Recovery of outpatient imaging utilization during the first wave of the COVID-19 pandemic.

OBJECTIVE: During the COVID-19 pandemic, Radiology practices experienced marked reductions in outpatient imaging volumes. Our purpose was to evaluate the timing, rate, and degree of recovery of outpatient imaging during the first wave of the pandemic. We also sought to ascertain the relationship of outpatient imaging recovery to the incidence of COVID-19 cases. METHODS: Retrospective study of outpatient imaging volumes in a large healthcare system was performed from January 1, 2019-August 25, 2020. Dataset was split to compare Pre-COVID (weeks 1-9), Peak-COVID (weeks 10-15) and Recovery-COVID (weeks 16-34) periods. Chi-square and Independent-samples t-tests compared weekly outpatient imaging volumes in 2020 and 2019. Regression analyses assessed the rate of decline and recovery in Peak-COVID and Recovery-COVID periods, respectively. RESULTS: Total outpatient imaging volume in 2020 (weeks 1-34) was 327,738 exams, compared to 440,314 in 2019. The 2020 mean weekly imaging volumes were significantly decreased in Peak-COVID (p = 0.0148) and Recovery-COVID (p = 0.0003) periods. Mean weekly decline rate was -2580 exams/week and recovery rate was +617 exams/week. The 2020 Post-COVID (weeks 10-34) period had an average decrease of 36.5% (4813.4/13,178.6) imaging exams/week and total estimated decrease of 120,335 exams. Significant inverse correlation (-0.8338, p < 0.0001) was seen between positive-tested COVID-19 cases and imaging utilization with 1-week lag during Post-COVID (weeks 10-34) period. CONCLUSION: Recovery of outpatient imaging volume during the first wave of COVID-19 pandemic showed a gradual return to pre-pandemic levels over the course of 3-4 months. The rate of imaging utilization was inversely associated with new positive-tested COVID-19 cases with a 1-week lag.

Sociodemographic predictors and transportation patterns of COVID-19 infection and mortality.

BACKGROUND: The United States Centers for Disease Control and Prevention (CDC)-sanctioned prevention strategies have included frequent handwashing with soap and water, covering the mouth and nose with a mask when around others, cleaning and disinfecting maintaining a distance of at least 6 feet from others, etc. Although many of these recommendations are based upon observation and past infection control practices, it is important to combine and explore public data sets to identify predictors of infection, morbidity and mortality to develop more finely honed interventions, based on sociodemographic factors. METHOD: Cross-sectional study of both states in the US and counties in NY state. RESULTS: Population density was found to be significantly associated with state-level coronavirus infection and mortality rate (b = 0.49, 95% confidence interval (CI): 0.34, 0.64, P < .0001). States that have lower socioeconomic status, lower mean age and denser populations are associated with higher incidence rates. In regard to NY state, counties with a higher percentage of minority residents had higher COVID-19 mortality rates (b = 2.61, 95% CI: 0.36, 4.87, P = 0.023). Larger population cohorts were associated with lower COVID-19 mortality rates after adjusting for other variables in the model (b = -1.39, 95% CI: -2.07, -0.71, P < 0.001). Population density was not significantly associated with COVID-19 mortality rates after adjustment across counties in the NY state. Public ridership was not indicative of cases or mortality across states in the USA; however, it is a significant factor associated with incidence (but not mortality) in NY counties. CONCLUSION: Population density was the only significant predictor of mortality across states in the USA. Lower mean age, lower median household incomes and more densely populated states were at higher risk of COVID-19 infection. Population density was not found to be a significant independent variable compared to minority status and socioeconomic factors in the New York epicenter. Meanwhile, public ridership was found to be a significant factor associated with incidence in New York counties.

BMI as a Risk Factor for Clinical Outcomes in Patients Hospitalized with COVID-19 in New York.

OBJECTIVE: This study examined the association between BMI and clinical outcomes among patients with coronavirus disease 2019 (COVID-19) infection. METHODS: A total of 10,861 patients with COVID-19 infection who were admitted to the Northwell Health system hospitals between March 1, 2020, and April 27, 2020, were included in this study. BMI was classified as underweight, normal weight, overweight, and obesity classes I, II, and III. Primary outcomes were invasive mechanical ventilation (IMV) and death. RESULTS: A total of 243 (2.2%) patients were underweight, 2,507 (23.1%) were normal weight, 4,021 (37.0%) had overweight, 2,345 (21.6%) had obesity class I, 990 (9.1%) had obesity class II, and 755 (7.0%) had obesity class III. Patients who had overweight (odds ratio [OR] = 1.27 [95% CI: 1.11-1.46]), obesity class I (OR = 1.48 [95% CI: 1.27-1.72]), obesity class II (OR = 1.89 [95% CI: 1.56-2.28]), and obesity class III (OR = 2.31 [95% CI: 1.88-2.85]) had an increased risk of requiring IMV. Underweight and obesity classes II and III were statistically associated with death (OR = 1.44 [95% CI: 1.08-1.92]; OR = 1.25 [95% CI: 1.03-1.52]; OR = 1.61 [95% CI: 1.30-2.00], respectively). Among patients who were on IMV, BMI was not associated with inpatient deaths. CONCLUSIONS: Patients who are underweight or who have obesity are at risk for mechanical ventilation and death, suggesting that pulmonary complications (indicated by IMV) are a significant contributor for poor outcomes in COVID-19 infection.

