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1.
Orthopade ; 51(5): 385-394, 2022 May.
Article in German | MEDLINE | ID: covidwho-1798515

ABSTRACT

No appeal by a health politician, no matter how insistent, has ever forced all the operational structures of our health-care system to examine their own efficiencies and cost reduction potentials as has SARS-CoV­2. Fast-track surgery, developed long before the current pandemic, can become an indispensable element of modern hospital routines through the integration of interlocked care structures. Patient satisfaction and clinical outcome can be improved by significantly shortening hospital stays, decreasing complication rates, and by additionally strengthening the competence and motivation of the patients involved. Hospital staff could be relieved of heavy workloads, and overall costs could be reduced by involving external prehabilitation centers. It is now necessary to further develop standards for the establishment and implementation of appropriately coordinated prehabilitation and rehabilitation concepts for elective total hip and knee replacement surgery and, ideally, to save resources at the same time through regional networking and integration.


Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , COVID-19 , Ambulatory Care , Arthroplasty, Replacement, Hip/rehabilitation , COVID-19/epidemiology , Humans , Length of Stay , Outpatients , Preoperative Exercise , SARS-CoV-2
2.
JAMA ; 328(16): 1595-1603, 2022 10 25.
Article in English | MEDLINE | ID: covidwho-2084929

ABSTRACT

Importance: The effectiveness of ivermectin to shorten symptom duration or prevent hospitalization among outpatients in the US with mild to moderate symptomatic COVID-19 is unknown. Objective: To evaluate the efficacy of ivermectin, 400 µg/kg, daily for 3 days compared with placebo for the treatment of early mild to moderate COVID-19. Design, Setting, and Participants: ACTIV-6, an ongoing, decentralized, double-blind, randomized, placebo-controlled platform trial, was designed to evaluate repurposed therapies in outpatients with mild to moderate COVID-19. A total of 1591 participants aged 30 years and older with confirmed COVID-19, experiencing 2 or more symptoms of acute infection for 7 days or less, were enrolled from June 23, 2021, through February 4, 2022, with follow-up data through May 31, 2022, at 93 sites in the US. Interventions: Participants were randomized to receive ivermectin, 400 µg/kg (n = 817), daily for 3 days or placebo (n = 774). Main Outcomes and Measures: Time to sustained recovery, defined as at least 3 consecutive days without symptoms. There were 7 secondary outcomes, including a composite of hospitalization or death by day 28. Results: Among 1800 participants who were randomized (mean [SD] age, 48 [12] years; 932 women [58.6%]; 753 [47.3%] reported receiving at least 2 doses of a SARS-CoV-2 vaccine), 1591 completed the trial. The hazard ratio (HR) for improvement in time to recovery was 1.07 (95% credible interval [CrI], 0.96-1.17; posterior P value [HR >1] = .91). The median time to recovery was 12 days (IQR, 11-13) in the ivermectin group and 13 days (IQR, 12-14) in the placebo group. There were 10 hospitalizations or deaths in the ivermectin group and 9 in the placebo group (1.2% vs 1.2%; HR, 1.1 [95% CrI, 0.4-2.6]). The most common serious adverse events were COVID-19 pneumonia (ivermectin [n = 5]; placebo [n = 7]) and venous thromboembolism (ivermectin [n = 1]; placebo [n = 5]). Conclusions and Relevance: Among outpatients with mild to moderate COVID-19, treatment with ivermectin, compared with placebo, did not significantly improve time to recovery. These findings do not support the use of ivermectin in patients with mild to moderate COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04885530.


