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1.
BMC Health Serv Res ; 22(1): 311, 2022 Mar 07.
Article in English | MEDLINE | ID: covidwho-1731529

ABSTRACT

BACKGROUND: In recent decades, there has been a significant focus towards the improvement of maternal mortality indicators in low-and middle-income countries. Though progress has been made around the world, West Africa has maintained an elevated burden of diseases. One proposed solution to increasing access to primary care services is health insurance coverage. As limited evidence exists, we sought to understand the relationship between health insurance coverage and at least four antenatal care (ANC) visits in West Africa. METHODS: Demographic and Health Survey data from 10 West African countries were weighted, cleaned, and analysed. The total sample was 79,794 women aged 15 to 49 years old were considered for the analysis. Health insurance coverage was the explanatory variable, and the outcome variable was number of ANC visits. The data were analysed using binary logistic regression. The results were presented using crude and adjusted odds ratio (aOR) at 95% confidence interval. RESULTS: Approximately 86.73% of women who were covered by health insurance had four or more ANC visits, compared to 55.15% for women without insurance. In total, 56.91% of the total sample attended a minimum of four ANC visits. Women with health insurance coverage were more likely to make the minimum recommended number of ANC visits than their non-insured-peers (aOR [95% CI] =1.55 [1.37-1.73]). CONCLUSION: Health insurance is a significant determinant in accessing primary care services for pregnant women. Yet, very few in the region are covered by an insurance scheme. In the wake of the COVID-19 pandemic, policy makers should prioritize rapid solutions to provide primary care while setting the infrastructure for long-term and sustainable options such as publicly run health insurance schemes.


Subject(s)
Facilities and Services Utilization , Insurance Coverage , Insurance, Health , Prenatal Care , Adolescent , Adult , Africa, Western/epidemiology , COVID-19/epidemiology , Facilities and Services Utilization/statistics & numerical data , Female , Humans , Insurance Coverage/statistics & numerical data , Insurance, Health/statistics & numerical data , Middle Aged , Pandemics , Pregnancy , Prenatal Care/statistics & numerical data , Young Adult
3.
JAMA ; 327(3): 237-247, 2022 01 18.
Article in English | MEDLINE | ID: covidwho-1669298

ABSTRACT

Importance: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance: Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.


Subject(s)
Ambulatory Care/trends , COVID-19/epidemiology , Pandemics , Adult , Aged , Aged, 80 and over , Ambulatory Care/statistics & numerical data , Colonoscopy/statistics & numerical data , Colonoscopy/trends , Databases, Factual , Fee-for-Service Plans/statistics & numerical data , Fee-for-Service Plans/trends , Female , Health Services Needs and Demand/statistics & numerical data , Health Services Needs and Demand/trends , Humans , Insurance, Health/statistics & numerical data , Insurance, Health/trends , Male , Mammography/statistics & numerical data , Mammography/trends , Medicaid/statistics & numerical data , Medicare/statistics & numerical data , Middle Aged , Retrospective Studies , Telemedicine/statistics & numerical data , Telemedicine/trends , Time Factors , United States/epidemiology , Young Adult
4.
Am J Perinatol ; 39(4): 354-360, 2022 03.
Article in English | MEDLINE | ID: covidwho-1565753

