White House Advisor Nahid Bhadelia, MD, MALD, on COVID-19 in Resource-Limited Nations-Undercounted Deaths, Vaccine Inequity, and More.

This Medical News article is an interview with Nahid Bhadelia, MD, MALD, the White House COVID-19 Response Team's senior policy advisor for Global COVID Response.

Comparison of Antimicrobial Stewardship and Infection Prevention and Control Activities and Resources Between Low-/Middle- and High-income Countries.

BACKGROUND: The growth of antimicrobial resistance worldwide has led to increased focus on antimicrobial stewardship (AMS) and infection prevention and control (IPC) measures, although primarily in high-income countries (HIC). We aimed to compare pediatric AMS and IPC resources/activities between low- and middle-income countries (LMIC) and HIC and to determine the barriers and priorities for AMS and IPC in LMIC as assessed by clinicians in those settings. METHODS: An online questionnaire was distributed to clinicians working in HIC and LMIC healthcare facilities in 2020. RESULTS: Participants were from 135 healthcare settings in 39 LMIC and 27 HIC. Formal AMS and IPC programs were less frequent in LMIC than HIC settings (AMS 42% versus 76% and IPC 58% versus 89%). Only 47% of LMIC facilities conducted audits of antibiotic use for pediatric patients, with less reliable availability of World Health Organization Access list antibiotics (29% of LMIC facilities). Hand hygiene promotion was the most common IPC intervention in both LMIC and HIC settings (82% versus 91%), although LMIC hospitals had more limited access to reliable water supply for handwashing and antiseptic hand rub. The greatest perceived barrier to pediatric AMS and IPC in both LMIC and HIC was lack of education: only 17% of LMIC settings had regular/required education on antimicrobial prescribing and only 25% on IPC. CONCLUSIONS: Marked differences exist in availability of AMS and IPC resources in LMIC as compared with HIC. A collaborative international approach is urgently needed to combat antimicrobial resistance, using targeted strategies that address the imbalance in global AMS and IPC resource availability and activities.

On the resilience of health systems: A methodological exploration across countries in the WHO African Region.

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to "prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it". There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

Analysis of the Effects of COVID-19 Mask Mandates on Hospital Resource Consumption and Mortality at the County Level.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) threatens vulnerable patient populations, resulting in immense pressures at the local, regional, national, and international levels to contain the virus. Laboratory-based studies demonstrate that masks may offer benefit in reducing the spread of droplet-based illnesses, but few data are available to assess mask effects via executive order on a population basis. We assess the effects of a county-wide mask order on per-population mortality, intensive care unit (ICU) utilization, and ventilator utilization in Bexar County, Texas. METHODS: We used publicly reported county-level data to perform a mixed-methods before-and-after analysis along with other sources of public data for analyses of covariance. We used a least-squares regression analysis to adjust for confounders. A Texas state-level mask order was issued on July 3, 2020, followed by a Bexar County-level order on July 15, 2020. We defined the control period as June 2 to July 2 and the postmask order period as July 8, 2020-August 12, 2020, with a 5-day gap to account for the median incubation period for cases; longer periods of 7 and 10 days were used for hospitalization and ICU admission/death, respectively. Data are reported on a per-100,000 population basis using respective US Census Bureau-reported populations. RESULTS: From June 2, 2020 through August 12, 2020, there were 40,771 reported cases of COVID-19 within Bexar County, with 470 total deaths. The average number of new cases per day within the county was 565.4 (95% confidence interval [CI] 394.6-736.2). The average number of positive hospitalized patients was 754.1 (95% CI 657.2-851.0), in the ICU was 273.1 (95% CI 238.2-308.0), and on a ventilator was 170.5 (95% CI 146.4-194.6). The average deaths per day was 6.5 (95% CI 4.4-8.6). All of the measured outcomes were higher on average in the postmask period as were covariables included in the adjusted model. When adjusting for traffic activity, total statewide caseload, public health complaints, and mean temperature, the daily caseload, hospital bed occupancy, ICU bed occupancy, ventilator occupancy, and daily mortality remained higher in the postmask period. CONCLUSIONS: There was no reduction in per-population daily mortality, hospital bed, ICU bed, or ventilator occupancy of COVID-19-positive patients attributable to the implementation of a mask-wearing mandate.