Subject(s)
Anti-Infective Agents , COVID-19 , Hospitalization , Ivermectin , Female , Humans , Middle Aged , COVID-19/drug therapy , COVID-19/mortality , COVID-19/prevention & control , COVID-19 Vaccines/therapeutic use , Double-Blind Method , Ivermectin/adverse effects , Ivermectin/therapeutic use , SARS-CoV-2 , Treatment Outcome , Anti-Infective Agents/adverse effects , Anti-Infective Agents/therapeutic use , Ambulatory Care , Drug Repositioning , Time Factors , Recovery of Function , Male , Adult
3.
Fam Med Community Health ; 10(4)2022 Oct.
Article in English | MEDLINE | ID: covidwho-2079000

ABSTRACT

OBJECTIVES: SARS-CoV-2 infection (COVID-19) has affected tertiary medical institutions and primary care. Admission for ambulatory care sensitive conditions (ACSCs) is an important indicator of primary care quality. However, no nationwide study, especially in Asia, has examined the association between admissions for ACSCs and local surges in COVID-19. This study aimed to examine how the number of admissions for ACSCs has changed in Japan between the areas with higher and lower rates of COVID-19 infection. DESIGN: This was a retrospective two-stage cross-sectional study. We employed a difference-in-difference design to compare the number of hospital admissions for ACSCs between the areas with higher and lower rates of COVID-19 infection in Japan. SETTING: The study used a nationwide database in Japan. PARTICIPANTS: All patients were aged 20 years and above and were admitted due to ACSCs during the study period between March and September 2019 (before the pandemic) and between March and September 2020 (during the pandemic). RESULTS: The total number of ACSC admissions was 464 560 (276 530 in 2019 and 188 030 in 2020). The change in the number of admissions for ACSCs per 100 000 was not statistically significant between the areas with higher and lower rates of COVID-19 infection: 7.50 (95% CI -87.02 to 102.01). In addition, in acute, chronic and preventable ACSCs, the number of admissions per 100 000 individuals did not change significantly. CONCLUSION: Although admissions for ACSCs decreased during the COVID-19 pandemic, there was no significant change between the areas with higher and lower rates of COVID-19 infection. This implies that the COVID-19 pandemic affected the areas with higher infection rates and the areas with lower rates.


Subject(s)
COVID-19 , Ambulatory Care , COVID-19/epidemiology , COVID-19/therapy , Cross-Sectional Studies , Humans , Japan/epidemiology , Pandemics , Retrospective Studies , SARS-CoV-2
4.
MSMR ; 29(6): 17-24, 2022 Jun 01.
Article in English | MEDLINE | ID: covidwho-2072759

ABSTRACT

In 2021, the overall numbers and rates of active component service member ambulatory care visits were the highest of any of the last 10 years. Most categories of illness and injury showed modest increases in numbers and rates. The proportions of ambulatory care visits that were accomplished via telehealth encounters fell to under 15% in 2021, compared to 19% in 2020. Although the response to the COVID-19 pandemic in 2020 may have been associated with decreases in the incidence of disease and injury diagnoses in the service member population receiving ambulatory care, the data for 2021 show a return to pre-pandemic levels. Moreover, the proportions of health care encounters delivered through telehealth have similarly reverted to the lower levels seen in the pre-pandemic period. Lessons learned may guide future steps in reducing disease and injury incidence in the postpandemic era.


Subject(s)
COVID-19 , Military Personnel , Telemedicine , Ambulatory Care , COVID-19/epidemiology , Humans , Incidence , Pandemics , United States/epidemiology
5.
Telemed J E Health ; 28(10): 1525-1533, 2022 10.
Article in English | MEDLINE | ID: covidwho-1733626