ABSTRACT

OBJECTIVE: To determine whether early postpartum discharge during the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in the odds of maternal postpartum readmissions. STUDY DESIGN: This is a retrospective analysis of uncomplicated postpartum low-risk women in seven obstetrical units within a large New York health system. We compared the rate of postpartum readmissions within 6 weeks of delivery between two groups: low-risk women who had early postpartum discharge as part of our protocol during the COVID-19 pandemic (April 1-June 15, 2020) and similar low-risk patients with routine postpartum discharge from the same study centers 1 year prior. Statistical analysis included the use of Wilcoxon's rank-sum and chi-squared tests, Nelson-Aalen cumulative hazard curves, and multivariate logistic regression. RESULTS: Of the 8,206 patients included, 4,038 (49.2%) were patients who had early postpartum discharge during the COVID-19 pandemic and 4,168 (50.8%) were patients with routine postpartum discharge prior to the COVID-19 pandemic. The rates of postpartum readmissions after vaginal delivery (1.0 vs. 0.9%; adjusted odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.39-1.45) and cesarean delivery (1.5 vs. 1.9%; adjusted OR: 0.65, 95% CI: 0.29-1.45) were similar between the two groups. Demographic risk factors for postpartum readmission included Medicaid insurance and obesity. CONCLUSION: Early postpartum discharge during the COVID-19 pandemic was associated with no change in the odds of maternal postpartum readmissions after low-risk vaginal or cesarean deliveries. Early postpartum discharge for low-risk patients to shorten hospital length of stay should be considered in the face of public health crises. KEY POINTS: · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after vaginal delivery.. · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after cesarean delivery.. · Early postpartum discharge for low-risk patients should be considered during a public health crisis..


Subject(s)
COVID-19 , Insurance, Health/statistics & numerical data , Medicaid/statistics & numerical data , Obesity, Maternal/epidemiology , Patient Discharge , Patient Readmission/statistics & numerical data , Postnatal Care/methods , Adult , Case-Control Studies , Cesarean Section , Cohort Studies , Delivery, Obstetric , Female , Humans , Length of Stay/statistics & numerical data , Logistic Models , Multivariate Analysis , Pregnancy , Proportional Hazards Models , Retrospective Studies , Risk Factors , SARS-CoV-2 , United States
5.
MMWR Morb Mortal Wkly Rep ; 70(41): 1435-1440, 2021 Oct 15.
Article in English | MEDLINE | ID: covidwho-1468852

ABSTRACT

Immunization is a safe and cost-effective means of preventing illness in young children and interrupting disease transmission within the community.* The Advisory Committee on Immunization Practices (ACIP) recommends vaccination of children against 14 diseases during the first 24 months of life (1). CDC uses National Immunization Survey-Child (NIS-Child) data to monitor routine coverage with ACIP-recommended vaccines in the United States at the national, regional, state, territorial, and selected local levels.† CDC assessed vaccination coverage by age 24 months among children born in 2017 and 2018, with comparisons to children born in 2015 and 2016. Nationally, coverage was highest for ≥3 doses of poliovirus vaccine (92.7%); ≥3 doses of hepatitis B vaccine (HepB) (91.9%); ≥1 dose of measles, mumps, and rubella vaccine (MMR) (91.6%); and ≥1 dose of varicella vaccine (VAR) (90.9%). Coverage was lowest for ≥2 doses of influenza vaccine (60.6%). Coverage among children born in 2017-2018 was 2.1-4.5 percentage points higher than it was among those born in 2015-2016 for rotavirus vaccine, ≥1 dose of hepatitis A vaccine (HepA), the HepB birth dose, and ≥2 doses of influenza vaccine. Only 1.0% of children had received no vaccinations by age 24 months. Disparities in coverage were seen for race/ethnicity, poverty status, and health insurance status. Coverage with most vaccines was lower among children who were not privately insured. The largest disparities between insurance categories were among uninsured children, especially for ≥2 doses of influenza vaccine, the combined 7-vaccine series, § and rotavirus vaccination. Reported estimates reflect vaccination opportunities that mostly occurred before disruptions resulting from the COVID-19 pandemic. Extra efforts are needed to ensure that children who missed vaccinations, including those attributable to the COVID-19 pandemic, receive them as soon as possible to maintain protection against vaccine-preventable illnesses.


Subject(s)
Vaccination Coverage/statistics & numerical data , Vaccines/administration & dosage , /statistics & numerical data , Health Care Surveys , Healthcare Disparities/statistics & numerical data , Humans , Immunization Schedule , Infant , Insurance, Health/statistics & numerical data , Poverty/statistics & numerical data , United States
8.
Hastings Cent Rep ; 50(5): 3-4, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-1361187

ABSTRACT

Our health care system in the United States reflects the inequities that are part of the larger society, which is why our system for financing access to needed and effective health care is so complicated and unfair.


