID-induced changes affected the ambulatory care experience, specifically access and satisfaction, among Veteran users of primary care at a large urban Veterans Health Administration (VHA) medical center.Design: We employed a semi-structured telephone interview consisting of 56 questions to capture quantitative and qualitative data. We randomly selected potential participants from among patients who were scheduled to see any of 31 primary care physicians between March 1 – June 30, 2020 at a single location. We evaluated quantitative data using descriptive statistics and categorized open-ended qualitative responses using a matrix analysis.Participants: The study sample of 40 veterans largely consisted of men, almost equally split between non-Hispanic Whites and African Americans. The majority (22, 55%) of the veterans were members of Priority Group 1, the VHA eligibility group that requires either a greater than 50% disability rating or deemed unemployable. Many of the veterans had other insurance coverage, including TRICARE (21, 52.5%), Medicare (8, 20%), and private insurance (5, 12.5%).Main Measures/Approach: We sought to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and their non-VHA primary care source. We also explored the context of veterans' daily lives during the pandemic, knowing that many people’s mental health, relationships, and employment were impacted.Key Results: Veterans completed (mean 2.6) more appointments than scheduled (mean 2.3) due to urgent or ‘sick’ visits with a shift to virtual modalities like telephone (mean: 2.1) and video (mean: 1.5). Those who reported decreased access to care (27, 67%) as compared to before the pandemic cited administrative barriers (15, 56%) and lack of physician availability (9, 33%) as key factors. While most veterans (31, 84%) were highly satisfied with their care, 9 (24%) reported a decrease in satisfaction since the pandemic. The few veterans who utilized non-VHA physicians were slightly more satisfied with their care. None of the veterans interviewed contracted COVID-19 during the study period, but many experienced indirect psychosocial effects such as the worsening or development of mental health conditions (6, 15%), anxiety concerning the virus (12, 30%), social isolation (8, 20%).Conclusions While the quantitative data suggests continued adequate access and satisfaction, the numerous comments regarding barriers to care illustrate a disconnect between veterans’ perceived experience and the quantitative findings. Given the VHA system’s efforts to scale up virtual care and pandemic-related messaging, the comments of this sample of veterans suggest that enhanced or different approaches may be warranted to maintain perceptions of access and satisfaction with primary care during times of crisis.

Association between City-wide Lockdown and COVID-19 Hospitalization Rates in Multigenerational Households in New York City (preprint)

BackgroundCity-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households. MethodsWe obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown. FindingsAmong individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22 - 96%); Q3 vs. Q1: 48%, (17 - 89%); Q4 vs. Q1: 66%, (30 - 211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7 -76%). InterpretationBy increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households. FundingNational Center for Advancing Translational Sciences; Clinical and Translational Science Center at Weill Cornell Medical College.

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study (preprint)

IntroductionThe role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households, and COVID-19 in New York City (NYC). MethodsWe conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as proportion of estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering. Results39,923 suspected COVID-19 cases presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant ({beta}interaction = 0.99, 95% CI: 0.99-1.00). ConclusionsOver-crowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Hyperglycemia in Acute COVID-19 is Characterized by Adipose Tissue Dysfunction and Insulin Resistance (preprint)

COVID-19 has proven to be a metabolic disease resulting in adverse outcomes in individuals with diabetes or obesity. Patients infected with SARS-CoV-2 and hyperglycemia suffer from longer hospital stays, higher risk of developing acute respiratory distress syndrome (ARDS), and increased mortality compared to those who do not develop hyperglycemia. Nevertheless, the pathophysiological mechanism(s) of hyperglycemia in COVID-19 remains poorly characterized. Here we show that insulin resistance rather than pancreatic beta cell failure is the prevalent cause of hyperglycemia in COVID-19 patients with ARDS, independent of glucocorticoid treatment. A screen of protein hormones that regulate glucose homeostasis reveals that the insulin sensitizing adipokine adiponectin is reduced in hyperglycemic COVID-19 patients. Hamsters infected with SARS-CoV-2 also have diminished expression of adiponectin. Together these data suggest that adipose tissue dysfunction may be a driver of insulin resistance and adverse outcomes in acute COVID-19.

SARS-CoV-2 Viral Load Predicts Mortality in Patients with and Without Cancer Who are Hospitalized with Coronavirus Disease 2019 (preprint)

Patients with cancer may be at increased risk of severe coronavirus disease 2019 (COVID-19), but the role of viral load on this risk is unknown. We measured SARS-CoV-2 viral load using cycle threshold (CT) values from reverse transcription-polymerase chain reaction assays applied to nasopharyngeal swab specimens in 100 patients with cancer and 2914 without cancer admitted to three New York City hospitals. Overall, the in-hospital mortality rate was 39.5% among patients with a high viral load (CT<25), 25.6% among patients with a medium viral load (CT 25-30), and 15.7% among patients with a low viral load (CT>30; P<0.001). Similar findings were observed in patients with cancer (high, 45.0% mortality; medium, 29.2%; low, 13.9%; P=0.003). Patients with hematologic malignancies had higher median viral loads (CT=25.0) than patients without cancer (CT=29.2; P=0.0039). SARS-CoV-2 viral load results may offer vital prognostic information for patients with and without cancer who are hospitalied with COVID-19.Funding: This work was partially supported by the National Centerfor Advancing Translational Science [UL1 TR002384 to Julianne Imperato-McGinley] at the National Institutes of Health.Conflict of Interest: L.F.W. reports receiving consulting fees from Roche Molecular Systems, Inc. M.M.S. receives grant support from Amgen, Inc. All other authors report no potential conflicts of interest.Ethical Approval Statement: The study was approved by the Institutional Review Board (#20-03021681) at Weill Cornell Medicine with a waiver of informed consent