ABSTRACT

Introduction: Cost studies of telehealth (TH) and virtual visits are few and report mixed results of the economic impact of virtual care and TH. Largely missing from the literature are studies that identify the cost of delivering TH versus in-person care. The objective was to demonstrate a modified time-driven activity-based costing (TDABC) approach to compare weighted labor cost of an in-person pediatric clinic sick visit before COVID-19 to the same virtual and in-person sick-visit during COVID-19. Methods: We examined visits before and during COVID-19 using: (1) recorded structured interviews with providers; (2) iterative workflow mapping; (3) electronic health records time stamps for validation; (4) standard cost weights for wages; and (5) clinic CPT billing code mix for complexity weighs. We examined the variability in estimated time using a decision tree model and Monte Carlo simulations. Results: Workflow charts were created for the clinic before COVID-19 and during COVID-19. Using TDABC and simulations for varying time, the weighted cost of clinic labor for sick visit before COVID-19 was $54.47 versus $51.55 during COVID-19. Discussion: The estimated mean labor cost for care during the pandemic has not changed from the pre-COVID period; however, this lack of a difference is largely because of the increased use of TH. Conclusions: Our TDABC approach is feasible to use under virtual working conditions; requires minimal provider time for execution; and generates detailed cost estimates that have "face validity" with providers and are relevant for economic evaluation.


Subject(s)
COVID-19 , Telemedicine , Ambulatory Care , Ambulatory Care Facilities , COVID-19/epidemiology , Child , Humans , Pandemics , Telemedicine/methods
6.
J Clin Psychiatry ; 82(3)2021 04 06.
Article in English | MEDLINE | ID: covidwho-2066783

ABSTRACT

OBJECTIVE: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020. METHODS: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician's decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity. RESULTS: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation). CONCLUSIONS: In the first 8 weeks of the COVID-19-induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.


Subject(s)
Ambulatory Care/statistics & numerical data , COVID-19 , Emergencies/epidemiology , Emergency Services, Psychiatric , Hospitalization/statistics & numerical data , Mental Disorders , Physical Distancing , Adolescent , Age Factors , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/psychology , Child , Communicable Disease Control/methods , Education, Distance , Emergency Services, Psychiatric/organization & administration , Emergency Services, Psychiatric/statistics & numerical data , Female , Humans , Italy/epidemiology , Male , Mental Disorders/epidemiology , Mental Disorders/psychology , Mental Disorders/therapy , Mental Health/statistics & numerical data , Organizational Innovation , SARS-CoV-2
7.
Int J Environ Res Public Health ; 19(19)2022 Sep 23.
Article in English | MEDLINE | ID: covidwho-2065919

ABSTRACT

BACKGROUND: To protect and improve the health of populations, the important role of primary health institutions has been strengthened through a series of health policies, especially the implementation of a national hierarchical diagnosis and treatment system. In this light, we aim to evaluate the development of primary health institutions between 2013, before the implementation of the hierarchical diagnosis and treatment system, and 2020 as well as people's perception of the quality of primary healthcare services. METHOD: The national-level data (e.g., the numbers of primary health institutions, personnel, beds, visits, and hospitalizations) regarding primary health institutions were collected from the Health Statistics Yearbook, and the perceptions of the quality of primary healthcare services were collected by a web-based questionnaire survey using an internationally recognized assessment tool (i.e., PCAT-AE). In total, 10,850 persons were surveyed, and 10,419 participants were incorporated into the final analysis after removing invalid questionnaires. A descriptive statistical analysis (i.e., frequency and percentage) was used to analyze the national-level characteristics of primary health institutions and people's perceptions of the quality of primary healthcare services. Moreover, a logistic regression model was used to analyze the factors influencing the perceptions of the quality of primary healthcare services. RESULTS: From the macro perspective, the number of primary health institutions, beds, and personnel per 10 thousand residents slightly increased from 2013 to 2020, especially in the eastern and central areas. However, the average number of visits and the hospitalization rate in primary health institutions showed a decrease, especially in central and eastern areas. Among participants, 92.2% (9606/10,419) of them had previously sought healthcare services in primary health institutions, and most were seeking general outpatient services (57.06-63.45%), followed by medicine purchasing (16.49-21.51%), physical examinations (9.91-11.49%), preventive health services (5.11-6.48%), and hospitalization services (3.17-5.67%). The total perception scores on the quality of primary healthcare services reported by the participants were 26.19 and 27.00 for rural and urban areas, respectively, which accounted for 65.5% and 67.5% of the total score, respectively, and 26.62, 26.86, and 25.89 for the eastern, central, and western areas, respectively, with percentages of 66.6%, 67.2%, and 64.7%. The perception score on the quality among people contracted with a family doctor (29.83, 74.58%) was much higher than those who were not (25.25, 63.13%), and the difference was statistically significant (p < 0.001). Moreover, people who were female, married, had higher incomes, and were diagnosed with various diseases had better perceptions of the primary healthcare services compared to their counterparts (p < 0.05). CONCLUSION: Improvements were seen for primary health institutions, especially in terms of hardware resources such as beds and personnel. However, the service utilization in primary health institutions did not improve between 2013 and 2020. The perception score on the quality of primary healthcare was moderate to low in rural and urban as well as eastern, central, and western areas, but it was significantly higher among people contracted with a family doctor than those who were not. Therefore, it is important for policy makers to take or adjust measures focusing on quality improvement and increasing the service utilization in primary health institutions with good first contact, accessibility, continuity, comprehensiveness, and coordination, such as raising the enrollment rate of family doctors and promoting the provision of high-quality services.


