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1.
Journal of General Internal Medicine ; 37:S335-S336, 2022.
Article in English | EMBASE | ID: covidwho-1995735

ABSTRACT

BACKGROUND: Following early reductions in U.S. emergency department (ED) care after the COVID-19 pandemic's onset, it is unclear whether avoidable and unavoidable ED visits returned to expected rates, particularly for socioeconomically disadvantaged Medicaid and dual eligible MedicareMedicaid patients. Further, the degree to which avoidable and unavoidable ED visits are associated with hospitalizations during the pandemic is unknown. METHODS: In a retrospective cohort study of ED care patterns from Jan 1, 2019-Feb 28, 2021, we analyzed claims data from multiple U.S. payers from MedInsight's research database. Using difference-in-differences methods, we assessed the degree to which ED use during the pandemic differed from expected rates had the pandemic not occurred. We compared rate changes between Jan-Feb 2020 and each subsequent 2-month timeframe during the pandemic vs changes in the corresponding months in the year prior. We stratified visits by avoidable vs unavoidable using MediCal avoidable ED visit criteria, which flags visits that generally could have been managed by a primary care physician (e.g., rhinitis, cystitis, administrative exams) had patients had access to one. We tested the relationship between avoidable vs unavoidable ED visits and hospitalization, and estimated age-sex adjusted Poisson regressions of monthly use counts, offsetting for total patient-months and stratifying by insurance. RESULTS: We studied 14.5 million U.S. adults (mean age 53;55% female) using 11 million ED visits (6% avoidable, 94% unavoidable) in 2019-21. Unavoidable visits had higher odds of hospitalization than avoidable visits in each insurance group (for all groups: OR 2.8 [2.7-2.8]). In Mar-Apr 2020, avoidable and unavoidable ED visits respectively declined similarly, to 68.1% [67-69%] and 68.9% [68-69%] of expected rates. By Nov-Dec 2020, avoidable visits declined further to 52.0% [51-53%], while unavoidable visits returned to 93.7% [93-94%] of expected rates. During pandemic wave 2 in Jan-Feb 2021, avoidable and unavoidable visits declined to 45.1% [44-46%] and 82.2% [82-83%] respectively and varied by insurance (Table). CONCLUSIONS: Following declines early in the pandemic, unavoidable ED visits nearly returned to expected rates by Nov-Dec 2020, only to decline again during pandemic wave 2 in Jan-Feb 2021. In contrast, avoidable visits consistently declined without rebound. While reductions in avoidable visits lower unnecessary costs, persistent declines in unavoidable visits raise concern that patients with more serious conditions may be delaying needed ED care, particularly among socioeconomically disadvantaged groups.

