Disparities in pediatric patients receiving proton therapy during the COVID-19 pandemic - A single institutional experience

Introduction: Our institution cares for a largely underserved urban population, treating about 120 children annually with radiation therapy;roughly 10% are referred for proton therapy elsewhere. COVID-19 led to some decreases in medical care due to uncertainties regarding the state of public health. The purpose of this study is to evaluate existing socioeconomic disparities using the University of Wisconsin Area Deprivation Index (ADI) and whether the pandemic impacted this referral pattern. Method(s): Over the last twenty years, approximately 2,275 children have presented to our institution for radiation treatment. A retrospective chart review was conducted and a patient database of demographic and clinical information was created. We used demographic data to obtain the ADI, and compared relative disparity rankings between proton therapy recipients and a random sample of patients from the 25 most common zip codes (representative of over 20% of the total cohort). We compared the number of patients treated only at the closest proton facility before and after the onset of the pandemic. Result(s): The demographic make-up of our patient population is approximately 53.7% Latino, 22.6% White, 9.5% African American, 9.2% Asian, and 5% Other. Of these patients, about 500 had diagnoses typically referred for proton therapy (such as brain tumors, neuroblastoma, sarcomas, and Hodgkin lymphoma). At baseline, we found a statistically significant difference in the median state ADI decile of 3 and 7 for protons and photons, respectively, reflecting lower socioeconomic disadvantage in the proton group. There was a difference in the median household income (based on zip code) of $102,028 and $70,479 between the proton and photon groups (p < 0.0001). There was also a difference in median household income of $57,871 and $76,808 between Latino and Non-Latino patients (p < 0.0001). Demographic data for the proton therapy cohort showed that 46.2% of these patients were White, 15.4% were Latino, 15.4% were African American, 7.7% were Asian, and 15.4% were Other. At the closest proton facility, between 2014-2019, 16 of our patients received radiation therapy. Since the beginning of pandemic associated restrictions in March 2020, 19 patients have received proton therapy at this center. Conclusion(s): Disparities preventing patients from receiving proton therapy have been described. Our work adds granular census block data and uses the ADI which takes into account median family income, unemployment rate, households without access to a vehicle, English language proficiency and more. Those with lower ADI risk rankings were overrepresented in the proton therapy group. Despite the pandemic and added referral challenges, the number of patients able to receive proton therapy did not decrease which we hypothesize may be due to many factors, including the unanticipated flexibility of remote work amongst those with lower ADI rankings. Latinos were least likely to have proton therapy, and further research is needed to ameliorate the disparities and barriers to care which they face.

Associations of positive and negative psychological factors with fear of COVID-19 among racially and ethnically diverse cardiac arrest survivors

Objective: To examine the association between psychological factors and fear of COVID-19. Background: Psychological distress due to the COVID-19 pandemic is pronounced in cardiovascular disease patients. Cardiac arrest (CA) survivors may be especially fearful due to recent public health policies (e.g. paramedics' policy of not taking CA patients to hospital if revival fails in-field). Positive psychological well-being has been associated with improved health and recovery, but its impact on fear of COVID-19 is unknown. Design/Methods: In May 2020, a month after the NYC COVID-19 pandemic peak, CA survivors participated in a telephone-based assessment of the pandemic's impact. Positive well-being was measured by the Life Orientation Test-Revised: "Overall, I expect more good things to happen to me than bad." Ill-being was measured by the 4-item Perceived Stress Scale. Fear of COVID-19 was measured by the Perceived Coronavirus Threat Questionnaire (range 1-42). Results: Of 130 approached, 105 CA survivors participated (53% male;mean±SD age 61±15 years;42% non-Hispanic White, 17% Black, 35% Latinx). The majority (75%) denied positive COVID-19 testing or symptoms. The median COVID-19 anxiety score was 28 (interquartile range [IQR]: 21-35). The median perceived stress score was 7.5 (IQR: 7-8). Participants [N=68/105;66% (56-74)] reporting higher optimism (agree or strongly agree) had significantly lower fear of COVID-19 than those with lower optimism (mean±SD: 26±8 vs 31±8, p = 0.003). In a multivariable model, higher optimism (β = -4, 95% CI: [-7, -1.0];p = 0.04) and lower perceived stress (β = 0.6, 95% CI: [0.1, 1.2];p = 0.05) were independently associated with reduced fear of COVID-19, adjusting for age, sex, race/ethnicity, and COVID-19 symptom status. Conclusions: Measures of positive psychological well-being were independently associated with reduced fear of COVID-19 in CA survivors. Future studies should take these measures into account while assessing the impact of COVID-19 anxiety on medical outcomes and quality of life.

Characterizing COVID-19 pandemic-related anxiety and its impact on cardioprotective health behaviors among racially and ethnically diverse cardiac arrest survivors in New York City

