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


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.

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


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.

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


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.

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