Imaging Utilization During the COVID-19 Pandemic Highlights Socioeconomic Health Disparities.

OBJECTIVE: The devastating impact from the coronavirus disease 2019 (COVID-19) pandemic highlights long-standing socioeconomic health disparities in the United States. The purpose of this study was to evaluate socioeconomic factors related to imaging utilization during the pandemic. METHODS: Retrospective review of consecutive imaging examinations was performed from January 1, 2019, to May 31, 2020, across all service locations (inpatient, emergency, outpatient). Patient level data were provided for socioeconomic factors (age, sex, race, insurance status, residential zip code). Residential zip code was used to assign median income level. The weekly total imaging volumes in 2020 and 2019 were plotted from January 1 to May 31 stratified by socioeconomic factors to demonstrate the trends during the pre-COVID-19 (January 1 to February 28) and post-COVID-19 (March 1 to May 31) periods. Independent-samples t tests were used to statistically compare the 2020 and 2019 socioeconomic groups. RESULTS: Compared with 2019, the 2020 total imaging volume in the post-COVID-19 period revealed statistically significant increased imaging utilization in patients who are aged 60 to 79 years (P = .0025), are male (P < .0001), are non-White (Black, Asian, other, unknown; P < .05), are covered by Medicaid or uninsured (P < .05), and have income below $80,000 (P < .05). However, there was a significant decrease in imaging utilization among patients who are younger (<18 years old; P < .0001), are female (P < .0001), are White (P = .0003), are commercially insured (P < .0001), and have income ≥$80,000 (P < .05). DISCUSSION: During the pandemic, there was a significant change in imaging utilization varying by socioeconomic factors, consistent with the known health disparities observed in the prevalence of COVID-19. These findings could have significant implications in directing utilization of resources during the pandemic and subsequent recovery.

Abdominal pelvic CT findings compared between COVID-19 positive and COVID-19 negative patients in the emergency department setting.

PURPOSE: Manifestations of COVID-19 are primarily respiratory based, however, gastrointestinal symptoms are now recognized as an important component of the disease. The purpose of this study is to evaluate differences in abdominal pelvic CT findings in the emergency department by COVID-19 test result. METHODS: This retrospective study identified patients tested by PCR for COVID-19 infection who underwent abdominal pelvic CT scan in the ED across an academic health system from March 15 to April 15, 2020. Radiology reports were reviewed for the presence of ground glass opacity in the lungs and acute abdominal pathology. A subset of patients with acute abdominal pathology were identified with inflammatory pathology in organs with high ACE2 receptor expression including bowel, pancreas, urinary bladder, and kidney. CT findings for COVID positive versus negative patients were compared with Chi-square test. RESULTS: 597 patients tested by PCR for COVID-19 infection underwent abdominal pelvic CT scan, 44% were COVID-19 positive. COVID-19 positive patients demonstrated significantly more ground glass opacity at the lung bases, 65.1%, (222/341) versus 12.4% (33/266), p < 0.001), and significantly less acute abdominal findings, 23.8% (81/341) versus 45.5% (121/266), p ≤ 0.001). When abdominal pathology was present, COVID-19 positive patients had higher rate of inflammatory pathology 58% (47/81) versus 29.8% (36/121). CONCLUSIONS: In patients undergoing abdominopelvic CT from the ED, COVID-19 positive patients are more likely to have ground glass opacities at the lung bases and less likely to have acute abdominal pathology compared with COVID-19 negative patients. Further, COVID-19 positive patients are more likely to have inflammation of organs with high expression of ACE2 receptors than other types of acute abdominal pathology.

Clinical Mortality Review in a Large COVID-19 Cohort.