Objective: We assessed the association of COVID-19 anxiety with physical activity (PA), sleep, and likelihood of seeking medical care among cardiac arrest (CA) survivors. Background: The COVID-19 pandemic has caused significant changes in the types of routine daily activities that can be safely performed, particularly for vulnerable patient populations. CA survivors' fear of contracting COVID-19 may limit their ability or willingness to perform cardio-protective health behaviors. Design/Methods: Between 5/15/20 and 7/31/20, CA survivors from a prospective cohort participated in a telephone-based assessment of COVID-19's impact on psychological and behavioral dimensions. COVID-19 anxiety was assessed using the 7-item Perceived Coronavirus Threat Questionnaire (PCTQ;range 1-42). PA in 7 days both pre- and during COVID-19 was categorized into International Physical Activity Questionnaire-based low, moderate, or high activity levels. Self-reported poor sleep quality and sleep duration were assessed via the Pittsburgh Sleep Quality Index. Participants self-reported their likelihood of delay in seeking care for non-COVID conditions. Results: Of 130 approached, 105 CA survivors participated (57% men;mean age 58.5±17 years;41% non-Hispanic White, 18% Black, 35% Latinx). The majority (75%) had negative COVID-19 test results and/or lacked symptoms. The median COVID-19 anxiety score was 29 (IQR: 20-32), indicating substantial fear. Black and Latinx participants reported greater anxiety than Whites(34±6 vs 31±8 vs 23±8 respectively, p<0.01). COVID-19 anxiety was highest for those withpreviously high PA and now had low PA (high-high:26±9, low-low: 28±9, high-low:32±9,ANOVA p=0.03). For every 1 SD increase in COVID-19 anxiety, participants reported 30 minutes less sleep per night (b=0.06, p=0.01) and poorer sleep quality (OR=1.07, 95% CI [1.0,1.1], p=0.01). Participants (42%) reporting "moderately-extremely" likely to delay seeking care for non-COVID conditions had greater COVID-19 anxiety (31±8 vs 26±9, p<0.01).Conclusions: COVID-19 anxiety was more frequent in Black and Latinx participants and wasassociated with poorer health behaviors.

Adverse emergency medical services related public health messaging during the COVID-19 pandemic was associated with increased psychological distress in cardiac arrest survivors

Objective: This study aimed to assess the contribution of adverse public health messaging related to emergency medical services during the peak of COVID-19 pandemic in New York City (NYC) on COVID-19-related anxiety. Background: New guidelines terminating resuscitation efforts in cases of out-of-hospital CA were issued by health agencies in cities hard-hit by the pandemic to protect the safety of EMS providers, to conserve hospital resources, and to ensure optimal use of equipment to save lives. However, the psychological impact of this public health messaging on existing CA survivors has not yet been studied. Design/Methods: Between 5/15/20-7/31/20, after the NYC pandemic peak, CA survivors from a prospective cohort participated in a telephone-based assessment of the pandemic's impact on psychological and behavioral dimensions. COVID-19 anxiety was assessed using the 7-item Perceived Coronavirus Threat Questionnaire (PCTQ;range 1-42). Fear and uncertainty in receiving immediate life-saving care in the event of a CA due to recent public health messaging was assessed on a self-reported 5-point Likert-scale (Not at all-extremely). Results: Of 130 approached, 105 CA survivors participated (57% male;mean±SD age 58.5±17 years;41% non-Hispanic White, 18% Black, 35% Latinx). The majority (75%) had no COVID-19 symptoms and had not been tested. The median PCTQ score was 28 (IQR: 21-35). Responders who were "very" to "extremely" afraid that emergency care would not come if they had another CA (n=43;42%) scored 1 SD higher (mean±SD 33±6 vs 24±8, p<0.001) on PCTQ scores than those with low fear about the availability of emergency care. The association was significant after adjusting for age, race/ethnicity, sex, and COVID-19 testing status (β=8.8;95% CI: 6, 12];p<0.001). Conclusions: A better understanding of the psychological impact of disaster-related public health messaging is needed to prevent additional psychological distress.

Increased utilization of non-pharmacological approaches to reduce COVID-19 anxiety in diverse cardiac arrest survivors in New York City

Objective: This study aimed to examine the utilization of pharmacological and nonpharmacological approaches to reduce COVID-19 anxiety in cardiac arrest (CA) survivors in New York City (NYC) and compare them to their pre-COVID proportions. Background: Psychological distress specific to the COVID-19 pandemic (i.e. COVID-19 anxiety: Fear of falling sick or dying from COVID-19) is widespread and pronounced in CA survivors, for whom the consequences of infection are dire. Preferred coping mechanisms in CA survivors during times of isolation and social distancing have not yet been studied. Design/Methods: Between 5/15/20-7/31/20, after the NYC pandemic peak, CA survivors from a prospective cohort participated in a telephone-based assessment of the pandemic's impact on psychological and behavioral dimensions. COVID-19 anxiety was assessed using the NIH 7-item Perceived Coronavirus Threat Questionnaire (PCTQ;range 1-42). Participant's current coping methods to alleviate stress or enhance psychological wellness were categorized as pharmacological (i.e. prescription psychiatric medications) or non-pharmacological (i.e. talk therapy, virtual support, or meditation practices), and noted if they were initiated as a result of COVID-19. Results: Of 130 approached, 105 CA survivors participated (57% male;mean±SD age 58.5±17 years;41% non-Hispanic White, 17% Black, 35% Latinx). The majority (75%) had not experienced COVID-19 symptoms or had not been tested. The median PCTQ score was 29 (IQR: 20-32). During the pandemic, the utilization of non-pharmacological stress-relieving reduction methods increased by 6.67% (39% vs 32%, p<0.05) compared to pre-COVID. Being a woman (51% vs 32%, p=0.04), younger (53±17 vs 63±16 years, p<0.01), and greater COVID-19 anxiety scale scores (31±7 vs 25±9, p<0.01), was associated with increased usage of nonpharmacological stress-reduction measures. Conclusions: CA survivors experienced heightened anxiety during COVID-19 pandemic and preferred non-pharmacological approaches to enhance psychological wellness. Further research is warranted to examine the efficacy of these stress-reduction tactics long-term on pandemic related anxiety.