The bystander effect: Impact of rural hospital closures on the operations and financial well-being of surrounding healthcare institutions.

INTRODUCTION: There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals". METHODS: Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures. RESULTS: We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259). CONCLUSION: These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.

COVID-19-related social support service closures and mental well-being in older adults and those affected by dementia: a UK longitudinal survey.

BACKGROUND: The COVID-19 pandemic has had a major impact on delivery of social support services. This might be expected to particularly affect older adults and people living with dementia (PLWD), and to reduce their well-being. AIMS: To explore how social support service use by older adults, carers and PLWD, and their mental well-being changed over the first 3 months since the pandemic outbreak. METHODS: Unpaid dementia carers, PLWD and older adults took part in a longitudinal online or telephone survey collected between April and May 2020, and at two subsequent timepoints 6 and 12 weeks after baseline. Participants were asked about their social support service usage in a typical week prior to the pandemic (at baseline), and in the past week at each of the three timepoints. They also completed measures of levels of depression, anxiety and mental well-being. RESULTS: 377 participants had complete data at all three timepoints. Social support service usage dropped shortly after lockdown measures were imposed at timepoint 1 (T1), to then increase again by T3. The access to paid care was least affected by COVID-19. Cases of anxiety dropped significantly across the study period, while cases of depression rose. Well-being increased significantly for older adults and PLWD from T1 to T3. CONCLUSIONS: Access to social support services has been significantly affected by the pandemic, which is starting to recover slowly. With mental well-being differently affected across groups, support needs to be put in place to maintain better well-being across those vulnerable groups during the ongoing pandemic.

Towards a more efficient healthcare system: Opportunities and challenges caused by hospital closures amid the COVID-19 pandemic.

A substantial number of United States (U.S.) hospitals have closed in recent years. The trend of closures has accelerated during the COVID-19 pandemic, as hospitals have experienced financial hardship from reduced patient volume and elective surgery cases, as well as the thin financial margins for treating patients with COVID-19. This trend of hospital closures is concerning for patients, healthcare providers, and policymakers. In this current opinion piece, we first describe the challenges caused by hospital closures and discuss what policymakers should know based on the existing research. We then discuss unique opportunities for researchers to inform policymakers by conducting careful studies that can shed light on different implications, trade-offs, and consequences of various strategies that can be followed.

[Telemedicine and epilepsy: healthcare experience of a national reference center during the COVID-19 pandemic]. / Telemedicina y epilepsia: experiencia asistencial de un centro de referencia nacional durante la pandemia de COVID-19.

INTRODUCTION: Countries worldwide are having to cope with the COVID-19 pandemic caused by SARS-CoV-2. The burden on their national health systems is currently at unprecedented levels. Telemedicine care was initiated at an early stage in our centre. PATIENTS AND METHODS: We conducted a descriptive and retrospective study to evaluate the usefulness of telemedicine during lockdown in our centre. Patients included in the study had a clinical diagnosis of epilepsy, with two visits via telemedicine, who had been followed up for at least six months during the normal situation prior to the COVID-19 pandemic and two face-to-face consultations during the same period. RESULTS: A total of 115 patients were included. The average age was 29 years, 53% were males, 52.2% had focal epilepsy, 58.3% with a structural causation and 57.4% had difficult-to-treat epilepsy. The mean number of seizures prior to lockdown was 9.73/month and 6.54/month during lockdown. The number of patients who were seizure-free when lockdown ended was higher than that observed in the phase before it began: 54 versus 45 out of 115. CONCLUSIONS: Telemedicine is a very useful strategy for monitoring the course, progress and therapeutic changes in epileptic patients in the short and medium term. The reduction in the seizure frequency can be sustained in the medium term, not only in the short term as corroborated in previous studies. Telemedicine allows access to virtually all patients and closer monitoring.