Subject(s)
Health Policy , Primary Health Care , Ambulatory Care , China , Female , Humans , Male , Rural Population
8.
BMJ Open ; 12(10): e054054, 2022 10 11.
Article in English | MEDLINE | ID: covidwho-2064148

ABSTRACT

INTRODUCTION: Public health crises such as pandemics can cause serious disruptions to the utilisation and provision of healthcare services with negative effects on morbidity and mortality. Despite the important role of paediatric primary care in maintaining high-quality healthcare services during crises, evidence about service utilisation and provision remains limited especially in Germany. This study, therefore, explores the utilisation and provision of paediatric primary care services during the ongoing COVID-19 pandemic and their barriers and facilitators. METHODS AND ANALYSIS: The study uses a convergent mixed-methods design and comprises online surveys to parents, adolescents and primary care paediatricians (PCPs) and semistructured interviews with parents and PCPs. We recruit parents and adolescents from paediatric primary care practices and PCPs via email using mailing lists of the German Professional Association of Paediatricians and the German Society of Ambulatory Primary Care Paediatrics. The parent and adolescent surveys assess, inter alia, the utilisation of paediatric primary care services and its correlates, aspects of parental and child health as well as socioeconomic characteristics. The PCP survey investigates the provision of paediatric primary care services and its correlates, aspects of PCP health as well as sociodemographic and practice characteristics. The semistructured interviews with parents and PCPs explore several aspects of the online surveys in more detail. We use descriptive statistics and generalised linear mixed models to assess service utilisation and provision and specific correlates covered in the online surveys and apply qualitative content analysis to explore barriers and facilitators of service utilisation and provision more broadly in the semistructured interviews. We will integrate findings from the quantitative and qualitative analyses at the interpretation stage. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethics Review Board of the Medical Faculty Mannheim at Heidelberg University (2020-650N). Study results will be published in journals with external peer-review.


Subject(s)
COVID-19 , Pediatrics , Adolescent , Ambulatory Care , COVID-19/epidemiology , Child , Humans , Pandemics , Primary Health Care , Public Health
9.
Telemed J E Health ; 28(10): 1404-1411, 2022 10.
Article in English | MEDLINE | ID: covidwho-2062834

ABSTRACT

Background: To describe the epidemiology of patients accessing a pediatric urgent care telemedicine platform during the COVID-19 pandemic. Study Design: We conducted a cross-sectional study of the first 30,000 pediatric patients who accessed our pediatric urgent care telemedicine platform during the beginning of the COVID-19 pandemic. The study population came from 15 states and included the dates May 15 through September 16, 2020. We also described the groups of patients referred for in-person evaluation in urgent care or emergency department (ED) settings. Results: Mean patient age was 7.6 ± 5.4 years and 51% of patients were male. Twenty-one percent were publicly insured. More than 60% of patients sought care between 12 and 7 p.m. The most common reasons for seeking care were concerns for COVID-19 (50.5%) and fever (6.8%). Antibiotics were prescribed in 4.3% of visits. Children had an in-person visit to our urgent care offices on the same day in 9% of visits. Less than 1% of children were referred to the ED. Conclusions: In this large series of telemedicine visits during the COVID-19 pandemic, fewer than 10% required escalation to an in-person office visit and fewer than 1% required escalation to an ED.