Subject(s)
African Americans , Anemia, Sickle Cell/ethnology , Health Services Accessibility/organization & administration , Health Status Disparities , Anemia, Sickle Cell/economics , COVID-19/ethnology , Health Services Accessibility/economics , Humans , Insurance Coverage/statistics & numerical data , Insurance, Health/statistics & numerical data , SARS-CoV-2 , United States
9.
Med Care ; 59(10): 888-892, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1337299

ABSTRACT

BACKGROUND: Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. OBJECTIVE: The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. RESEARCH DESIGN: Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. SUBJECTS: Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. MEASURES: The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. RESULTS: Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. CONCLUSIONS: Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.


Subject(s)
COVID-19/epidemiology , Hospital Mortality/trends , Residence Characteristics/statistics & numerical data , Age Factors , COVID-19 Testing , Comorbidity , Humans , Insurance, Health/statistics & numerical data , Male , Middle Aged , Midwestern United States/epidemiology , Poverty/statistics & numerical data , Retrospective Studies , Sex Factors
10.
West J Emerg Med ; 22(3): 552-560, 2021 Apr 28.
Article in English | MEDLINE | ID: covidwho-1266882

ABSTRACT

INTRODUCTION: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.


Subject(s)
COVID-19/ethnology , Emergency Service, Hospital/statistics & numerical data , Healthcare Disparities/statistics & numerical data , Adolescent , Adult , Aged , Child , Child, Preschool , Economic Status/statistics & numerical data , Humans , Infant , Infant, Newborn , Insurance, Health/statistics & numerical data , Male , Medicaid/statistics & numerical data , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index , United States/epidemiology , Young Adult
11.
J Prev Med Public Health ; 54(3): 161-165, 2021 May.
Article in English | MEDLINE | ID: covidwho-1259659

ABSTRACT

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads heterogeneously, disproportionately impacting poor and minority communities. The relationship between poverty and race is complex, with a diverse set of structural and systemic factors driving higher rates of poverty among minority populations. The factors that specifically contribute to the disproportionate rates of SARS-CoV-2 infection, however, are not clearly understood. METHODS: We evaluated SARS-CoV-2 test results from community-based testing sites in Los Angeles, California, between June and December, 2020. We used tester zip code data to link those results with United States Census report data on average annual household income, rates of healthcare coverage, and employment status by zip code. RESULTS: We analyzed 2 141 127 SARS-CoV-2 test results, of which 245 154 (11.4%) were positive. Multivariable modeling showed a higher likelihood of SARS-CoV-2 test positivity among Hispanic communities than among other races. We found an increased risk for SARS-CoV-2 positivity among individuals from zip codes with an average annual household income

Subject(s)
COVID-19/ethnology , Poverty/statistics & numerical data , Adolescent , Adult , Aged , Asian Americans/statistics & numerical data , COVID-19/epidemiology , COVID-19 Testing/statistics & numerical data , Cross-Sectional Studies , Employment/statistics & numerical data , Female , Humans , Insurance Coverage/statistics & numerical data , Insurance, Health/statistics & numerical data , Los Angeles/epidemiology , Male , Middle Aged , Pandemics , SARS-CoV-2 , Young Adult
13.
Eur J Vasc Endovasc Surg ; 62(1): 119-125, 2021 07.
Article in English | MEDLINE | ID: covidwho-1171631