TITLE: Telemedicina y epilepsia: experiencia asistencial de un centro de referencia nacional durante la pandemia de COVID-19.Introducción. El mundo entero está afrontando la pandemia por COVID-19 causada por el SARS-CoV-2. Los sistemas de salud nacionales están sometidos a niveles de sobrecarga sin precedentes. En nuestro centro se inició de forma temprana la asistencia a través de telemedicina. Pacientes y métodos. Es un estudio descriptivo y retrospectivo para evaluar la utilidad de la telemedicina durante el confinamiento en nuestro centro. Se incluyó a los pacientes con diagnóstico clínico de epilepsia, con dos asistencias a través de telemedicina, que tuvieran seguimiento durante al menos seis meses durante la situación de normalidad previa a la pandemia por COVID-19 y dos consultas presenciales durante ese mismo período. Resultados. Se incluyó a 115 pacientes. La media de edad fue de 29 años, el 53% fueron varones, el 52,2% con epilepsia focal, el 58,3% de etiología estructural y el 57,4% presentaba epilepsia de difícil control. La media de crisis preconfinamiento fue de 9,73/mes y de 6,54/mes durante el confinamiento. El número de pacientes libres de crisis fue mayor al final del confinamiento respecto a la fase preconfinamiento, 54 frente a 45/115. Conclusiones. La telemedicina es una estrategia de mucha utilidad en la monitorización de la evolución, el control evolutivo y los cambios terapéuticos en pacientes epilépticos a corto y medio plazo. La reducción de la frecuencia de crisis puede mantenerse a medio plazo, no sólo a corto plazo como se corroboró en estudios previos. La telemedicina permite acceder a prácticamente la totalidad de los pacientes y realizar un seguimiento más cercano.

First Into the Lifeboats: Protecting Medical Student Education During the Hahnemann University Hospital Closure.

The announcement of the closure of Philadelphia's Hahnemann University Hospital in June 2019 sent shock waves through the academic community. The closure had a devastating impact on the residents and fellows who trained there, the patients who had long received their care there, and faculty and staff who had provided care there for decades. Since its beginnings, the hospital, established as part of Hahnemann Medical College in 1885, was a major site for medical student education. The authors share the planning before and actions during the crisis that protected the educational experiences of third- and fourth-year medical students at Drexel University College of Medicine assigned to Hahnemann University Hospital. The lessons they learned can be helpful to leadership in academic health systems in the United States facing a diminishing number of clinical training sites for medical and other health professions students, a situation that is likely to worsen as the COVID-19 pandemic continues to weaken the health care ecosystem.

Rebirth in a COVID hospital: a point of view.

BACKGROUND: Since COVID-19 was declared a pandemic, governments have taken actions to limit the transmission of the virus such as lockdown measures and reorganization of the local Health System. Quarantine measures have influenced pregnant women's daily lives. The aim of this study was to understand the impact of the changes imposed by COVID-19 emergency on the well-being of pregnant women and how the transformation of Schiavonia Hospital into a dedicated COVID hospital affected their pregnancy experience. METHODS: A cross-sectional survey was conducted. Pregnant women who gave birth in Schiavonia Hospital during the period May-September 2020 have been included. The assessment examined clinical characteristics, attitudes in relation to the pandemic and how it affected birth plans, perception of information received, and attitudes regards giving birth in a COVID hospital. RESULTS: One hundred four women responded to the survey, with an enrolment rate of 58%. About the influence of COVID-19 pandemic, 51% of respondents reported changing some aspect of their lifestyle. The identification of Schiavonia Hospital as COVID hospital did not modify the trust in the facility and in the obstetrics ward for the 90% of women, in fact for the 85.6% it was the planned Birth Center since the beginning of pregnancy. The communication was complete and exhaustive for 82.7% of the respondents. CONCLUSIONS: Despite the COVID hospital transformation, the women who came to give birth at Schiavonia Birth Center rated the healthcare assistance received at high level, evidencing high affection for the structure and the healthcare workers.

Impact of temporary closures of emergency departments during the COVID-19 outbreak on clinical outcomes for emergency patients in a metropolitan area.

BACKGROUND: During the early phase of the coronavirus disease 2019 (COVID-19) outbreak, many emergency departments (EDs) were exposed to COVID-19 and were temporarily closed according to national protocol of Korea. We aimed to evaluate the effect of concurrent and recurrent temporary closures of EDs on the clinical outcomes of patients who visited EDs during the COVID-19 outbreak. METHODS: This cross-sectional study used a nationwide emergency patient database. Patients who visited one of the 46 EDs in Daegu and Gyeongbuk between January 21 and April 14, 2020 were included. The main exposure variable was the first medical contact (ED visit or 119 call to emergency medical services (EMS)) during closure of at least one ED. There were 25 temporary closures of six Level-1 and Level-2 EDs between February 18 and March 17, 2020. We constructed a dataset by performing bidirectional crossover matching and conducted a conditional logistic regression analysis where the primary outcome was in-hospital mortality. RESULTS: Of the 94,360 eligible study participants, 36,327 were classified into the non-EMS-use group and 10,116 were classified into the EMS-use group. In-hospital mortality rates were 2.0% and 1.6% for the temporary-closure and no-closure groups in the non-EMS-use group (p-value, 0.03) and 8.7% and 7.4% in the EMS-use group (p-value, 0.02), respectively. In the conditional logistic analysis for in-hospital mortality, the odds ratios (95% confidence intervals) of the temporary-closure group compared the no-closure group were 1.22 (1.03-1.44) among the non-EMS-use group and 1.23 (1.04-1.46) among the EMS-use group. CONCLUSION: The temporary closures of EDs due to the unpredicted COVID-19 exposure resulted in an increase in emergency patients' in-hospital mortality rates irrespective of whether they used EMS. Preparing regional EMS systems to cope with new outbreaks is essential to protect the safety of all citizens.

