Competition and firm recovery post-COVID-19

Plain English SummaryThe COVID-19 crisis had a profound impact on firms. Firms which were more productive pre-crisis fared relatively better, particularly in countries with a more competitive business environment. Using survey data for about 8000 firms, including both small and large firms, in 23 emerging and developing countries in Europe and Central Asia, the paper finds that during the COVID-19 crisis, smaller firms were hit harder, and economic activity was reallocated toward firms with higher pre-crisis labor productivity. Countries with a strong competition environment experienced more reallocation from less productive to more productive firms than countries with a weak competition environment. The evidence also suggests that reallocation from low- to high-productivity firms during the COVID-19 crisis was stronger compared with pre-crisis times. Finally, the analysis shows that government support measures implemented in response to the crisis went to less productive and larger firms, regardless of their pre-crisis innovation. Thus, government support measures during the COVID-19 crisis may have had adverse effects on competition and productivity growth. As economies enter the economic recovery phase, it will be important for policymakers to phase out support measures as soon as appropriate and focus on fostering a competitive business environment. This paper examines the impact of the COVID-19 crisis on the reallocation of economic activity across firms and whether this reallocation depends on the competition environment. The paper uses the World Bank's Enterprise Surveys COVID-19 Follow-up Surveys for about 8000 firms, including both small and large firms, in 23 emerging and developing countries in Europe and Central Asia, matched with 2019 Enterprise Surveys data. It finds that during the COVID-19 crisis, smaller firms were hit harder, and economic activity was reallocated toward firms with higher pre-crisis labor productivity. Countries with a strong competition environment experienced more reallocation from less productive to more productive firms than countries with a weak competition environment. The evidence also suggests that reallocation from low- to high-productivity firms during the COVID-19 crisis was stronger compared with pre-crisis times. Finally, the analysis shows that government support measures implemented in response to the crisis may have adverse effects on competition and productivity growth since support went to less productive and larger firms, regardless of their pre-crisis innovation.

Older Adults' Perspectives on Emergency Department Costs During COVID-19

OBJECTIVES: COVID-19 has strained the household finances of many Americans who are already experiencing increasing health care expenses. Concerns about the cost of care may deter patients from seeking even urgent care from the emergency department (ED). This study examines predictors of older Americans' concerns about ED visit costs and how cost concerns may have influenced their ED use in the early stages of the pandemic.STUDY DESIGN: This was a cross-sectional survey study using a nationally representative sample of US adults aged 50 to 80 years (N = 2074) in June 2020.METHODS: Multivariate logistic regressions assessed the relationships of sociodemographic, insurance, and health factors with cost concerns for ED care.RESULTS: Of the respondents, 80% were concerned (45% very, 35% somewhat) about costs of an ED visit and 18% were not confident in their ability to afford an ED visit. Of the entire sample, 7% had avoided ED care because of cost concerns in the past 2 years. Of those who may have needed ED care, 22% had avoided care. Predictors of cost-related ED avoidance included being aged 50 to 54 years (adjusted odds ratio [AOR], 4.57;95% CI, 1.44-14.54), being uninsured (AOR, 2.93;95% CI, 1.35-6.52), having poor or fair mental health (AOR, 2.82;95% CI, 1.62-4.89), and having an annual household income of less than $30,000 (AOR, 2.30;95% CI, 1.19-4.46).CONCLUSIONS: During the early COVID-19 pandemic, most older US adults expressed concerns about the financial impact of ED use. Further research should examine how insurance design could alleviate the perceived financial burden of ED use and prevent cost-related care avoidance, especially for those at higher risk in future pandemic surges.Am J Manag Care. 2023;29(4):204-208. doi:10.37765/ajmc.2023.89282