BACKGROUND: Northwell Health (Northwell), an integrated health system in New York, treated more than 15000 inpatients with coronavirus disease (COVID-19) at the US epicenter of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We describe the demographic characteristics of COVID-19 mortalities, observation of frequent rapid response teams (RRT)/cardiac arrest (CA) calls for non-intensive care unit (ICU) patients, and factors that contributed to RRT/CA calls. METHODS: A team of registered nurses reviewed medical records of inpatients who tested positive for SARS-CoV-2 via polymerase chain reaction (PCR) before or on admission and died between March 13 (first Northwell inpatient expiration) and April 30, 2020 at 15 Northwell hospitals. Findings for these patients were abstracted into a database and statistically analyzed. FINDINGS: Of 2634 COVID-19 mortalities, 56.1% had oxygen saturation levels greater than or equal to 90% on presentation and required no respiratory support. At least one RRT/CA was called on 42.2% of patients at a non-ICU level of care. Before the RRT/CA call, the most recent oxygen saturation levels for 76.6% of non-ICU patients were at least 90%. At the time RRT/CA was called, 43.1% had an oxygen saturation less than 80%. INTERPRETATION: This study represents one of the largest cohorts of reviewed mortalities that also captures data in non-structured fields. Approximately 50% of deaths occurred at a non-ICU level of care, despite admission to the appropriate care setting with normal staffing. The data imply a sudden, unexpected deterioration in respiratory status requiring RRT/CA in a large number of non-ICU patients. Patients admitted to a non-ICU level of care suffer rapid clinical deterioration, often with a sudden decrease in oxygen saturation. These patients could benefit from additional monitoring (eg, continuous central oxygenation saturation), although this approach warrants further study.

Cerebrovascular Complications of COVID-19.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) evolved quickly into a global pandemic with myriad systemic complications, including stroke. We report the largest case series to date of cerebrovascular complications of COVID-19 and compare with stroke patients without infection. METHODS: Retrospective case series of COVID-19 patients with imaging-confirmed stroke, treated at 11 hospitals in New York, between March 14 and April 26, 2020. Demographic, clinical, laboratory, imaging, and outcome data were collected, and cases were compared with date-matched controls without COVID-19 from 1 year prior. RESULTS: Eighty-six COVID-19-positive stroke cases were identified (mean age, 67.4 years; 44.2% women). Ischemic stroke (83.7%) and nonfocal neurological presentations (67.4%) predominated, commonly involving multivascular distributions (45.8%) with associated hemorrhage (20.8%). Compared with controls (n=499), COVID-19 was associated with in-hospital stroke onset (47.7% versus 5.0%; P<0.001), mortality (29.1% versus 9.0%; P<0.001), and Black/multiracial race (58.1% versus 36.9%; P=0.001). COVID-19 was the strongest independent risk factor for in-hospital stroke (odds ratio, 20.9 [95% CI, 10.4-42.2]; P<0.001), whereas COVID-19, older age, and intracranial hemorrhage independently predicted mortality. CONCLUSIONS: COVID-19 is an independent risk factor for stroke in hospitalized patients and mortality, and stroke presentations are frequently atypical.

Coronavirus Disease 2019 (COVID-19) Pandemic Shifts Inpatient Imaging Utilization.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on imaging utilization across practice settings. The purpose of this study was to quantify the change in the composition of inpatient imaging volumes for modality types and Current Procedural Terminology-coded groups during the COVID-19 pandemic. METHODS: A retrospective study of inpatient imaging volumes in a large health care system was performed, analyzing weekly imaging volumes by modality types (radiography, CT, MRI, ultrasound, interventional radiology, nuclear medicine) in years 2020 and 2019. The data set was split to compare pre-COVID-19 (weeks 1-9) and post-COVID-19 (weeks 10-16) periods. Further subanalyses compared early post-COVID-19 (weeks 10-13) and late post-COVID-19 (weeks 14-16) periods. Statistical comparisons were performed using χ2 and independent-samples t tests. RESULTS: Compared with 2019, total inpatient imaging volume in 2020 post-COVID-19, early and late post-COVID-19 periods, declined by 13.6% (from 78,902 to 68,168), 16.6% (from 45,221 to 37,732), and 9.6% (from 33,681 to 30,436), respectively. By week 16, inpatient imaging volume rebounded and was only down 4.2% (from 11,003 to 10,546). However, a statistically significant shift (P < .0001) in the 2020 composition mix was observed largely comprised of radiography (74.3%), followed by CT (12.7%), ultrasound (8%), MRI (2.4%), interventional radiology (2.3%), and nuclear medicine (0.4%). Although the vast majority of imaging studies declined, few Current Procedural Terminology-coded groups showed increased trends in imaging volumes in the late post-COVID-19 period, including CT angiography chest, radiography chest, and ultrasound venous duplex. DISCUSSION: During the COVID-19 pandemic, we observed a decrease in inpatient imaging volumes accompanied by a shift away from cross-sectional imaging toward radiography. These findings could have significant implications in planning for a potential resurgence.