Right Under Our Noses: Nursing Homes and COVID-19.

A medical mission volunteer bears witness to nightmarish inequalities.

Collateral damage: the impact of the COVID-19 pandemic on the care of a patient with tuberculous neuroretinitis in Lagos, Nigeria.

Tuberculous neuroretinis, a relatively rare manifestation of extra-pulmonary tuberculosis, is characterized by optic disc edema, peripapillary and macula swelling, with hard exudates forming a partial or complete 'macular star' While the disease may present a diagnostic challenge for Ophthalmologists, prognosis is usually good, with proper management. The Coronavirus Disease 2019 (COVID-19) pandemic has presented a healthcare delivery dilemma in many parts of the world, with poor accessibility to, and under-utilization of, important healthcare services by non-COVID-19-related cases. Herein is a report of a case of tuberculous neuroretinitis in Lagos, Nigeria, whose care was negatively impacted by the ongoing pandemic through the combined factors of the interruption of clinical services during the lockdown, patient avoidance of healthcare facilities and the absence of robust telehealth services. These all culminated in the delayed institution of therapy which may be responsible for the poor visual outcome of no-light-perception.

Investigating the initial effect of COVID-19 on the functioning of outpatient diagnostic imaging facilities.

INTRODUCTION: As a result of the COVID-19 pandemic, outpatient diagnostic imaging (DI) facilities experienced decreased operations and even unprecedented closures. The purpose of this study was to examine the impact of COVID-19 on the practices of DI clinics, and investigate the reasons for the change in their operations during the initial period of the pandemic starting in mid-March 2020. MATERIALS AND METHODS: A questionnaire was created and distributed to the managers of eighteen outpatient DI clinics in London, Hamilton, and Halton, Ontario, Canada. The managers indicated whether their clinics had closed or decreased operations, the reasons for closure, and the types of imaging examinations conducted in the initial period of the COVID-19 pandemic. RESULTS: Fifty percent of the DI clinics surveyed (9/18) closed as a result of COVID-19, and those that remained open had decreased hours of operation. The clinics that closed indicated decreased referrals as the primary reason for closure, followed by staff shortage, concerns for safety, and suspension of elective imaging. Chest radiography and obstetric ultrasound were the most commonly conducted examinations. Clinics that were in close geographical proximity were able to redistribute imaging examinations amongst themselves. All DI clinics had suspended BMD examinations and elective breast screening, and some transitioned to booked appointments only. CONCLUSION: Many DI clinics needed to close or decrease operations as a result of COVID-19, a phenomenon that is unprecedented in radiological practice. The results of this study can assist outpatient DI clinics in preparing for subsequent waves of COVID-19, future pandemics, and other periods of crisis.

Schiavonia Hospital response to COVID-19 outbreak: a first single-center experience.

INTRODUCTION: On 21 February 2020, Schiavonia Hospital (SH) detected the first 2 cases of COVID-19 in Veneto Region. As a result of the underlying concomitant spread of infection, SH had to rearrange the clinical services in terms of structural changes to the building, management of spaces, human resources and supplies, in order to continue providing optimal care to the patients and staff safety. The aim of this article is to describe how SH was able to adjust its services coping with the epidemiological stages of the pandemic. MATERIAL AND METHODS: Three periods can be identified; in each one the most important organizational modifications are analyzed (hospital activities, logistical changes, communication, surveillance on HCW). RESULTS: The first period, after initial cases' identification, was characterized by the hospital isolation. In the second period the hospital reopened and it was divided into two completely separated areas, named COVID-19 and COVID-free, to prevent intra-hospital contamination. The last period was characterized by the re-organization of the facility as the largest COVID Hospital in Veneto, catching exclusively COVID-19 patients from the surrounding areas. CONCLUSIONS: SH changed its organization three times in less than two months. From the point of view of the Medical Direction of the Hospital the challenges had been many but it allowed to consolidate an organizational model which could answer to health needs during the emergency situation.