ABSTRACT

OBJECTIVE: A previous study revealed a preliminary trend towards higher in hospital mortality in patients admitted as an emergency with acute stroke during the COVID-19 pandemic in Germany. The current study aimed to further examine the possible impact of a confirmed SARS-CoV-2 infection on in hospital mortality. METHODS: This was a retrospective analysis of health insurance claims data from the second largest insurance fund in Germany, BARMER. Patients hospitalised for ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, acute limb ischaemia (ALI), aortic rupture, acute stroke, or transient ischaemic attack (TIA) between 1 January 2017, and 31 October 2020, were included. Admission rates per 10 000 insured and mortality were compared between March - June 2017 - 2019 (pre-COVID) and March - June 2020 (COVID). Mortality rates were determined by the occurrence of a confirmed SARS-CoV-2 infection. RESULTS: A total of 316 718 hospitalisations were included (48.7% female, mean 72.5 years), and 21 191 (6.7%, 95% CI 6.6% - 6.8%) deaths occurred. In hospital mortality increased during the COVID-19 pandemic when compared with the three previous years for patients with acute stroke from 8.3% (95% CI 8.0 - 8.5) to 9.6% (95% CI 9.1 - 10.2), while no statistically significant changes were observed for STEMI, NSTEMI, ALI, aortic rupture, and TIA. When comparing patients with confirmed SARS-CoV-2 infection (2.4%, 95% CI 2.3 - 2.5) vs. non-infected patients, a higher in hospital mortality was observed for acute stroke (12.4% vs. 9.0%), ALI (14.3% vs. 5.0%), and TIA (2.7% vs. 0.3%), while no statistically significant differences were observed for STEMI, NSTEMI, and aortic rupture. CONCLUSION: This retrospective analysis of claims data has provided hints of an association between the COVID-19 pandemic and increased in hospital mortality in patients with acute stroke. Furthermore, confirmed SARS-CoV-2 infection was associated with increased mortality in patients with stroke, TIA, and ALI. Future studies are urgently needed to better understand the underlying mechanism and relationship between the new coronavirus and acute stroke.


Subject(s)
COVID-19/complications , Ischemic Attack, Transient/mortality , Peripheral Arterial Disease/mortality , Stroke/mortality , Administrative Claims, Healthcare/statistics & numerical data , Aged , COVID-19/diagnosis , COVID-19/epidemiology , Emergencies/epidemiology , Extremities/blood supply , Female , Germany/epidemiology , Hospital Mortality/trends , Humans , Insurance, Health/statistics & numerical data , Ischemic Attack, Transient/complications , Ischemic Attack, Transient/therapy , Male , Pandemics/statistics & numerical data , Peripheral Arterial Disease/complications , Peripheral Arterial Disease/therapy , Retrospective Studies , SARS-CoV-2/isolation & purification , Stroke/complications , Stroke/therapy
14.
Int J Equity Health ; 20(1): 91, 2021 04 06.
Article in English | MEDLINE | ID: covidwho-1169965

ABSTRACT

BACKGROUND: COVID-19 has an inevitable burden on public health, potentially widening the gender gap in healthcare and the economy. We aimed to assess gender-based desparities during COVID-19 in Jordan in terms of health indices, mental well-being and economic burden. METHODS: A nationally representative sample of 1300 participants ≥18 years living in Jordan were selected using stratified random sampling. Data were collected via telephone interviews in this cross-sectional study. Chi-square was used to test age and gender differences according to demographics, economic burden, and health indices (access to healthcare, health insurance, antenatal and reproductive services). A multivariable logistic regression analysis was used to estimate the beta-coefficient (ß) and 95% confidence interval (CI) of factors correlated with mental well-being, assessed by patients' health questionnaire 4 (PHQ-4). RESULTS: 656 (50.5%) men and 644 (49.5%) women completed the interview. Three-fourths of the participants had health insurance during the COVID-19 crisis. There was no significant difference in healthcare coverage or access between women and men (p > 0.05). Half of pregnant women were unable to access antenatal care. Gender was a significant predictor of higher PHQ-4 scores (women vs. men: ß: 0.88, 95% CI: 0.54-1.22). Among women, age ≥ 60 years and being married were associated with significantly lower PHQ-4 scores. Only 0.38% of the overall participants lost their jobs; however, 8.3% reported a reduced payment. More women (13.89%) were not paid during the crisis as compared with men (6.92%) (P = 0.01). CONCLUSIONS: Our results showed no gender differences in healthcare coverage or access during the COVID-19 crisis generally. Women in Jordan are experiencing worse outcomes in terms of mental well-being and economic burden. Policymakers should give priority to women's mental health and antenatal and reproductive services. Financial security should be addressed in all Jordanian COVID-19 national plans because the crisis appears widening the gender gap in the economy.