Infection prevention and control (IPC) implementation in low-resource settings: a qualitative analysis.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has again demonstrated the critical role of effective infection prevention and control (IPC) implementation to combat infectious disease threats. Standards such as the World Health Organization (WHO) IPC minimum requirements offer a basis, but robust evidence on effective IPC implementation strategies in low-resource settings remains limited. We aimed to qualitatively assess IPC implementation themes in these settings. METHODS: Semi-structured interviews were conducted with IPC experts from low-resource settings, guided by a standardised questionnaire. Applying a qualitative inductive thematic analysis, IPC implementation examples from interview transcripts were coded, collated into sub-themes, grouped again into broad themes, and finally reviewed to ensure validity. Sub-themes appearing ≥ 3 times in data were highlighted as frequent IPC implementation themes and all findings were summarised descriptively. RESULTS: Interviews were conducted with IPC experts from 29 countries in six WHO regions. Frequent IPC implementation themes including the related critical actions to achieve the WHO IPC core components included: (1) To develop IPC programmes: continuous advocacy with leadership, initial external technical assistance, stepwise approach to build resources, use of catalysts, linkages with other programmes, role of national IPC associations and normative legal actions; (2) To develop guidelines: early planning for their operationalization, initial external technical assistance and local guideline adaption; (3) To establish training: attention to methods, fostering local leadership, and sustainable health system linkages such as developing an IPC career path; (4) To establish health care-associated (HAI) surveillance: feasible but high-impact pilots, multidisciplinary collaboration, mentorship, careful consideration of definitions and data quality, and "data for action"; (5) To implement multimodal strategies: clear communication to explain multimodal strategies, attention to certain elements, and feasible but high-impact pilots; (6) To develop monitoring, audit and feedback: feasible but high-impact pilots, attention to methods such as positive (not punitive) incentives and "data for action"; (7) To improve staffing and bed occupancy: participation of national actors to set standards and attention to methods such as use of data; and (8) To promote built environment: involvement of IPC professionals in facility construction, attention to multimodal strategy elements, and long-term advocacy. CONCLUSIONS: These IPC implementation themes offer important qualitative evidence for IPC professionals to consider.

Acute Care Resource Use After Elective Surgery in the United States: Implications During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic created pressure to delay inpatient elective surgery to increase US health care capacity. This study examined the extent to which common inpatient elective operations consume acute care resources. METHODS: This cross-sectional study used the Premier Healthcare Database to examine the distribution of inpatient elective operations in the United States from the fourth quarter of 2015 through the second quarter of 2018. Primary outcomes were measures of acute care use after 4 common elective operations: joint replacement, spinal fusion, bariatric surgery, and coronary artery bypass grafting. A framework for matching changing demand with changes in supply was created by overlaying acute care data with publicly available outbreak capacity data. RESULTS: Elective coronary artery bypass grafting (n = 117 423) had the highest acute care use: 92.8% of patients used intensive care unit beds, 89.1% required postoperative mechanical ventilation, 41.0% required red blood cell transfusions, and 13.3% were readmitted within 90 days of surgery. Acute care use was also substantial after spinal fusion (n = 203 789): 8.3% of patients used intensive care unit beds, 2.2% required postoperative mechanical ventilation, 9.2% required red blood cell transfusions, and 9.3% were readmitted within 90 days of surgery. An example of a framework for matching hospital demand with elective surgery supply is provided. CONCLUSIONS: Acute care needs after elective surgery in the United States are consistent and predictable. When these data are overlaid with national hospital capacity models, rational decisions regarding matching supply to demand can be achieved to meet changing needs.

Development of a Resource Guide to Support the Engagement of Mental Health Providers and Patients With Digital Health Tools: Multimethod Study.