Neglecting the effect of COVID-19 on neglected tropical diseases: the Ethiopian perspective.

Countries around the world are facing an enormous challenge due to the COVID-19 pandemic. The pressure that the pandemic inflicts on health systems could certainly impact on the care, control, and elimination of neglected tropical diseases (NTDs). From mid-January 2020, Ethiopia started to prepare for the prevention and treatment of COVID-19. The Federal Ministry of Health pledged to continue essential healthcare, including NTD care, during this pandemic. However, some hospitals have been closed for other healthcare services and have been turned into isolation and treatment centers for COVID-19. In addition to the healthcare facility measures, all community-based health promotion and disease prevention services have been stopped. The current shift in attention towards COVID-19 is expected to have a negative impact on NTD prevention and care.

Patients Left Behind: Ethical Challenges in Caring for Indirect Victims of the Covid-19 Pandemic.

In response to the Covid-19 pandemic, health care systems worldwide canceled or delayed elective surgeries, outpatient procedures, and clinic appointments. Although such measures may have been necessary to preserve medical resources and to prevent potential exposures early in the pandemic, moving forward, the indirect effects of such an extensive medical shutdown must not outweigh the direct harms of Covid-19. In this essay, we argue for the reopening of evidence-based health care with assurance provided to patients about the safety and necessity of high-value vaccinations, screenings, therapeutics, and procedures. To ensure that virtually all non-Covid-related services do not come to a halt again, health care systems and physician practices must preemptively increase their capacity, secure adequate personal protective equipment to safeguard health care personnel, and develop a measured approach to reclosing such routine health care, should it become necessary in the future.

Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions.