Subject(s)
COVID-19/economics , Health Services Accessibility/statistics & numerical data , Health Status Disparities , Mental Health/statistics & numerical data , Prenatal Care/statistics & numerical data , SARS-CoV-2 , Adult , Cross-Sectional Studies , Female , Humans , Insurance, Health/statistics & numerical data , Jordan , Male , Middle Aged , Pregnancy , Sex Factors
15.
CMAJ Open ; 9(1): E302-E308, 2021.
Article in English | MEDLINE | ID: covidwho-1159903

ABSTRACT

BACKGROUND: It is unclear what the best strategy is for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among residents of homeless shelters and what individual factors are associated with testing positive for the virus. We sought to evaluate factors associated with testing positive for SARS-CoV-2 among residents of homeless shelters and to evaluate positivity rates in shelters where testing was conducted in response to coronavirus disease 2019 (COVID-19) outbreaks or for surveillance. METHODS: We conducted a retrospective chart audit to obtain repeated cross-sectional data from outreach testing done at homeless shelters between Apr. 1 and July 31, 2020, in Toronto, Ontario, Canada. We compared the SARS-CoV-2 positivity rate for shelters where testing was conducted because of an outbreak (at least 1 known case) with those tested for surveillance (no known cases). A patient-level analysis evaluated differences in demographic, health and behavioural characteristics of residents who did and did not test positive for SARS-CoV-2 at shelters with at least 2 positive cases. RESULTS: One thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive for SARS-CoV-2 and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive for SARS-CoV-2 were significantly less likely to have a health insurance card (54% v. 72%, p = 0.03) or to have visited another shelter in the last 14 days (0% v. 18%, p < 0.01). There was no association between SARS-CoV-2 positivity and medical history or symptoms. INTERPRETATION: Our findings support testing of asymptomatic shelter residents for SARS-CoV-2 when a positive case is identified at the same shelter. Surveillance testing when there are no known positive cases may detect outbreaks, but further research should identify efficient strategies given scarce testing resources.


Subject(s)
COVID-19 Testing/statistics & numerical data , COVID-19/diagnosis , Homeless Persons/statistics & numerical data , SARS-CoV-2/genetics , Adolescent , Adult , Aged , COVID-19/epidemiology , COVID-19/transmission , COVID-19/virology , Child , Child, Preschool , Cross-Sectional Studies , Disease Outbreaks/statistics & numerical data , Female , Humans , Infant , Infant, Newborn , Insurance, Health/statistics & numerical data , Male , Middle Aged , Ontario/epidemiology , Retrospective Studies , SARS-CoV-2/isolation & purification , Young Adult
16.
JAMA Netw Open ; 4(3): e212618, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1146714

ABSTRACT

Importance: This study assesses the role of telehealth in the delivery of care at the start of the COVID-19 pandemic. Objectives: To document patterns and costs of ambulatory care in the US before and during the initial stage of the pandemic and to assess how patient, practitioner, community, and COVID-19-related factors are associated with telehealth adoption. Design, Setting, and Participants: This is a cohort study of working-age persons continuously enrolled in private health plans from March 2019 through June 2020. The comparison periods were March to June in 2019 and 2020. Claims data files were provided by Blue Health Intelligence, an independent licensee of the Blue Cross and Blue Shield Association. Data analysis was performed from June to October 2020. Main Outcomes and Measures: Ambulatory encounters (in-person and telehealth) and allowed charges, stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code. Results: A total of 36 568 010 individuals (mean [SD] age, 35.71 [18.77] years; 18 466 557 female individuals [50.5%]) were included in the analysis. In-person contacts decreased by 37% (from 1.63 to 1.02 contacts per enrollee) from 2019 to 2020. During 2020, telehealth visits (0.32 visit per person) accounted for 23.6% of all interactions compared with 0.3% of contacts in 2019. When these virtual contacts were added, the overall COVID-19 era patient and practitioner visit rate was 18% lower than that in 2019 (1.34 vs 1.64 visits per person). Behavioral health encounters were far more likely than medical contacts to take place virtually (46.1% vs 22.1%). COVID-19 prevalence in an area was associated with higher use of telehealth; patients from areas within the top quintile of COVID-19 prevalence during the week of their encounter were 1.34 times more likely to have a telehealth visit compared with those in the lowest quintile (the reference category). Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates). Per enrollee medical care costs decreased by 15% between 2019 and 2020 (from $358.32 to $306.04 per person per month). During 2020, those with 1 or more COVID-19-related service (1 470 721 members) had more than 3 times the medical costs ($1701 vs $544 per member per month) than those without COVID-19-related services. Persons with 1 or more telehealth visits in 2020 had considerably higher costs than persons having only in-person ambulatory contacts ($2214.10 vs $1337.78 for the COVID-19-related subgroup and $735.87 vs $456.41 for the non-COVID-19 subgroup). Conclusions and Relevance: This study of a large cohort of patients enrolled in US health plans documented patterns of care at the onset of COVID-19. The findings are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the pandemic and afterward.


