School-Based Telemedicine and Reduced Avoidable Emergency Care Among Rural Pediatric Patients.

Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.

An equity-focused approach to improving access to COVID-19 vaccination using mobile health clinics.

This article describes the implementation of an equity-focused strategy to increase the uptake of COVID-19 vaccination among communities of color and in traditionally underserved geographic areas using mobile health clinics (MHCs). The MHC Vaccination Program was implemented through a large integrated healthcare system in North Carolina using a grassroots development and engagement strategy along with a robust model for data-informed decision support to prioritize vulnerable communities. Several valuable lessons from this work can replicated for future outreach initiatives and community-based programming: •Health systems can no longer operate under the assumption that community members will come to them, particularly those experiencing compounding social and economic challenges. The MHC model had to be a proactive outreach to community members, rather than a responsive delivery mechanism. •Barriers to access included financial, legal, and logistical challenges, in addition to mistrust among historically underserved and marginalized communities. •A MHC model can be adaptable and responsive to data-informed decision-making approaches for targeted service delivery. •A MHC model is not a one-dimensional solution to access, but part of a broader strategy to create diverse points of entry into the healthcare system that fall within the rhythm of life of community members.

Evaluating Racial/Ethnic Differences in Care Escalation Among COVID-19 Patients in a Home-Based Hospital.

The novel coronavirus disease 2019 (COVID-19) has infected over 414 million people worldwide with 5.8 million deaths, as of February 2022. Telemedicine-based interventions to expand healthcare systems' capacity and reduce infection risk have rapidly increased during the pandemic, despite concerns regarding equitable access. Atrium Health Hospital at Home (AH-HaH) is a home-based program that provides advanced, hospital-level medical care and monitoring for patients who would otherwise be hospitalized in a traditional setting. Our retrospective cohort study of positive COVID-19 patients who were admitted to AH-HaH aims to investigate whether the rate of care escalation from AH-HaH to traditional hospitalization differed based on patients' racial/ethnic backgrounds. Logistic regression was used to examine the association between care escalation within 14 days from index AH-HaH admission and race/ethnicity. We found approximately one in five patients receiving care for COVID-19 in AH-HaH required care escalation within 14 days. Odds of care escalation were not significantly different for Hispanic or non-Hispanic Blacks compared to non-Hispanic Whites. However, secondary analyses showed that both Hispanic and non-Hispanic Black patients were younger and with fewer comorbidities than non-Hispanic Whites. The study highlights the need for new care models to vigilantly monitor for disparities, so that timely and tailored adaptations can be implemented for vulnerable populations.

Disparities in Level of Care and Outcomes Among Patients with COVID-19: Associations Between Race/Ethnicity, Social Determinants of Health and Virtual Hospitalization, Inpatient Hospitalization, Intensive Care, and Mortality.

OBJECTIVE: To examine the role of race/ethnicity and social determinants of health on COVID-19 care and outcomes for patients within a healthcare system that provided virtual hospital care. METHODS: This retrospective cohort study included 12,956 adults who received care for COVID-19 within an integrated healthcare system between 3/1/2020 and 8/31/2020. Multinomial models were used to examine associations between race/ethnicity, insurance, neighborhood deprivation measured by Area Deprivation Index (ADI), and outcomes of interest. Outcomes included (1) highest level of care: virtual observation (VOU), virtual hospitalization (VACU), or inpatient hospitalization; (2) intensive care (ICU); and (3) all-cause 30-day mortality. RESULTS: Patients were 41.8% White, 27.2% Black, and 31.0% Hispanic. Compared to White patients, Black patients had 1.86 higher odds of VACU admission and 1.43 higher odds of inpatient hospitalization (vs. VOU). Hispanic patients had 1.24 higher odds of inpatient hospitalization (vs. VOU). In models stratified by race/ethnicity, Hispanic and Black patients had higher odds of inpatient hospitalization (vs. VOU) if Medicaid insured compared to commercially insured. Hispanic patients living in the most deprived neighborhood had higher odds of inpatient hospitalization, compared to those in the least deprived neighborhood. Black and Hispanic patients had higher odds of ICU admission and 30-day mortality after adjustment for other social determinants. CONCLUSIONS: Insurance and ADI were associated with COVID-19 outcomes; however, associations varied by race/ethnicity. Racial/ethnic disparities in outcomes are not fully explained by measured social determinants of health, highlighting the need for further investigation into systemic causes of inequities in COVID-19 outcomes.