2.
PubMed; 2021.
Preprint in English | PubMed | ID: ppcovidwho-296601

ABSTRACT

Background: By August 2021, South Africa experienced three SARS-CoV-2 waves;the second and third associated with emergence of Beta and Delta variants respectively. Methods: We conducted a prospective cohort study during July 2020-August 2021 in one rural and one urban community. Mid-turbinate nasal swabs were collected twice-weekly from household members irrespective of symptoms and tested for SARS-CoV-2 using real-time reverse transcription polymerase chain reaction (rRT-PCR). Serum was collected every two months and tested for anti-SARS-CoV-2 antibodies. Results: Among 115,759 nasal specimens from 1,200 members (follow-up rate 93%), 1976 (2%) were SARS-CoV-2-positive. By rRT-PCR and serology combined, 62% (749/1200) of individuals experienced >=1 SARS-CoV-2 infection episode, and 12% (87/749) experienced reinfection. Of 662 PCR-confirmed episodes with available data, 15% (n=97) were associated with >=1 symptom. Among 222 households, 200 (90%) had >=1 SARS-CoV-2-positive individual. Household cumulative infection risk (HCIR) was 25% (213/856). On multivariable analysis, accounting for age and sex, index case lower cycle threshold value (OR 3.9, 95%CI 1.7-8.8), urban community (OR 2.0,95%CI 1.1-3.9), Beta (OR 4.2, 95%CI 1.7-10.1) and Delta (OR 14.6, 95%CI 5.7-37.5) variant infection were associated with increased HCIR. HCIR was similar for symptomatic (21/110, 19%) and asymptomatic (195/775, 25%) index cases (p=0.165). Attack rates were highest in individuals aged 13-18 years and individuals in this age group were more likely to experience repeat infections and to acquire SARS-CoV-2 infection. People living with HIV who were not virally supressed were more likely to develop symptomatic illness, and shed SARS-CoV-2 for longer compared to HIV-uninfected individuals. Conclusions: In this study, 85% of SARS-CoV-2 infections were asymptomatic and index case symptom status did not affect HCIR, suggesting a limited role for control measures targeting symptomatic individuals. Increased household transmission of Beta and Delta variants, likely contributed to successive waves, with >60% of individuals infected by the end of follow-up. Research in context: Evidence before this study: Previous studies have generated wide-ranging estimates of the proportion of SARS-CoV-2 infections which are asymptomatic. A recent systematic review found that 20% (95% CI 3%-67%) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections remained asymptomatic throughout infection and that transmission from asymptomatic individuals was reduced. A systematic review and meta-analysis of 87 household transmission studies of SARS-CoV-2 found an estimated secondary attack rate of 19% (95% CI 16-22). The review also found that household secondary attack rates were increased from symptomatic index cases and that adults were more likely to acquire infection. As of December 2021, South Africa experienced three waves of SARS-CoV-2 infections;the second and third waves were associated with circulation of Beta and Delta variants respectively. SARS-CoV-2 vaccines became available in February 2021, but uptake was low in study sites reaching 5% fully vaccinated at the end of follow up. Studies to quantify the burden of asymptomatic infections, symptomatic fraction, reinfection frequency, duration of shedding and household transmission of SARS-CoV-2 from asymptomatically infected individuals have mostly been conducted as part of outbreak investigations or in specific settings. Comprehensive systematic community studies of SARS-CoV-2 burden and transmission including for the Beta and Delta variants are lacking, especially in low vaccination settings. Added value of this study: We conducted a unique detailed COVID-19 household cohort study over a 13 month period in South Africa, with real time reverse transcriptase polymerase chain reaction (rRT-PCR) testing twice a week irrespective of symptoms and bimonthly serology. By the end of the study in August 2021, 749 (62%) of 1200 individuals from 222 randomly sampled households in a rural and an urban community in South Africa had at least one confirmed SARS-CoV-2 infection, detected on rRT-PCR and/or serology, and 12% (87/749) experienced reinfection. Symptom data were analysed for 662 rRT-PCR-confirmed infection episodes that occurred >14 days after the start of follow-up (of a total of 718 rRT-PCR-confirmed episodes), of these, 15% (n=97) were associated with one or more symptoms. Among symptomatic indvidiausl, 9% (n=9) were hospitalised and 2% (n=2) died. Ninety percent (200/222) of included households, had one or more individual infected with SARS-CoV-2 on rRT-PCR and/or serology within the household. SARS-CoV-2 infected index cases transmitted the infection to 25% (213/856) of susceptible household contacts. Index case ribonucleic acid (RNA) viral load proxied by rRT-PCR cycle threshold value was strongly predictive of household transmission. Presence of symptoms in the index case was not associated with household transmission. Household transmission was four times greater from index cases infected with Beta variant and fifteen times greater from index cases infected with Delta variant compared to wild-type infection. Attack rates were highest in individuals aged 13-18 years and individuals in this age group were more likely to experience repeat infections and to acquire SARS-CoV-2 infection within households. People living with HIV (PLHIV) who were not virally supressed were more likely to develop symptomatic illness when infected with SARS-CoV-2, and shed SARS-CoV-2 for longer when compared to HIV-uninfected individuals. Implications of all the available evidence: We found a high rate of SARS-CoV-2 infection in households in a rural community and an urban community in South Africa, with the majority of infections being asymptomatic in individuals of all ages. Asymptomatic individuals transmitted SARS-CoV-2 at similar levels to symptomatic individuals suggesting that interventions targeting symptomatic individuals such as symptom-based testing and contact tracing of individuals tested because they report symptoms may have a limited impact as control measures. Increased household transmission of