Subject(s)
Ambulatory Care , COVID-19 , Practice Patterns, Physicians' , Telemedicine , Adult , Ambulatory Care/economics , Ambulatory Care/methods , Ambulatory Care/statistics & numerical data , COVID-19/epidemiology , COVID-19/prevention & control , Cohort Studies , Costs and Cost Analysis , Female , Humans , Infection Control/methods , Insurance, Health/statistics & numerical data , Male , Organizational Innovation/economics , Practice Patterns, Physicians'/economics , Practice Patterns, Physicians'/organization & administration , Practice Patterns, Physicians'/statistics & numerical data , SARS-CoV-2 , Telemedicine/economics , Telemedicine/organization & administration , Telemedicine/statistics & numerical data , United States/epidemiology
17.
Public Health Rep ; 137(2): 301-309, 2022.
Article in English | MEDLINE | ID: covidwho-1125372

ABSTRACT

OBJECTIVES: Essential workers in the United States need access to health care services for preventive care and for diagnosis and treatment of illnesses (coronavirus disease 2019 [COVID-19] or other infectious or chronic diseases) to remain healthy and continue working during a pandemic. This study evaluated access to health care services among selected essential workers. METHODS: We used the most recent data from the Behavioral Risk Factor Surveillance System, 2017-2018, to estimate the prevalence of 4 measures of health care access (having health insurance, being able to afford to see a doctor when needed, having a personal health care provider, and having a routine checkup in the past year) by broad and detailed occupation group among 189 208 adults aged 18-64. RESULTS: Of all occupations studied, workers in farming, fishing, and forestry occupations were most likely to have no health insurance (46.4%). Personal care aides were most likely to have been unable to see a doctor when needed because of cost (29.3%). Construction laborers were most likely to lack a personal health care provider (51.1%) and to have not had a routine physical checkup in the past year (50.6%). Compared with workers in general, workers in 3 broad occupation groups-food preparation and serving; building and grounds cleaning and maintenance; and construction trades-had significantly lower levels of health care access for all 4 measures. CONCLUSION: Lack of health insurance and underinsurance were common among subsets of essential workers. Limited access to health care might decrease essential workers' access to medical testing and needed care and hinder their ability to address underlying conditions, thereby increasing their risk of severe outcomes from some infectious diseases, such as COVID-19. Improving access to health care for all workers, including essential workers, is critical to ensure workers' health and workforce stability.


Subject(s)
Health Services Accessibility , Occupations/classification , Workforce/classification , Adult , Behavioral Risk Factor Surveillance System , Humans , Insurance, Health/statistics & numerical data , Middle Aged , Occupations/statistics & numerical data , United States , Workforce/statistics & numerical data , Young Adult
18.
Epidemiol Health ; 43: e2021007, 2021.
Article in English | MEDLINE | ID: covidwho-1094290