BACKGROUND: As mental illness continues to affect 1 in 5 individuals, and the need for support has increased during the COVID-19 pandemic, the promise of digital mental health tools remains largely unrealized due to a lack of uptake by patients and providers. Currently, most efforts on supporting the uptake of digital mental health tools remain fragmented across organizations and geography. There is a critical need to synthesize these efforts in order to provide a coordinated strategy of supporting the adoption of digital mental health tools. OBJECTIVE: The specific aim of this project is to develop a web-based resource document to support the engagement of mental health providers and patients in the use of digital mental health tools. METHODS: The web-based resource was developed using a multimethod approach. A grey literature review was conducted in 2019 to identify relevant toolkits that are available in the public domain. This was supplemented with an environmental scan where individuals with expertise in the development, acquisition, implementation, and evaluation of digital mental health tools were invited to contribute additional tools or documents not identified in the grey literature search. An engagement workshop was held with stakeholders to explore how the resource document should be developed and delivered. These findings were collectively used to develop the final iteration of the resource document. RESULTS: Based on a gray literature review and environmental scan with 27 experts, 25 resources were identified and included in the resource guide. These resources were developed for patients and providers by organizations from 5 countries. An engagement workshop was held with 14 stakeholders, and barriers related to cultural sensitivity, sustainability, and accessibility of the toolkit were identified. The final iteration of the resource document was developed by the research team using findings from the gray literature review, environmental scan, and engagement workshop. The contents of the 45-page resource guide are directed at mental health care providers, administrators, and patients (inclusive of families and caregivers). CONCLUSIONS: The use of a multimethod approach led to the development of a resource guide that builds on existing evidence on digital mental health tools and was co-designed with stakeholders and end-users. The resource guide is now publicly available online for free and is being promoted through digital health and mental health websites. Future work should explore how this document can be integrated into clinical care delivery and pathways.

Effects of medical resource capacities and intensities of public mitigation measures on outcomes of COVID-19 outbreaks.

BACKGROUND: The COVID-19 pandemic is complex and is developing in different ways according to the country involved. METHODS: To identify the key parameters or processes that have the greatest effects on the pandemic and reveal the different progressions of epidemics in different countries, we quantified enhanced control measures and the dynamics of the production and provision of medical resources. We then nested these within a COVID-19 epidemic transmission model, which is parameterized by multi-source data. We obtained rate functions related to the intensity of mitigation measures, the effective reproduction numbers and the timings and durations of runs on medical resources, given differing control measures implemented in various countries. RESULTS: Increased detection rates may induce runs on medical resources and prolong their durations, depending on resource availability. Nevertheless, improving the detection rate can effectively and rapidly reduce the mortality rate, even after runs on medical resources. Combinations of multiple prevention and control strategies and timely improvement of abilities to supplement medical resources are key to effective control of the COVID-19 epidemic. A 50% reduction in comprehensive control measures would have led to the cumulative numbers of confirmed cases and deaths exceeding 590,000 and 60,000, respectively, by 27 March 2020 in mainland China. CONCLUSIONS: Multiple data sources and cross validation of a COVID-19 epidemic model, coupled with a medical resource logistic model, revealed the key factors that affect epidemic progressions and their outbreak patterns in different countries. These key factors are the type of emergency medical response to avoid runs on medical resources, especially improved detection rates, the ability to promote public health measures, and the synergistic effects of combinations of multiple prevention and control strategies. The proposed model can assist health authorities to predict when they will be most in need of hospital beds and equipment such as ventilators, personal protection equipment, drugs, and staff.

Mechanical-Ventilation Supply and Options for the COVID-19 Pandemic. Leveraging All Available Resources for a Limited Resource in a Crisis.