Subject(s)
COVID-19 , Telemedicine , Adolescent , Ambulatory Care , Anti-Bacterial Agents , COVID-19/epidemiology , Child , Child, Preschool , Cross-Sectional Studies , Female , Humans , Male , Pandemics
10.
J Med Internet Res ; 24(9): e39920, 2022 09 08.
Article in English | MEDLINE | ID: covidwho-2054801

ABSTRACT

BACKGROUND: Although videoconferencing between oncology patients and nurses became routine during the pandemic, little is known about the development of clinician-patient rapport in this care environment. Evidence that virtual visits may challenge nurses' ability to form connections with patients, demonstrate empathy, and provide support suggests that videoconferencing may not ensure optimal care for persons with cancer. Establishing rapport during videoconferencing visits (VCVs) is important in oncology nursing, as rapport enables the nurse to provide emotional support and assistance to patients as they navigate their cancer journey. OBJECTIVE: This study investigated the nature of nurse-patient rapport in ambulatory cancer care videoconferencing telehealth visits. Objectives included exploring (1) how patients with cancer and nurses describe experiences of and strategies for cultivating rapport and (2) similarities and differences between rapport in videoconferencing and in-person visits (IPVs). METHODS: In this qualitative descriptive study, interviews were conducted from October 2021 to March 2022 with 22 participants, including patients with cancer (n=10, 45%) and oncology nurses (n=12, 55%), about their experiences of rapport building during VCVs. All interviews were analyzed using conventional content analysis. Data from nurses and patients were analyzed separately using identical procedures, with a comparative analysis of patient and nurse results performed in the final analysis. RESULTS: Most patients in the study had experienced 3-5 video visits within the past 12 months (n=7, 70%). Half of the nurse participants (n=6, 50%) reported having participated in over 100 VCVs, and all had experiences with videoconferencing (ranging from 3 to 960 visits) over the past 12 months. In total, 3 themes and 6 categories were derived from the patient data, and 4 themes and 13 categories were derived from the nurse data. Comparisons of themes derived from participant interviews identified similarities in how nurses and patients described experiences of rapport during VCVs. Three themes fit the collective data: (1) person-centered and relationship-based care is valued and foundational to nurse-patient rapport in oncology ambulatory care regardless of how care is delivered, (2) adapting a bedside manner to facilitate rapport during VCVs is feasible, and (3) nurses and patients can work together to create person-centered options across the care trajectory to ensure quality care outcomes. Barriers to relationship building in VCVs included unexpected interruptions from others, breaks in the internet connection, concerns about privacy, and limitations associated with not being physically present. CONCLUSIONS: Person-centered and relationship-based approaches can be adapted to support nurse-patient rapport in VCVs, including forming a personal connection with the patient and using active listening techniques. Balancing the challenges and limitations with the benefits of videoconferencing is an essential competency requiring additional research and guidelines. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/27940.


Subject(s)
Neoplasms , Videoconferencing , Ambulatory Care/methods , Humans , Neoplasms/therapy , Patient Outcome Assessment , Qualitative Research
11.
J Med Internet Res ; 24(10): e38604, 2022 10 25.
Article in English | MEDLINE | ID: covidwho-2054783

ABSTRACT

BACKGROUND: Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear. OBJECTIVE: We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care. METHODS: Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses. RESULTS: During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99). CONCLUSIONS: Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.