Effectiveness of Four Vaccines in Preventing SARS-CoV-2 Infection in Kazakhstan

Background. In February 2021 Kazakhstan began offering COVID-19 vaccines to adults. Breakthrough SARS-CoV-2 infections raised concerns about real-world vaccine effectiveness. We aimed to evaluate effectiveness of four vaccines against SARS-CoV-2 infection. Methods. We conducted a retrospective cohort analysis among adults in Almaty using aggregated vaccination data and individual-level breakthrough COVID-19 cases (>=14 days from 2nd dose) using national surveillance data. We ran time-adjusted Cox-proportional-hazards model with sensitivity analysis accounting for varying entry into vaccinated cohort to assess vaccine effectiveness for each vaccine (measured as 1-adjusted hazard ratios) using the unvaccinated population as reference (N=565,390). We separately calculated daily cumulative hazards for COVID-19 breakthrough among vaccinated persons by age and vaccine month. Results. From February 22 to Sept 1, 2021 in Almaty, 747,558 (57%) adults were fully vaccinated (received 2 doses) and 108,324 COVID-19 cases (11,472 breakthrough) were registered. Vaccine effectiveness against infection was 78% (sensitivity estimates: 74-82%) for QazVac, 77% (72-81%) for Sputnik V, 71% (69-72%) for Hayat-Vax, and 69% (64-72%) for CoronaVac. Among vaccinated persons, the 90-day follow-up cumulative hazard for breakthrough infection was 2.2%. Cumulative hazard was 2.9% among people aged >=60 years versus 1.9% among persons aged 18-39 years (p< 0.001), and 1.2% for people vaccinated in February-May versus 3.3% in June-August (p< 0.001). Conclusion. Our analysis demonstrates high effectiveness of COVID-19 vaccines against infection in Almaty similar to other observational studies. Higher cumulative hazard of breakthrough among people >60 years of age and during variant surges warrants targeted booster vaccination campaigns. (Figure Presented).

JOY AND STRESS DURING THE COVID-19 PANDEMIC: FINDINGS FROM THE NATIONAL POLL ON HEALTHY AGING

This poll aimed to better understand the complex impacts of the COVID-19 pandemic on the emotional and mental health of older adults. In August 2021, the National Poll on Healthy Aging surveyed a national sample of adults age 50–80 about joys, stresses, and resilience during the pandemic. Most reported feeling a lot (30%) or some (53%) joy these days, while 17% reported feeling very little or no joy. Reports of joy and stress differed substantially by age, sex, physical health, mental health, and household income. For example, people age 50–64 were more likely to report feeling a lot of stress compared with those age 65–80 (25% vs 13%), as were women compared with men (24% vs 15%). The findings may inform public health and policy efforts to support older adults at-risk for poor emotional and mental health, and help cultivate resilience during and after the pandemic.

LESSONS FROM FIVE YEARS OF POLLING THROUGH THE NATIONAL POLL ON HEALTHY AGING

Since 2017, the National Poll on Healthy Aging (NPHA) has surveyed older adults on a vast array of topics related to health, health care and health policy. With robust nationally representative samples of 2,000 adults age 50-80, the poll's format allows for the fielding of timely questions with important public health and policy implications. For example, polls examining delayed care during the COVID-19 pandemic and experiences of physical deconditioning and falls helped to demonstrate the ways in which the pandemic may have long-lasting effects if strategies are not implemented to address them. In this presentation we will discuss how the NPHA has increased awareness of the facilitators and barriers to healthy aging and where gaps exist in supporting older adults to live with optimal health and well-being. This presentation will also describe how researchers can access publicly available NPHA data to inspire their own future research.

A RANDOMIZED CLINICAL TRIAL OF SCREENING FOR ATRIAL FIBRILLATION WITH A 14-DAY PATCH MONITOR: ANALYSIS OF ECG RECORDINGS FROM THE GUARD-AF STUDY

Background: Screening for atrial fibrillation (AF) is attractive because AF can remain undiagnosed and AF-related stroke can be prevented by anticoagulants (OAC). Methods: A randomized trial of screening for AF in individuals ≥70 years old without AF. Stroke and major bleeding are the efficacy and safety outcomes, ascertained from claims databases and electronic health records. Screening is done using a Zio®XT 14-day continuous cardiac rhythm patch monitor and compared, 1:1, to usual care. Use of OAC for detected AF is decided by patients and their physicians. The planned sample size was 52,000 recruited from U.S. primary care practices. Enrollment was severely hampered by the COVID-19 pandemic and stopped May 31, 2021 with 11,931 participants. Follow-up for stroke and bleeding events continues. Here, we report patch monitor findings from the 5,965 participants randomized to the screening arm. Results: 5,720 (96%) participants returned patches with analyzable data, the largest sample of patch monitor AF screening to date. Median (IQR) age was 75 (72, 79) years;57% were women. Median wear time was 13.9 (13.7, 14.0) days and median analyzable time was 98.4% (95.6, 99.5). 255 (4.5%) participants had AF, including 30 (0.5%) with 100% AF. 100% AF was more common in those age ≥80 (1.0%) than among younger participants (0.40%), p<.01. In the 225 participants with paroxysmal AF (PAF), median AF “burden” was 0.48% (0.016-2.5) of time monitored [78 (3.2, 454) minutes]. Median number of AF episodes during monitoring was 3 (1, 19). Median longest single AF episode was 60 (3-278) minutes. AF burden and length of longest episode were highly correlated (r=0.79, p<.001). Neither of these measures of PAF were associated with either age or sex. Conclusion: In GUARD-AF’s older primary care population, 0.5% of screened participants had persistent AF and 4% had PAF detected within 2 weeks of monitoring. In those with PAF, average AF burden was low but >25% had an episode of ≥4.6 hours of continuous AF, suggesting increased stroke risk. The need for stroke-preventive interventions (e.g., OAC) for screen-detected PAF remains a critically important research question.