The novel coronavirus disease (COVID-19) has exposed critical supply shortages both in the United States and worldwide, including those in intensive care unit (ICU) and hospital bed supply, hospital staff, and mechanical ventilators. Many of those who are critically ill have required days to weeks of supportive invasive mechanical ventilation (IMV) as part of their treatment. Previous estimates set the U.S. availability of mechanical ventilators at approximately 62,000 full-featured ventilators, with 98,000 non-full-featured devices (including noninvasive devices). Given the limited availability of this resource both in the United States and in low- and middle-income countries, we provide a framework to approach the shortage of IMV resources. Here we discuss evidence and possibilities to reduce overall IMV needs, discuss strategies to maximize the availability of IMV devices designed for invasive ventilation, discuss the underlying methods in the literature to create and fashion new sources of potential ventilation that are available to hospitals and front-line providers, and discuss the staffing needs necessary to support IMV efforts. The pandemic has already pushed cities like New York and Boston well beyond previous ICU capacity in its first wave. As hot spots continue to develop around the country and the globe, it is evident that issues may arise ahead regarding the efficient and equitable use of resources. This unique challenge may continue to stretch resources and require care beyond previously set capacities and boundaries. The approaches presented here provide a review of the known evidence and strategies for those at the front line who are facing this challenge.

COVID-19: Adaptation of a model to predicting healthcare resources needs in Valle del Cauca, Colombia.

BACKGROUND: Valle del Cauca is the region with the fourth-highest number of COVID-19 cases in Colombia (>50,000 on September 7, 2020). Due to the lack of anti-COVID-19 therapies, decision-makers require timely and accurate data to estimate the incidence of disease and the availability of hospital resources to contain the pandemic. METHODS: We adapted an existing model to the local context to forecast COVID-19 incidence and hospital resource use assuming different scenarios: (1) the implementation of quarantine from September 1st to October 15th (average daily growth rate of 2%); (2-3) partial restrictions (at 4% and 8% growth rates); and (4) no restrictions, assuming a 10% growth rate. Previous scenarios with predictions from June to August were also presented. We estimated the number of new cases, diagnostic tests required, and the number of available hospital and intensive care unit (ICU) beds (with and without ventilators) for each scenario. RESULTS: We estimated 67,700 cases by October 15th when assuming the implementation of a quarantine, 80,400 and 101,500 cases when assuming partial restrictions at 4% and 8% infection rates, respectively, and 208,500 with no restrictions. According to different scenarios, the estimated demand for reverse transcription-polymerase chain reaction tests ranged from 202,000 to 1,610,600 between September 1st and October 15th. The model predicted depletion of hospital and ICU beds by September 20th if all restrictions were to be lifted and the infection growth rate increased to 10%. CONCLUSION: Slowly lifting social distancing restrictions and reopening the economy is not expected to result in full resource depletion by October if the daily growth rate is maintained below 8%. Increasing the number of available beds provides a safeguard against slightly higher infection rates. Predictive models can be iteratively used to obtain nuanced predictions to aid decision-making.

INTRODUCCIÓN: Valle del Cauca es el departamento con el cuarto mayor número de casos de COVID-19 en Colombia (>50,000 en septiembre 7, 2020). Debido a la ausencia de tratamientos efectivos para COVID-19, los tomadores de decisiones requieren de acceso a información actualizada para estimar la incidencia de la enfermedad, y la disponibilidad de recursos hospitalarios para contener la pandemia. MÉTODOS: Adaptamos un modelo existente al contexto local para estimar la incidencia de COVID-19, y la demanda de recursos hospitalarios en los próximos meses. Para ello, modelamos cuatro escenarios hipotéticos: (1) el gobierno local implementa una cuarentena desde el primero de septiembre hasta el 15 de octubre (asumiendo una tasa promedio de infecciones diarias del 2%); (2-3) se implementan restricciones parciales (tasas de infección del 4% y 8%); (4) se levantan todas las restricciones (tasa del 10%). Los mismos escenarios fueron previamente evaluados entre julio y agosto, y los resultados fueron resumidos. Estimamos el número de casos nuevos, el número de pruebas diagnósticas requeridas, y el numero de camas de hospital y de unidad de cuidados intensivos (con y sin ventilación) disponibles, para cada escenario. RESULTADOS: El modelo estimó 67,700 casos a octubre 15 al asumir la implementación de una nueva cuarentena, 80,400 y 101,500 al asumir restricciones parciales al 4 y 8% de infecciones diarias, respectivamente, y 208,500 al asumir ninguna restricción. La demanda por pruebas diagnósticas (de reacción en cadena de la polimerasa) fue estimada entre 202,000 y 1,610,600 entre septiembre 1 y octubre 15, a través de los diferentes escenarios evaluados. El modelo estimó un agotamiento de camas de cuidados intensivos para septiembre 20 al asumir una tasa de infecciones del 10%. Conclusión: Se estima que el levantamiento paulatino de las restricciones de distanciamiento social y la reapertura de la economía no debería causar el agotamiento de recursos hospitalarios si la tasa de infección diaria se mantiene por debajo del 8%. Sin embargo, incrementar la disponibilidad de camas permitiría al sistema de salud ajustarse rápidamente a potenciales picos inesperados de infecciones nuevas. Los modelos de predicción deben ser utilizados de manera iterativa para depurar las predicciones epidemiológicas y para proveer a los tomadores de decisiones con información actualizada.