Subject(s)
COVID-19 , Telemedicine , Humans , Middle Aged , Adult , COVID-19/epidemiology , Pandemics , Ontario/epidemiology , Ambulatory Care , Hospitals
12.
BMC Prim Care ; 23(1): 245, 2022 09 21.
Article in English | MEDLINE | ID: covidwho-2038662

ABSTRACT

BACKGROUND: The COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans' ambulatory care experience, specifically access and satisfaction, early in the pandemic. METHODS: We employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 - June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans' perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis. RESULTS: Veterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers ("The phone would hang up on me") and 9 (33%) reported a lack of provider availability ("They are not reaching out like they used to"). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0-10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)). Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), "I stay inside and away from people"). CONCLUSIONS: While the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis.


Subject(s)
COVID-19 , Veterans , Ambulatory Care , COVID-19/epidemiology , Health Services Accessibility , Humans , Pandemics , Personal Satisfaction , Primary Health Care , United States/epidemiology , United States Department of Veterans Affairs , Veterans/psychology
13.
BMJ Open ; 12(9): e064979, 2022 09 22.
Article in English | MEDLINE | ID: covidwho-2038321

ABSTRACT

OBJECTIVES: To estimate the treatment incidence of post-COVID syndrome (postinfectious sequelae present at least 12 weeks following infection) in the context of ambulatory care in Bavaria, Germany, and to establish whether related diagnoses occur more frequently than in patients with no known history of COVID-19. DESIGN: Retrospective cohort analysis of routinely collected claims data. SETTING: Ambulatory care in Bavaria, Germany, observed from January 2020 to March 2022 (data accessed May 2022). PARTICIPANTS: 391 990 patients with confirmed COVID-19 diagnosis, 62 659 patients with other respiratory infection and a control group of 659 579 patients with no confirmed or suspected diagnosis of COVID-19. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome is diagnosis of post-COVID syndrome documented in ambulatory care. Secondary outcomes are: chronic fatigue syndrome, psychological disorder, fatigue, mild cognitive impairment, disturbances of taste and smell, dyspnoea, pulmonary embolism and myalgia. RESULTS: Among all patients with confirmed COVID-19, 14.2% (95% CI 14.0% to 14.5%) received a diagnosis of a post-COVID syndrome, and 6.7% (95% CI 6.5% to 6.9%) received the diagnosis in at least two quarterly periods during a 2-year follow-up. Compared with patients with other respiratory infections and with controls, patients with COVID-19 more frequently received a variety of diagnoses including chronic fatigue syndrome (1.6% vs 0.6% and 0.3%, respectively), fatigue (13.3% vs 9.2% and 6.0%), dyspnoea (9.9% vs 5.1% and 3.2%) and disturbances of taste and smell (3.2% vs 1.2% and 0.5%). The treatment incidence of post-COVID syndrome was highest among adults aged 40-59 (19.0%) and lowest among children aged below 12 years (2.6%). CONCLUSIONS: Our results demonstrate a moderately high incidence of post-COVID syndrome 2 years after COVID-19 diagnosis. There is an urgent need to find efficient and effective solutions to help patients with dyspnoea, fatigue, cognitive impairment and loss of smell. Guidelines and treatment algorithms, including referral criteria, and occupational and physical therapy, require prompt and coherent implementation.


Subject(s)
COVID-19 , Fatigue Syndrome, Chronic , Adult , Ambulatory Care , COVID-19/complications , COVID-19/epidemiology , COVID-19 Testing , Child , Cohort Studies , Dyspnea/epidemiology , Dyspnea/etiology , Germany/epidemiology , Humans , Incidence , Retrospective Studies , SARS-CoV-2
14.
Med Care ; 60(11): 860-867, 2022 11 01.
Article in English | MEDLINE | ID: covidwho-2037581

ABSTRACT

BACKGROUND: Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC). OBJECTIVE: We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth. DESIGN: Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews. SUBJECTS: Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020. KEY RESULTS: In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction. CONCLUSIONS: CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans' optimal and equitable access to care.