STUDY QUESTION: What are appraisals, coping strategies and emotional reactions of patients to coronavirus disease 2019 (COVID-19) fertility clinic closures? SUMMARY ANSWER: Clinic closure was appraised as stressful due to uncertainty and threat to the attainability of the parenthood goal but patients were able to cope using strategies that fit the uncertainty of the situation. WHAT IS KNOWN ALREADY: Psychological research on COVID-19 suggests that people are more anxious than historical norms and moderately to extremely upset about fertility treatment cancellation owing to COVID-19. STUDY DESIGN, SIZE, DURATION: The study was of cross-sectional design, comprising a mixed-methods, English language, anonymous, online survey posted from April 9 to 21 to social media. Eligibility criteria were being affected by COVID-19 fertility clinic closure, 18 years of age or older and able to complete the survey in English. In total, 946 people clicked on the survey link, 76 did not consent, 420 started but did not complete the survey and 450 completed (48% completion, 446 women, four men). PARTICIPANTS/MATERIALS, SETTING, METHODS: Overall 74.7% (n = 336) of respondents were residents in the UK with an average age of 33.6 years (SD = 4.4) and average years trying to conceive, 3.5 years (SD = 2.22). The survey comprised quantitative questions about the intensity of cognitive appraisals and emotions about clinic closure, and ability to cope with clinic closure. Open-text questions covered their understanding of COVID-19 and its effect on reproductive health and fertility plans, concerns and perceived benefits of clinic closure, and knowledge about closure. Sociodemographic information was collected. Descriptive and inferential statistics were used on quantitative data. Thematic qualitative analysis (inductive coding) was performed on the textual data from each question. Deductive coding grouped themes from each question into meta-themes related to cognitive stress and coping theory. MAIN RESULTS AND THE ROLE OF CHANCE: Most patients (81.6%, n = 367) had tests or treatments postponed, with these being self (41.3%, n = 186) or publicly (46.4%, n = 209) funded. Patients appraised fertility clinic closure as having potential for a more negative than positive impact on their lives, and to be very or extremely uncontrollable and stressful (P ≤ 0.001). Most reported a slight to moderate ability to cope with closure. Data saturation was achieved with all open-text questions, with 33 broad themes identified and four meta-themes linked to components of the cognitive stress and coping theory. First, participants understood clinic closure was precautionary due to unknown effects of COVID-19 but some felt clinic closure was unfair relative to advice about getting pregnant given to the public. Second, closure was appraised as a threat to attainability of the parenthood goal largely due to uncertainty of the situation (e.g. re-opening, effect of delay) and intensification of pre-existing hardships of fertility problems (e.g. long time waiting for treatment, history of failed treatment). Third, closure taxed personal coping resources but most were able to cope using thought-management (e.g. distraction, focusing on positives), getting mentally and physically fit for next treatments, strengthening their social network, and keeping up-to-date. Finally, participants reported more negative than positive emotions (P ≤ 0.001) and, almost all participants reported stress, worry and frustration at the situation, while some expressed anger and resentment at the unfairness of the situation. Overall, 11.8% were not at all able to cope, with reports of intense feelings of hopelessness and deteriorating well-being and mental health. LIMITATIONS, REASONS FOR CAUTION: The survey captures patient reactions at a specific point in time, during lockdown and before clinics announced re-opening. Participants were self-selected (e.g. UK residents, women, 48% starting but not completing the survey), which may affect generalisability. WIDER IMPLICATIONS OF THE FINDINGS: Fertility stakeholders (e.g. clinics, patient support groups, regulators, professional societies) need to work together to address the great uncertainty from COVID-19. This goal can be met proactively by setting up transparent processes for COVID-19 eventualities and signposting to information and coping resources. Future psychological research priorities should be on identifying patients at risk of distress with standardised measures and developing digital technologies appropriate for the realities of fertility care under COVID-19. STUDY FUNDING/COMPETING INTEREST(S): University funded research. Outside of the submitted work, Prof. J.B. reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S; grants from Merck Serono Ltd; and that she is co-developer of the Fertility Quality of Life (FertiQoL) and MediEmo apps. Outside of the submitted work, Dr R.M. reports personal or consultancy fees from Manchester Fertility, Gedeon Richter, Ferring and Merck. Outside of the submitted work, Dr S.G. reports consultancy fees from Ferring Pharmaceuticals A/S, Access Fertility and SONA-Pharm LLC, and grants from Merck Serono Ltd. The other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Recommendations of the Spanish Association of Neurogastroenterology and Motility (ASENEM) to restart the activity of gastrintestinal motility laboratories after the state of alarm called due to the Covid-19 pandemic. / Recomendaciones de la Asociación Española de Neurogastroenterología y Motilidad (ASENEM) para el reinicio de la actividad de los laboratorios de motilidad digestiva, tras el confinamiento por el estado de alarma decretado a raíz de la pandemia por COVID-19.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was responsible for the outbreak of the 2019 coronavirus disease (COVID-19), which is now considered as a pandemic. The prevention strategies adopted have included social distancing measures and the modification, reduction or interruption of a large proportion of routine healthcare activity. This has had a significant impact on the care provided in Gastrointestinal Motility Units. Having passed the peak, in terms of mortality and infections, a gradual reduction in transmission figures has been observed in Spain and other European countries. The risk of reactivation, however, remains high, so it is necessary to have a plan in place that allows healthcare centres to safely resume, for their patients and professionals, instrumental examinations linked to the management of motor pathology. Based on the available scientific evidence and the consensus of a panel of experts, the Spanish Association of Neurogastroenterology and Motility (ASENEM) has drawn up a series of practical recommendations, which have been adapted to the risks inherent in each activity. These include individual protection proposals, as well as organisational and structural measures, which are conceived to allow for the gradual resumption of examinations while minimising the possibility of contagion.

Surgical, Economic, and Psychological Impacts of SARS-COV-2 on a Kansas Community Hospital System.

The chief of surgery of a 264-bed acute care facility and clinic system in Topeka, KS, USA, gives a chronology that illustrates the rapid and profound clinical, economic, and emotional impact of the SARS-CoV-2 outbreak on his hospital and community. In his view, the pandemic has laid bare the weaknesses of several factors basic to the modern US health care system and the resulting economic crisis: just-in-time supply chain technology; foreign sourcing of masks, gowns, and critical equipment, all at critical shortages during the crisis; rural hospital closings; lack of excess capacity through maximization of utilization for efficiency; and an overreliance on high revenue elective procedures and tests. His team was tested by an emergency operation for bowel obstruction that put all the isolation protocols into action. Despite their readiness and the success of the operation and the potential for telemedicine as an alternative to in-person evaluations and outpatient visits, the forced cancellation of all elective operations have led to the loss of revenue for both hospital system and providers, furlough and termination of workers, and financial hardship and uncertainty.