A multimodal intervention to decrease inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated healthcare system.

OBJECTIVE: To evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years. DESIGN: Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016-October 2017 and May 2018-March 2020. SETTING: The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region. PARTICIPANTS: Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate. METHODS: Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing. RESULTS: Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, -20.4%), internal medicine (-19.5%), pediatric medicine (-17.2%), and urgent care (-16.6%). CONCLUSIONS: A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.

Feasibility of At-Home Virological and Serological Testing for SARS-CoV-2 in Children.

Longitudinal virological and serological surveillance is essential for understanding severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) transmission among children but requires increased test capacity. We assessed the uptake of serial at-home testing in children (2-17 years) via mailed SARS-CoV-2 antibody and molecular tests. Completion rates demonstrated the feasibility and sustainability of at-home testing across age groups.

Reducing the rates of household transmission: The impact of COVID-19 vaccination in healthcare workers with a known household exposure.

OBJECTIVE: To determine the impact of COVID-19 vaccination oninfectionratesin healthcare workers(HCWs) with a householdexposure. METHODS: Retrospectivecohort study8410HCWs(400 fullyvaccinated, 1645partially vaccinated,6365 unvaccinated),employed by a large integrated healthcare system in the southeastern United States,tested for SARS-CoV-2between January 1 and February 26, 2021. RESULTS: Benefit of vaccination persisted even with household exposure, with unvaccinated HCWs being 3.7 to 7.7 times more likely to be infected than partially or fully vaccinated HCW with positive household contacts respectively (partial OR = 3.73, 95% CI 2.17 - 6.47; full OR = 7.67, CI 2.75 - 21.35). Whereas 89.4% of unvaccinated COVID-positive HCWs with known household exposures were symptomatic, 50% of fully vaccinated HCWs had symptoms, reducing risk of secondary spread from and between HCWs. CONCLUSIONS: COVID-19vaccinationprovided protection against infection evenamongst healthcare workerswithclose household contact,and after adjusting for community prevalence.

Diversification of COVID-19 Testing Resources to Decrease Racial/Ethnic Disparities: Comparative Use of Adaptive Approaches to Community Testing Across an Integrated Healthcare System.

Background: Access to SARS-CoV-2 testing is a crucial component of early identification and disease containment. Racial and ethnic health disparities exist related to testing utilization. To optimize testing with limited resources, Atrium Health developed free-standing and roving testing centers outside of the traditional clinical settings in hopes of meeting the needs of a diverse urban community. The objective of this study is to evaluate differences in testing site utilization based on demographic factors, particularly race/ethnicity. Methods:A cohort study of patients tested for COVID-19 between March 10 and October 26, 2020, within the Atrium Health system. Results: 128,258 persons under investigation (PUIs) were tested across our health system, including 25,434 patients at our Mobile Integrated Health (previously called Community Paramedicine) drive-thru testing sites and community roving testing units. PUIs were on average 47 years old (SD = 17.7); approximately half were female and White/Caucasian. Drive-thru testing sites were utilized proportionally more by non-Hispanic Whites and African Americans, and less by Hispanic PUIs. Roving testing units were used significantly more by younger PUIs, Hispanics, and PUIs of other races/ethnicities. Conclusions: Diversification in testing site locations optimized testing resources, allowed for significant reduction in the burden of patient volumes, and avoided alteration of workflow in our urgent care facilities and Emergency Departments. Additionally, roving testing units may help to decrease racial/ethnic disparities in access to COVID-19 testing. Our results highlight the importance of offering a variety of testing modalities to reach different populations.