Subject(s)
COVID-19 , Telemedicine , Veterans , Ambulatory Care , COVID-19/epidemiology , Humans , Pandemics , Telemedicine/methods , United States , Veterans Health
15.
PLoS One ; 17(6): e0269821, 2022.
Article in English | MEDLINE | ID: covidwho-2021802

ABSTRACT

INTRODUCTION: Outpatient care for children and adolescents with chronic conditions needs to be continuous and programmed, encompassing comprehensive care, with periodically scheduled consultations, exams, and procedures, to promote quality of life and reduce mortality. In the context of the new coronavirus pandemic, however, outpatient care for children and adolescents with chronic conditions, in person, was hampered in favor of social isolation, a necessary sanitary measure to reduce and prevent the spread of Coronavirus Disease 2019. In response to this need, studies suggest telehealth in pediatrics as a fertile and expanding field especially in times of pandemics. Here, we aimed to map the evidence related to telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, to identify which strategies were implemented and their impacts on the continuity of care. METHODS: A scoping review protocol is reported and guided by the Scoping Reviews Manual of the Joanna Briggs Institute. The search for evidence will cover the following databases: MEDLINE/PubMed, Cochrane Libary; Embase; Web of Science; Scopus; Cinahl and PsycINFO, plus additional sources, such as The British Library, Google Scholar, and Preprints [medRXiv]. No date or language restrictions will be employed in this scoping review. Two independent researchers will conduct the search strategy, study selection, data charting, and data synthesis. RESULTS: The findings will be presented through tables, charts, narrative summaries, and assessed based on the type of data charted as well as outcomes. Additionally, the meaning of these findings will be considered as they relate to the guiding question, the characterization and measurement of the impact of different telehealth modalities used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, and the implications for practice and further research. DISCUSSION: To the best of our knowledge, this will be the first scoping review to look specifically at the telehealth modalities to be used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic. We expect that our results will be of interest to practitioners as well as researchers concerned with this particular emerging issue in the pandemic context. Also, the plans for the dissemination of this study comprise peer-reviewed publication and conference presentations. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/5pqgu.


Subject(s)
COVID-19 , Telemedicine , Adolescent , Ambulatory Care , COVID-19/epidemiology , Child , Chronic Disease , Humans , Pandemics , Quality of Life , Research Design , Review Literature as Topic
16.
N Engl J Med ; 387(10): 955, 2022 09 08.
Article in English | MEDLINE | ID: covidwho-2016957
17.
J Gen Intern Med ; 37(4): 707-713, 2022 03.
Article in English | MEDLINE | ID: covidwho-1579038

ABSTRACT

BACKGROUND: Care delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today's exponential adoption of telemedicine. OBJECTIVE: The objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine ("tele-urgent care") from the perspective of clinicians experienced in telemedicine. APPROACH: We conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach. KEY RESULTS: Among the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important. CONCLUSION: As telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future.


Subject(s)
COVID-19 , Telemedicine , Academic Medical Centers , Ambulatory Care , COVID-19/epidemiology , Female , Humans , Male , Pandemics , SARS-CoV-2 , Telemedicine/methods
18.
Dtsch Arztebl Int ; 119(19): 342-349, 2022 05 13.
Article in English | MEDLINE | ID: covidwho-2002483

