Covid-Induced Changes in Health Care Delivery - Can They Last?

Variation in telemedicine usage in gynecologic cancer: Are we widening or narrowing disparities?

INTRODUCTION

Telemedicine rapidly increased with the COVID-19 pandemic and could reduce cancer care disparities. Our objective was to evaluate sociodemographic (race, insurance), patient, health system, and cancer factors associated with telemedicine use in gynecologic cancers.

METHODS

We conducted a retrospective cohort study of patients with endometrial cancer and epithelial ovarian cancer with at least one visit from March 2020 to October 2021, using a real-world electronic health record-derived database, representing approximately 800 sites in US academic (14%) and community practices (86%). We used multivariable Poisson regression modeling to analyze the association of ever using telemedicine with patient, sociodemographic, health system, and cancer factors.

RESULTS

Of 3950 patients with ovarian cancer, 1119 (28.3%) had at least one telemedicine visit. Of 2510 patients with endometrial cancer, 720 (28.7%) had at least one telemedicine visit. At community cancer practices, patients who identified as Black were less likely to have a telemedicine visit than patients who identified as white in both ovarian and endometrial cancer (Ovarian: RR 0.62, 95% CI 0.42-0.9; Endometrial: RR 0.56, 95% CI 0.38-0.83). Patients in the Southeast, Midwest, West, and Puerto Rico were less likely to have telemedicine visits than patients in the Northeast. Uninsured patients were less likely, and patients with Medicare were more likely, to have one or more telemedicine visit than patients with private insurance.

CONCLUSIONS

In this national cohort study, <30% of patients ever used telemedicine, and significant racial and regional disparities existed in utilization. Telemedicine expansion efforts should include programs to improve equity in access to telemedicine.

Disembodied, dehumanised but safe and feasible: The social-spatial flow of a pandemic OSCE

INTRODUCTION

The Objective Structured Clinical Examination (OSCE) is a key feature of healthcare education assessment. Many aspects of the OSCE are well-investigated, but not so its sociomaterial assemblage. The Covid-19 pandemic provided a unique opportunity to (re)consider taken-for-granted OSCE practices. Drawing on Law's modes of ordering, our aim was to demonstrate the 'mangle of practice' between space and people; the spatialised and spatialising processes of an OSCE.

METHODS

We used a case study approach to critically examine a redesigned final year MBChB OSCE held during the pandemic. We used multiple sources of data to attune to human and non-human actors: OSCE documentation, photographs, field notes and semi-structured interviews with OSCE staff/organisers. Law's modes of ordering was used as an analytical lens to critically consider how people and things flowed through the adapted OSCE.

FINDINGS

The overarching ordering was the delivery of a 'pandemic safe' OSCE. This necessitated reordering of 'usual' process to deliver a socially distanced, safe flow of human and non-human actors through the assessment space. