Changes in Diagnostic and Demographic Characteristics of Patients Seeking Mental Health Care During the Early COVID-19 Pandemic in a Large, Community-Based Health Care System.

OBJECTIVE: The early COVID-19 pandemic resulted in great psychosocial disruption and stress, raising speculation that psychiatric disorders may worsen. This study aimed to identify patients vulnerable to worsening mental health during the COVID-19 pandemic. METHODS: This retrospective observational study used electronic health records from March 9 to May 31 in 2019 (n = 94,720) and 2020 (n = 94,589) in a large, community-based health care system. Percent change analysis compared variables standardized to the average patient population for the respective time periods. RESULTS: Compared to 2019, psychiatric visits increased significantly (P < .0001) in 2020, with the majority being telephone/video-based (+264%). Psychiatric care volume increased overall (7%), with the greatest increases in addiction (+42%), behavioral health in primary care (+17%), and adult psychiatry (+5%) clinics. While patients seeking care with preexisting psychiatric diagnoses were mainly stable (−2%), new patients declined (−42%). Visits for substance use (+51%), adjustment (+15%), anxiety (+12%), bipolar (+9%), and psychotic (+6%) disorder diagnoses, and for patients aged 18­25 years (+4%) and 26­39 years (+4%), increased. Child/adolescent and older adult patient visits decreased (−22.7% and −5.5%, respectively), and fewer patients identifying as White (−3.8%) or male (−5.0) or with depression (−3%) or disorders of childhood (−2%) sought care. CONCLUSIONS: The early COVID-19 pandemic was associated with dramatic changes in psychiatric care facilitated by a rapid telehealth care transition. Patient volume, demographic, and diagnostic changes may reflect comfort with telehealth or navigating the psychiatric care system. These data can inform health system resource management and guide future work examining how care delivery changes impact psychiatric care quality and access.

The effect of primary health care on tuberculosis in a nationwide cohort of 7·3 million Brazilian people: a quasi-experimental study.

BACKGROUND: Universal health coverage is one of the WHO End TB Strategy priority interventions and could be achieved-particularly in low-income and middle-income countries-through the expansion of primary health care. We evaluated the effects of one of the largest primary health-care programmes in the world, the Brazilian Family Health Strategy (FHS), on tuberculosis morbidity and mortality using a nationwide cohort of 7·3 million individuals over a 10-year study period. METHODS: We analysed individuals who entered the 100 Million Brazilians Cohort during the period Jan 1, 2004, to Dec 31, 2013, and compared residents in municipalities with no FHS coverage with residents in municipalities with full FHS coverage. We used a cohort design with multivariable Poisson regressions, adjusted for all relevant demographic and socioeconomic variables and weighted with inverse probability of treatment weighting, to estimate the effect of FHS on tuberculosis incidence, mortality, cure, and case fatality. We also performed a range of stratifications and sensitivity analyses. FINDINGS: FHS exposure was associated with lower tuberculosis incidence (rate ratio [RR] 0·78, 95% CI 0·72-0·84) and mortality (0·72, 0·55-0·94), and was positively associated with tuberculosis cure rates (1·04, 1·00-1·08). FHS was also associated with a decrease in tuberculosis case-fatality rates, although this was not statistically significant (RR 0·84, 95% CI 0·55-1·30). FHS associations were stronger among the poorest individuals for all the tuberculosis indicators. INTERPRETATION: Community-based primary health care could strongly reduce tuberculosis morbidity and mortality and decrease the unequal distribution of the tuberculosis burden in the most vulnerable populations. During the current marked rise in global poverty due to the COVID-19 pandemic, investments in primary health care could help protect against the expected increases in tuberculosis incidence worldwide and contribute to the attainment of the End TB Strategy goals. FUNDING: TB Modelling and Analysis Consortium (Bill & Melinda Gates Foundation), Wellcome Trust, and Brazilian Ministry of Health. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Community-Based Testing for SARS-CoV-2 - Chicago, Illinois, May-November 2020.

On May 13, 2020, Chicago established a free community-based testing (CBT) initiative for SARS-CoV-2, the virus that causes COVID-19, using reverse transcription-polymerase chain reaction (RT-PCR). The initiative focused on demographic groups and geographic areas that were underrepresented in testing by clinical providers and had experienced high COVID-19 incidence, including Hispanic persons and those who have been economically marginalized. To assess the CBT initiative, the Chicago Department of Public Health (CDPH) compared demographic characteristics, economic marginalization, and test positivity between persons tested at CBT sites and persons tested in all other testing settings in Chicago. During May 13-November 14, a total of 253,904 SARS-CoV-2 RT-PCR tests were conducted at CBT sites. Compared with those tested in all other testing settings in Chicago, persons tested at CBT sites were more likely to live in areas that are economically marginalized (38.6% versus 32.0%; p<0.001) and to be Hispanic (50.9% versus 20.7%; p<0.001). The cumulative percentage of positive test results at the CBT sites was higher than that at all other testing settings (11.1% versus 7.1%; p<0.001). These results demonstrate the ability of public health departments to establish community-based testing initiatives that reach communities with less access to testing in other settings and that experience disproportionately higher incidences of COVID-19.

Shifting psychosocial oncology care to telepsychology during the COVID-19 pandemic.

BACKGROUND: The novel coronavirus (COVID-19) rapidly shifted psychosocial services to telepsychology, including psychosocial oncology (PSO) practices. PSO providers work with patients undergoing treatment, experiencing treatment delays and/or immuno-suppression in the context of a global pandemic. There is evidence to support the acceptability of telepsychology among cancer patients and an emerging need for data to inform the design and provision of telepsychology PSO care during the pandemic and beyond. RESEARCH OBJECTIVES: This study examined engagement in telepsychology PSO care at an outpatient community cancer center. METHODS: The current study analyzed practice data from a PSO department from March 2020 through September 2020. The sample included 354 patients (91 established; 263 newly referred). Descriptive, correlational, and comparative analyses were conducted. RESULTS: Among established patients, 93% continued with telepsychology PSO care after the pandemic and 94% completed at least one telepsychology appointment. Among newly referred patients, 50.6% scheduled a telepsychology appointment, consistent with the scheduling rate for the proceeding calendar year (50%). Across patients scheduling telepsychology PSO appointments (N = 194), 68 initially engaged in phone-based services with 20 converting to video, for a total of 127 (76.5%) patients utilizing video-based PSO services. Common reasons for phone-based services included 'patient preference' (N = 14), 'lack of access' (N = 9), and 'technology barriers' (N = 8). During this timeframe, 18% had at least one no-show, which is significantly less than the preceding year (23%). Phone-based patients were significantly older (p =.007). A greater proportion of males engaged in phone-based services compared to females (p = .006). CONCLUSIONS: Telepsychology PSO engages new and existing patients during the COVID-19 pandemic. There may be an increased demand for services and increased utilization in the context of the pandemic and the availability of telepsychology. There are disparities and access issues that should be considered and addressed.

Obesity is a Major Risk Factor for Hospitalization in Community-Managed COVID-19 Pneumonia.

OBJECTIVE: We aimed to investigate whether the stratification of outpatients with coronavirus disease 2019 (COVID-19) pneumonia by body mass index (BMI) can help predict hospitalization and other severe outcomes. PATIENTS AND METHODS: We prospectively collected consecutive cases of community-managed COVID-19 pneumonia from March 1 to April 20, 2020, in the province of Bergamo and evaluated the association of overweight (25 kg/m2 ≤ BMI <30 kg/m2) and obesity (≥30 kg/m2) with time to hospitalization (primary end point), low-flow domiciliary oxygen need, noninvasive mechanical ventilation, intubation, and death due to COVID-19 (secondary end points) in this cohort. We analyzed the primary end point using multivariable Cox models. RESULTS: Of 338 patients included, 133 (39.4%) were overweight and 77 (22.8%) were obese. Age at diagnosis was younger in obese patients compared with those overweight or with normal weight (P<.001), whereas diabetes, dyslipidemia, and heart diseases were differently distributed among BMI categories. Azithromycin, hydroxychloroquine, and prednisolone use were similar between BMI categories (P>.05). Overall, 105 (31.1%) patients were hospitalized, and time to hospitalization was significantly shorter for obese vs over- or normal-weight patients (P<.001). In the final multivariable analysis, obese patients were more likely to require hospitalization than nonobese patients (hazard ratio, 5.83; 95% CI, 3.91 to 8.71). Results were similar in multiple sensitivity analyses. Low-flow domiciliary oxygen need, hospitalization with noninvasive mechanical ventilation, intubation, and death were significantly associated with obesity (P<.001). CONCLUSION: In patients with community-managed COVID-19 pneumonia, obesity is associated with a higher hospitalization risk and overall worse outcomes than for nonobese patients.

Change of Use in Community Services among Disabled Older Adults during COVID-19 in Japan.

During the COVID-19 pandemic, social interactions were restricted, including community services for disabled older adults. This study aimed to describe the change of use in community services related to long-term care insurance (LTCI) during the pandemic in Japan. A retrospective descriptive study was conducted using data collected via a cloud-based management support platform for older adult care provider "Kaipoke", by a private-sector company "SMS Co., Ltd.", in which care-managers of LTCI manage their office work. Data collection occurred from July 2019 to June 2020. Study subjects were LTCI service users aged 65 years and above. Subjects were living at home. We examined changes in the number of users of LTCI services before and after the COVID-19 pandemic began, using an interrupted time-series analysis. Results indicated that the use of outpatient services was reduced; however, home-visit services were maintained. The decrease in use was significant in the seven prefectures where the infection initially spread. There are concerns that older adults or surrounding caregivers can be affected by such changes in LTC service use. It is therefore necessary to implement sustainable measures from a long-term perspective and investigate their influence as part of future studies.

Impact of the COVID-19 pandemic on specialty community practices: an oncology perspective.

OBJECTIVES: Typically, a community-based specialty practice is prepared for a limited public health crisis that is driven by a natural disaster or a localized environment event. This article describes the unexpected impact that the coronavirus disease 2019 (COVID-19) pandemic has had on community-based specialty practices across the United States, especially oncology practices. STUDY DESIGN AND METHODS: We conducted an electronic national survey of community-based specialty practice administrators to determine the impact of COVID-19 on their practices and their ability to manage through a global pandemic. The 22-question survey focused on an initial observation period of March 15, 2020, to May 15, 2020, compared with a second period of May 16, 2020, to August 15, 2020. RESULTS: Oncology practices accounted for 46% of the 155 specialty practices that participated in the survey. Overall, 57% of respondents saw at least a 30% decline in total patient volume and/or financial impact during the initial observation period, compared with a 38% decline for the oncology practices. More than 70% of all practices experienced improvement after May 15, 2020, with at least 60% improving regardless of specialty. The initial decline was primarily driven by declines in new patient volume and procedures. Approximately 62% of practices anticipate a moderate-to-significant impact on patient outcomes over the next 12 months. The impact expected was slightly higher in retina and ophthalmology practices than oncology. CONCLUSIONS: Although unexpectedly impacted in delivering care for their patients, specialty practices generally and oncology practices especially have been resilient by leveraging federal funds and adopting operational enhancements.

The early impact of COVID-19 on mental health and community physical health services and their patients' mortality in Cambridgeshire and Peterborough, UK.

BACKGROUND: COVID-19 has affected social interaction and healthcare worldwide. METHODS: We examined changes in presentations and referrals to the primary provider of mental health and community health services in Cambridgeshire and Peterborough, UK (population ~0·86 million), plus service activity and deaths. We conducted interrupted time series analyses with respect to the time of UK "lockdown", which was shortly before the peak of COVID-19 infections in this area. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI). RESULTS: Referrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality was primarily in the over-70s. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity. CONCLUSIONS: COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. "Supply" changes may have reduced access to mental health services for some. "Demand" changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.