3.
Frontiers in Built Environment ; 7:10, 2021.
Article in English | Web of Science | ID: covidwho-1486750

ABSTRACT

There is growing evidence that viruses responsible for pandemics, such as Middle East respiratory syndrome and severe acute respiratory syndrome, are mainly spread through aerosols. Recommendations have been introduced to reduce the transmission risks of virulent airborne viral particles by increasing ventilation rates, expressed in air changes per hour (ACHs), effectively improving the dilution of pathogens via mechanical ventilation. However, infrastructural and operational costs associated with upgrades of building heating, ventilation, and air conditioning systems make these solutions expensive. It is well documented that Ultraviolet Subtype C (UVC) disinfection can help lower exposure risks by inactivating viruses and the performance of such solutions can translate into equivalent ventilation. Here, we present the first framework to extract the optimal UVC requirements to improve facility management yet ensuring compliance with ventilation guidelines at lower energy costs. The Kahn-Mariita (KM) model considers the air quality of shared enclosed spaces over time by supplementing the existing mechanical ventilation with localized UVC air treatment and includes variables such as room size, occupancy, existing ventilation, and target equivalent ACH. For example, the model applied to a conference room shows that a UVC chamber with recirculation rates of 160 m(3)/h increases ventilation from an ACH 3 to 7.9 and reduces the room's reset time from 46 to <10 min with as little as 1 W. Recirculation rates of 30 m(3)/h however offer no benefits beyond 200 mW, with an eACH of 3.9 and reset time of 31 min. The first finding is that single-pass disinfection is not an appropriate metric of performance, i.e., low recirculation rates increase single-pass disinfection, and, however, only treats a portion of the space volume within a given time, limiting the overall performance. Conversely, higher recirculation rates decrease single-pass disinfection but treat larger portions of air, potentially multiple times, and are therefore expected to lower the transmission risk faster. The second result is that for fixed amounts of recirculating air flow, increasing UVC power helps with diminishing return, while for a fixed UVC power, increasing the recirculating air flow will always help. This dynamic is particularly important toward optimizing solutions, given the constraints system engineers must work with, and particularly to design for end-user benefits such as increased occupancy, in-dwelling time, or reduction of shared-space reset time.

4.
Journal of General Internal Medicine ; 36(SUPPL 1):S83-S83, 2021.
Article in English | Web of Science | ID: covidwho-1349014
5.
J Gen Intern Med ; 36(6): 1613-1621, 2021 06.
Article in English | MEDLINE | ID: covidwho-898113

ABSTRACT

BACKGROUND: Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure. OBJECTIVE: As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients. DESIGN: For 18 months in 2015-2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention's impact on inpatient utilization. We used internal electronic health records and claims data across six payers. PARTICIPANTS: A total of 1442 stage 4-5 CKD patients at a large academic medical center. INTERVENTION: Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4-5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs. MAIN MEASURES: Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions. KEY RESULTS: During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4-7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0-2.2%) per month (p = 0.004). Medicare CKD patients' monthly ED visit rate of decline was 3.0% (95% CI: 1.2-4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: - 0.8 to 1.6%) per month (p = 0.02). CONCLUSIONS: By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization.


Subject(s)
COVID-19 , Population Health , Renal Insufficiency, Chronic , Aged , Emergency Service, Hospital , Hospitalization , Humans , Medicare , Renal Insufficiency, Chronic/epidemiology , Renal Insufficiency, Chronic/therapy , SARS-CoV-2 , United States
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