Impact of COVID 19 on urgent care diagnoses and stewardship metrics

Background. The percentage of all respiratory diagnoses prescribed an antibiotic is an outpatient stewardship metric and was introduced as a HEDIS measure in 2022. Given a stable case mix, this metric is not affected by differences in coding practices between clinicians or health systems since all respiratory diagnoses are considered together. The onset of the COVID-19 pandemic introduced a high number of viral illness episodes where antibiotics are not recommended. The impact of this shift in case mix on respiratory diagnosis coding and prescribing metrics has not been explored. Methods. We examined antibiotic prescribing rates for respiratory diagnoses in a network of urgent care clinics affiliated with the University of Utah during two periods. Pre-Pandemic was Mar 2019-Feb 2020 and Pandemic was Mar 2020-Mar 2022. Respiratory diagnoses were identified using ICD10 codes and further stratified into 3 Tiers (Tier 1: antibiotics indicated;Tier 2: antibiotics sometimes indicated;Tier 3: antibiotics not indicated). We examined trends in antibiotic prescribing across these periods including the percentage of all respiratory visits prescribed antibiotics and by Tier and the distribution of diagnoses by Tier. No formalized stewardship interventions were introduced during these periods. Results. There were 146,897 urgent care visits during the study period (47,423 Pre Pandemic and 99,474 Pandemic). The respiratory prescribing rate declined from 42.3% Pre Pandemic to 26.2% during the Pandemic (Figure). The distribution of respiratory diagnoses by Tier and prescribing within Tier are shown in the Table. Tier 3 diagnoses increased from 48% to 67%, while Tier 2 diagnoses declined from 47% to 31%. Antibiotic prescribing declined for both Tier 2 and Tier 3 diagnoses. 15,429 (23%) of Tier 3 diagnoses during the Pandemic were coded as COVID-19. 50% of the reduction in prescribing is attributable to changes in Tiers alone. Figure Table Conclusion. The COVID 19 pandemic was associated with a reduction in the percentage of respiratory diagnoses prescribed antibiotics. Half was due to an increase in Tier 3 encounters although declines in prescribing occurred with Tiers in addition. Using this metric for benchmarking requires accounting for the impact of case mix differences over time or between systems and clinicians.

Addressing vaccine hesitancy: survey and experimental evidence from Papua New Guinea

This paper examines the drivers of COVID-19 vaccine hesitancy and tests various means of increasing people's willingness to receive a COVID-19 vaccine. The study draws on data collected through a broadly representative phone survey with 2,533 respondents and an online randomized survey experiment with 2,392 participants in Papua New Guinea. Both surveys show that less than 20 percent of the respondents who were aware a vaccine existed were willing to be vaccinated. The main reason respondents stated for their hesitancy regarding the vaccine was concern about side effects;however, the majority also said health workers could change their mind, particularly if information was communicated in person. The phone survey illustrated that people's level of trust in the vaccine and their beliefs about the behavior of others are strongly associated with their intention to get a COVID-19 vaccine. In contrast, people's concern about COVID-19, most trusted source of information (including social media), and vaccination history were unrelated to their intention to get vaccinated. The online experiment showed that a message that emphasized the relative safety of the vaccine by highlighting that severe side effects are rare, while also emphasizing the dangers of COVID-19, increased intention to get vaccinated by around 50 percent. Collectively, these results suggest that policy makers would be well placed to direct their efforts to boosting the general population's trust that getting vaccinated substantially reduces the risk of severe illness or death from COVID-19.

Kwatra v Minister for Immigration, Citizenship, Migrant Services and Multicultural Affairs 2021 FCA 58 (4 February 2021)

The appellant was an Indian national who arrived in Australia in 1996, and had his visa cancelled in 2019 on the basis that he did not pass the character test in section 501 of the Migration Act due to his extensive criminal record. Kwatra applied to have the original decision cancelling his visa revoked, but his application was denied by a delegate of the Minister and on appeal to the Administrative Appeals Tribunal. He appealed to the Federal Court of Australia arguing, inter alia, that the Tribunal failed to carry out its statutory task of review with respect to assessing if the impediments he might face upon his return to India constituted 'another reason' for revoking cancellation pursuant to section 501CA. In particular, Kwatra raised concerns before the Tribunal about returning to India due to the COVID-19 pandemic, noting that he had various health concerns, and would not have job prospects or access to social welfare and therefore would not be able to afford medical assistance. Burley J held that Kwatra had made a sufficiently dear claim concerning dangers to his health arising from the COVID-19 pandemic, but that nowhere in its substantive reasons did the Tribunal refer to the COVID-19 pandemic, its effect on the health-care system in India, or its likely or possible effect on Kwatra should he be deported to India during the pandemic. This failure to address the issue in its reasons left open the inference that the Tribunal did not consider Kwatra's claim to fear harm due to COVID-19 in India as it was required to do. The failure to consider this claim was material to the Tribunal's decision not to revoke Kwatra's visa cancellation. Kwatra had made a material claim concerning Australia's non-refoulement obligations and, had the identified risk of harm upon his return to India been considered, it could, realistically, when weighed with other factors, have provided 'another reason' for revoking the visa cancellation within the requirements of the legislative framework. Burley J was satisfied that a different decision might have been made had there been active intellectual engagement with the claim. This ground of review was upheld. The decision of the Tribunal was quashed and the matter was sent back to the Tribunal, differently constituted, to redetermine according to law.

Team Approach: Virtual Care in the Management of Orthopaedic Patients

>>: Telemedicine and remote care administered through technology are among the fastest growing sectors in health care. The utilization and implementation of virtual-care technologies have further been accelerated with the recent COVID-19 pandemic. >>: Remote, technology-based patient care is not a "one-size-fits-all" solution for all medical and surgical conditions, as each condition presents unique hurdles, and no true consensus exists regarding the efficacy of telemedicine across surgical fields. >>: When implementing virtual care in orthopaedics, as with standard in-person care, it is important to have a well-defined team structure with a deliberate team selection process. As always, a team with a shared vision for the care they provide as well as a supportive and incentivized environment are integral for the success of the virtual-care mechanism. >>: Future studies should assess the impact of primarily virtual, integrated, and multidisciplinary team-based approaches and systems of care on patient outcomes, health-care expenditure, and patient satisfaction in the orthopaedic population.