Site of Care for COVID-19-Like Respiratory Illnesses.

COVID-19 is primarily a respiratory illness. Historically, upper and lower respiratory illness has been cared for at home or in the ambulatory primary care setting. It is likely that patients experiencing COVID-19-like symptoms may first contact their primary care provider. The Medical Expenditure Panel Survey (MEPS) is a representative sample of patients from the United States that regularly assesses their use of medical care services. We analyzed 2017 MEPS data to determine the number and proportion of patients who were seen in primary care or family medicine ambulatory settings or hospitalized for upper or lower respiratory illness or pneumonia. In a given year, 19.5 million patients are seen by primary care for an upper respiratory illness, 10.7 million patients for bronchitis, and 9 million for pneumonia. In contrast, 890,000 patients are hospitalized with pneumonia. Given that a primary etiology for respiratory illness in early 2020 was SARS CoV-2 (COVID-19), primary care practices likely were the site of first contact for most patients with COVID-19 illness. Unfortunately, there has been inadequate support for in-person and telehealth visits. Primary care clinicians reported serious shortages of personal protective equipment (PPE) and testing capacity. Inadequate reimbursement for telehealth visits coupled with decreased in-person visits put primary care practices at risk of layoffs and closure. Policies related to primary care payment, federal relief efforts, PPE access, testing and follow-up capacity, and telehealth technical support are essential so primary care can provide first contact and continuity for their patients and communities throughout the COVID-19 pandemic response and recovery.

Medical resources and coronavirus disease (COVID-19) mortality rate: Evidence and implications from Hubei province in China.

In light of the ongoing coronavirus disease (COVID-19) pandemic, this study aims to examine the relationship between the availability of public health resources and the mortality rate of this disease. We conducted empirical analyses using linear regression, a time-varying effect model, and a regression discontinuity design to investigate the association of medical resources with the mortality rate of the COVID-19 patients in Hubei, China. The results showed that the numbers of hospital beds, healthcare system beds, and medical staff per confirmed cases all had significant negative effects on the coronavirus disease mortality rate. Furthermore, in the context of the severe pandemic currently being experienced worldwide, the present study summarized the experience and implications in pandemic prevention and control in Hubei province from the perspective of medical resource integration as follows: First, hospitals' internal medical resources were integrated, breaking interdepartmental barriers. Second, joint pandemic control was realized by integrating regional healthcare system resources. Finally, an external medical resource allocation system was developed.

Hospital Nursing Staff Perceptions of Resources Provided by Their Organizations During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted the health and psychological well-being of hospital nursing staff. While additional support is needed to better cope with increased job stressors, little is known about what types of hospital resources have been provided and how nursing staff perceive them. This study addressed this gap by describing nursing staff perceptions of resources provided by hospitals during the COVID-19 pandemic in the United States. METHODS: Registered nurses and nursing assistants who were working in hospitals during the pandemic were recruited to an online survey via social media posts and emails between May and June 2020. A total of 360 free-text responses to an open-ended survey question were analyzed using content analysis. RESULTS: Over half of participants reported being provided with hospital resources. "Basic needs" resources that included food on-site, groceries, and childcare support were the most frequently reported compared with four other types of resources (personal health and safe practice, financial support, managerial support, communication). Four themes emerged related to staff perceptions of support: community support, unequal benefits, decreasing resources, and insufficient personal protective equipment. CONCLUSION: Our findings can assist organizational leaders in the planning and allocation of different types of resources that are meaningful to nursing staff and thus ensure sustainability, optimal performance, and worker well-being during crises.