ABSTRACT

BACKGROUND: One of the purposes of outpatient treatment for COVID-19 patients is to prevent severe disease courses and hospitalization. There is a need for evidence-based recommendations to be applied in primary care and specialized outpatient settings. METHODS: This guideline was developed on the basis of publications that were retrieved by a systematic search for randomized controlled trials in the Cochrane COVID-19 trial registry. The quality of evidence was assessed with GRADE, and structured consensus generation was carried out with MAGICapp. RESULTS: Unvaccinated COVID-19 outpatients with at least one risk factor for a severe disease course may be treated in the early phase of the disease with sotrovimab, remdesivir, or nirmatrelvir/ritonavir. Molnupiravir may also be used for such patients if no other clinically appropriate treatment options are available. Immunosuppressed persons with COVID-19 who are at high risk, and whose response to vaccination is expected to be reduced, ought to be treated with sotrovimab. It should be noted, however, that the clinical efficacy of sotrovimab against infections with the omicron subtype BA.2 is uncertain at the currently used dose, as the drug has displayed reduced activity against this subtype in vitro. COVID-19 patients at risk of a severe course may be offered budesonide inhalation, according to an off-label recommendation of the German College of General Practitioners and Family Physicians (other medical societies do not recommend either for or against this treatment). Thrombo - embolism prophylaxis with low-molecular-weight heparin may be given to elderly patients or those with a pre-existing illness. No recommendation is made concerning fluvoxamine or colchicine. Acetylsalicylic acid, azithromycin, ivermectin, systemic steroids, and vitamin D should not be used for the outpatient treatment of COVID-19. CONCLUSION: Drug treatment is now available for outpatients with COVID-19 in the early phase. Nearly all of the relevant trials have been conducted in unvaccinated subjects; this needs to be kept in mind in patient selection.


Subject(s)
Ambulatory Care , COVID-19 , Practice Guidelines as Topic , Aged , Antibodies, Monoclonal, Humanized/therapeutic use , Antibodies, Neutralizing/therapeutic use , COVID-19/drug therapy , Humans , Randomized Controlled Trials as Topic , Systematic Reviews as Topic , Treatment Outcome
19.
J Gen Intern Med ; 37(15): 3979-3988, 2022 Nov.
Article in English | MEDLINE | ID: covidwho-2000087

ABSTRACT

BACKGROUND: The first surge of the COVID-19 pandemic entirely altered healthcare delivery. Whether this also altered the receipt of high- and low-value care is unknown. OBJECTIVE: To test the association between the April through June 2020 surge of COVID-19 and various high- and low-value care measures to determine how the delivery of care changed. DESIGN: Difference in differences analysis, examining the difference in quality measures between the April through June 2020 surge quarter and the January through March 2020 quarter with the same 2 quarters' difference the year prior. PARTICIPANTS: Adults in the MarketScan® Commercial Database and Medicare Supplemental Database. MAIN MEASURES: Fifteen low-value and 16 high-value quality measures aggregated into 8 clinical quality composites (4 of these low-value). KEY RESULTS: We analyzed 9,352,569 adults. Mean age was 44 years (SD, 15.03), 52% were female, and 75% were employed. Receipt of nearly every type of low-value care decreased during the surge. For example, low-value cancer screening decreased 0.86% (95% CI, -1.03 to -0.69). Use of opioid medications for back and neck pain (DiD +0.94 [95% CI, +0.82 to +1.07]) and use of opioid medications for headache (DiD +0.38 [95% CI, 0.07 to 0.69]) were the only two measures to increase. Nearly all high-value care measures also decreased. For example, high-value diabetes care decreased 9.75% (95% CI, -10.79 to -8.71). CONCLUSIONS: The first COVID-19 surge was associated with receipt of less low-value care and substantially less high-value care for most measures, with the notable exception of increases in low-value opioid use.


Subject(s)
COVID-19 , Aged , Adult , Female , Humans , United States/epidemiology , Male , COVID-19/epidemiology , COVID-19/therapy , Pandemics , Analgesics, Opioid/therapeutic use , Medicare , Ambulatory Care
20.
BMC Health Serv Res ; 22(1): 1045, 2022 Aug 16.
Article in English | MEDLINE | ID: covidwho-2002171

ABSTRACT

OBJECTIVE: Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS. METHODS: We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 - March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients' health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40. CONCLUSIONS: Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.


Subject(s)
Residential Treatment , Substance-Related Disorders , Ambulatory Care , Harm Reduction , Humans , Ontario , Substance-Related Disorders/therapy
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