Racial/Ethnic Disparities in Health Care Setting Choice for Adults Seeking Severe Acute Respiratory Syndrome Coronavirus 2 Testing.

OBJECTIVES: Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates. METHODS: We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system. RESULTS: Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP. CONCLUSIONS: Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.

Modeling COVID-19 Latent Prevalence to Assess a Public Health Intervention at a State and Regional Scale: Retrospective Cohort Study.

BACKGROUND: Emergence of the coronavirus disease (COVID-19) caught the world off guard and unprepared, initiating a global pandemic. In the absence of evidence, individual communities had to take timely action to reduce the rate of disease spread and avoid overburdening their health care systems. Although a few predictive models have been published to guide these decisions, most have not taken into account spatial differences and have included assumptions that do not match the local realities. Access to reliable information that is adapted to local context is critical for policy makers to make informed decisions during a rapidly evolving pandemic. OBJECTIVE: The goal of this study was to develop an adapted susceptible-infected-removed (SIR) model to predict the trajectory of the COVID-19 pandemic in North Carolina and the Charlotte Metropolitan Region, and to incorporate the effect of a public health intervention to reduce disease spread while accounting for unique regional features and imperfect detection. METHODS: Three SIR models were fit to infection prevalence data from North Carolina and the greater Charlotte Region and then rigorously compared. One of these models (SIR-int) accounted for a stay-at-home intervention and imperfect detection of COVID-19 cases. We computed longitudinal total estimates of the susceptible, infected, and removed compartments of both populations, along with other pandemic characteristics such as the basic reproduction number. RESULTS: Prior to March 26, disease spread was rapid at the pandemic onset with the Charlotte Region doubling time of 2.56 days (95% CI 2.11-3.25) and in North Carolina 2.94 days (95% CI 2.33-4.00). Subsequently, disease spread significantly slowed with doubling times increased in the Charlotte Region to 4.70 days (95% CI 3.77-6.22) and in North Carolina to 4.01 days (95% CI 3.43-4.83). Reflecting spatial differences, this deceleration favored the greater Charlotte Region compared to North Carolina as a whole. A comparison of the efficacy of intervention, defined as 1 - the hazard ratio of infection, gave 0.25 for North Carolina and 0.43 for the Charlotte Region. In addition, early in the pandemic, the initial basic SIR model had good fit to the data; however, as the pandemic and local conditions evolved, the SIR-int model emerged as the model with better fit. CONCLUSIONS: Using local data and continuous attention to model adaptation, our findings have enabled policy makers, public health officials, and health systems to proactively plan capacity and evaluate the impact of a public health intervention. Our SIR-int model for estimated latent prevalence was reasonably flexible, highly accurate, and demonstrated efficacy of a stay-at-home order at both the state and regional level. Our results highlight the importance of incorporating local context into pandemic forecast modeling, as well as the need to remain vigilant and informed by the data as we enter into a critical period of the outbreak.

Relational Uncertainty and Cortisol Responses to Hurtful and Supportive Messages from a Dating Partner.

This paper evaluates theoretical claims linking relational uncertainty about a relationship partner to experiences of stress during interactions with that partner. Two observational studies were conducted to evaluate the association between relational uncertainty and salivary cortisol in the context of hurtful and supportive interactions. In Study 1, participants (N = 89) engaged in a conversation about core traits or values with a partner, who was trained to be hurtful. In Study 2, participants (N = 89) received supportive messages after completing a series of stressful tasks and receiving negative performance feedback. As predicted, partner uncertainty was associated with greater cortisol reactivity to the hurtful interaction in Study 1. Contrary to expectations, Study 1 results also indicated that self uncertainty was associated with less cortisol reactivity, when self, partner, and relationship uncertainty were tested in the same model. Study 2 revealed that relational uncertainty dampened cortisol reactions to performing poorly on tasks while the partner observed. As predicted, Study 2 also found that partner uncertainty was associated with less cortisol recovery after the supportive interaction, but neither self nor relationship uncertainty was associated with rate of cortisol change during the recovery period.