Estimating healthcare resource needs for COVID-19 patients in Nigeria.

INTRODUCTION: continuous assessment of healthcare resources during the COVID-19 pandemic will help in proper planning and to prevent an overwhelming of the Nigerian healthcare system. In this study, we aim to predict the effect of COVID-19 on hospital resources in Nigeria. METHODS: we adopted a previously published discrete-time, individual-level, health-state transition model of symptomatic COVID-19 patients to the Nigerian healthcare system and COVID-19 epidemiology in Nigeria by September 2020. We simulated different combined scenarios of epidemic trajectories and acute care capacity. Primary outcomes included the expected cumulative number of cases, days until depletion resources and the number of deaths associated with resource constraints. Outcomes were predicted over a 60-day time horizon. RESULTS: in our best-case epidemic trajectory, which implies successful implementation of public health measures to control COVID-19 spread, assuming all three resource scenarios, hospital resources would not be expended within the 60-days time horizon. In our worst-case epidemic trajectory, assuming conservative resource scenario, only ventilated ICU beds would be depleted after 39 days and 16 patients were projected to die while waiting for ventilated ICU bed. Acute care resources were only sufficient in the three epidemic trajectory scenarios when combined with a substantial increase in healthcare resources. CONCLUSION: substantial increase in hospital resources is required to manage the COVID-19 pandemic in Nigeria, even as the infection growth rate declines. Given Nigeria's limited health resources, it is imperative to focus on maintaining aggressive public health measures as well as increasing hospital resources to reduce COVID-19 transmission further.

COVID-19 Epidemic in the Middle Province of Northern Italy: Impact, Logistics, and Strategy in the First Line Hospital.

The novel coronavirus (COVID-19) began in China in early December 2019 and rapidly has spread to many countries around the globe, with the number of confirmed cases increasing every day. An epidemic has been recorded since February 20 in a middle province in Northern Italy (Lodi province, in the low Po Valley). The first line hospital had to redesign its logistical and departmental structure to respond to the influx of COVID-19-positive patients who needed hospitalization. Logistical and structural strategies were guided by the crisis unit, managing in 8 days from the beginning of the epidemic to prepare the hospital to be ready to welcome more than 200 COVID-19-positive patients with different ventilatory requirements, keeping clean emergency access lines, and restoring surgical interventions and deferred urgent, routine activity.

Estimated Impact of Public and Private Sector COVID-19 Diagnostics and Treatments on US Healthcare Resource Utilization.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has imposed a considerable burden on the United States (US) health system, with particular concern over healthcare capacity constraints. METHODS: We modeled the impact of public and private sector contributions to developing diagnostic testing and treatments on COVID-19-related healthcare resource use. RESULTS: We estimated that public sector contributions led to at least 30% reductions in COVID-19-related healthcare resource utilization. Private sector contributions to expanded diagnostic testing and treatments led to further reductions in mortality (- 44%), intensive care unit (ICU) and non-ICU hospital beds (- 30% and - 28%, respectively), and ventilator use (- 29%). The combination of lower diagnostic test sensitivity and proportions of patients self-isolating may exacerbate case numbers, and policies that encourage self-isolating should be considered. CONCLUSION: While mechanisms exist to facilitate research, development, and patient access to diagnostic testing, future policies should focus on ensuring equitable patient access to both diagnostic testing and treatments that, in turn, will alleviate COVID-19-related resource constraints.

Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic. METHODS: We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children's hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017-2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low-resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed. RESULTS: ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017-2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low-resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period. CONCLUSIONS: The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.