ABSTRACT

OBJECTIVES: This study explored socioeconomic disparities in Korea using health insurance type as a proxy during the ongoing coronavirus disease 2019 (COVID-19) pandemic. METHODS: We conducted a retrospective cohort study using Korea's nationwide healthcare database, which contained all individuals who received a diagnostic test for COVID-19 (n=232,390) as of May 15, 2020. We classified our cohort by health insurance type into beneficiaries of the National Health Insurance (NHI) or Medicaid programs. Our study outcomes were infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19-related outcomes, a composite of all-cause death, intensive care unit admission, and mechanical ventilation use. We estimated age-, sex-, and Charlson comorbidity index score-adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using a multivariable logistic regression analysis. RESULTS: Of the 218,070 NHI and 14,320 Medicaid beneficiaries who received COVID-19 tests, 7,777 and 738 tested positive, respectively. The Medicaid beneficiaries were older (mean age, 57.5 vs. 47.8 years), more likely to be males (47.2 vs. 40.2%), and had a higher comorbidity burden (mean CCI, 2.0 vs. 1.7) than NHI beneficiaries. Compared to NHI beneficiaries, Medicaid beneficiaries had a 22% increased risk of SARS-CoV-2 infection (aOR, 1.22; 95% CI, 1.09 to 1.38), but had no significantly elevated risk of COVID-19-related outcomes (aOR 1.10, 95% CI 0.77 to 1.57); the individual events of the composite outcome yielded similar findings. CONCLUSIONS: As socioeconomic factors, with health insurance as a proxy, could serve as determinants during the current pandemic, pre-emptive support is needed for high-risk groups to slow its spread.


Subject(s)
COVID-19 Testing/statistics & numerical data , COVID-19/diagnosis , Healthcare Disparities/economics , Insurance, Health/statistics & numerical data , Pandemics , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , Databases, Factual , Female , Humans , Insurance Claim Review , Male , Middle Aged , Republic of Korea/epidemiology , Retrospective Studies , Socioeconomic Factors , Young Adult
19.
J Intensive Care Med ; 36(3): 271-276, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1067075

ABSTRACT

BACKGROUND: The United States currently has more confirmed cases of COVID-19 than any other country in the world. Given the variability in COVID-19 testing and prevention capability, identifying factors associated with mortality in patients requiring mechanical ventilation is critical. This study aimed to identify which demographics, comorbidities, markers of disease progression, and interventions are associated with 30-day mortality in COVID-19 patients requiring mechanical ventilation. METHODS: Adult patients with a confirmed diagnosis of COVID-19 admitted to one of the health system's intensive care units and requiring mechanical ventilation between March 9, 2020 and April 1, 2020, were included in this observational cohort study. We used Chi-Square and Mann-Whitney U tests to compare patient characteristics between deceased and living patients and multiple logistic regression to assess the association between independent variables and the likelihood of 30-day mortality. RESULTS: We included 85 patients, of which 20 died (23.5%) within 30 days of the first hospital admission. In the univariate analysis, deceased patients were more likely ≥60 years of age (p < 0.001), non-Hispanic (p = 0.026), and diagnosed with a solid malignant tumor (p = 0.003). Insurance status also differed between survivors and non-survivors (p = 0.019). Age ≥60 and malignancy had a 9.5-fold (95% confidence interval 1.4-62.3, p = 0.020) and 5.8-fold higher odds ratio (95% confidence interval 1.2-28.4, p = 0.032) for 30-day mortality after adjusted analysis using multivariable logistic regression, while other independent variables were no longer significant. CONCLUSIONS: In our observational cohort study of 85 mechanically ventilated COVID-19 patients, age, and a diagnosis of a solid malignant tumor were associated with 30-day mortality. Our findings validate concerns for the survival of elderly and cancer patients in the face of the COVID-19 pandemic in the United States, where testing capabilities and preventative measures have been inconsistent. Preventative efforts geared to patients at risk for intensive care unit mortality from COVID-19 should be explored.


Subject(s)
COVID-19/mortality , Insurance, Health/statistics & numerical data , Neoplasms/epidemiology , Respiration, Artificial , African Americans/statistics & numerical data , Age Factors , Aged , COVID-19/epidemiology , COVID-19/therapy , Cohort Studies , Comorbidity , Female , Humans , Logistic Models , Male , Managed Care Programs/statistics & numerical data , Medicaid/statistics & numerical data , Medicare/statistics & numerical data , Middle Aged , Mortality , Multivariate Analysis , Odds Ratio , Risk Factors , SARS-CoV-2 , United States/epidemiology , /statistics & numerical data
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