Modeled Impact of the COVID-19 Pandemic and Associated Reduced Adult Vaccinations on Herpes Zoster in the United States

Background. During the COVID-19 pandemic, adult vaccination in the United States (US) decreased substantially in 2020. Unlike other vaccine-preventable diseases where individuals may have experienced reduced risk due to COVID-related mitigation efforts (e.g., lockdown restrictions, use of face masks), individuals remained at risk of herpes zoster (HZ). This study projects the impact of reduced recombinant zoster vaccine (RZV) use on HZ cases and complications in the US. Methods. A multi-cohort Markov model estimated the impact of missed RZV vaccinations, by comparing scenarios with and without missed vaccinations between Apr-Dec 2020, on cases of HZ, postherpetic neuralgia (PHN), and quality-adjusted life-years (QALYs) among US adults aged ≥ 50 years. Epidemiology, RZV efficacy, and utility inputs were obtained from standard US sources, clinical trial data, and published literature. Missed doses were estimated using data on RZV doses and an assumed 43% reduction in RZV vaccinations during the pandemic, based on publicly available data. Deterministic sensitivity and scenario analyses were conducted. Results. In 2020, approximately 21 million (M) RZV distributed doses were expected, including an estimated 9.2M RZV series initiations in Apr-Dec. An estimated 3.9M RZV series initiations were missed, resulting in 31,945 projected HZ cases, 2,714 PHN cases, and 610 lost QALYs projected over a 1-year follow up. If individuals with missed RZV initiations remain unvaccinated in 2021, avoidable HZ cases will increase to 63,117 over 2 years. Further, if the same number of RZV initiations are missed in 2021, 95,062 avoidable HZ cases are expected. In a sensitivity analysis assuming 30% RZV reduction, 18,020 avoidable HZ cases and 1,531 PHN cases were observed over 1 year. Conclusion. Adding to the substantial COVID-19 infection-related morbidity and mortality, reduced RZV use during the pandemic resulted in further burden from avoidable HZ cases. Health care providers should continue to emphasize the importance of vaccination against HZ and other preventable diseases during the pandemic. Funding. GlaxoSmithKline Biologicals SA (GSK study identifier: [VEO-000222]).

Creative Staffing during a Pandemic: Training and Utilizing an on-Campus Student Worker While Working Remotely

In Fall 2020, Lasell University trained a student assistant to handle the physical aspects of interlibrary loan lending while the interlibrary loan librarian was unable to return to campus due to COVID-19 concerns. This article outlines the breakdown of duties between librarian and student worker and discusses how the student was trained and supervised remotely. © 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.

Invasive ventilation and increased COVID-19 mortality: A propensity-score matched retrospective cohort study

Rationale: There has been controversy about the timing and safety of intubation and mechanical ventilation in coronavirus disease (COVID-19).Objectives: To determine the effect of intubation and mechanical ventilation on all-cause, in-hospital mortality for COVID-19 patients.Methods: Retrospective cohort study of adult patients who tested positive for COVID-19 in the emergency department and were subsequently admitted to one of 11 New York City municipal hospitals. Patients with do not intubate orders were excluded.Measurements and Main Results: Data from 6591 COVID-19 patients were included;of these, 1633 (25%) were intubated overall and 791 (12%) were intubated within 48 hours of triage. After controlling for likely confounders, intubation rates for COVID-19 patients varied significantly across hospitals and decreased as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher allcause mortality (hazard ratio = 1.34, 1.09 to 1.65, p = 0.006), as was intubation at any time point (hazard ratio = 1.22, 1.02 to 1.45, p = 0.026). These results remained robust to multiple sensitivity analyses.Conclusions: Intubation and mechanical ventilation was associated with increased mortality in COVID-19 patients. Further caution should be taken in attempting to avoid intubating these patients.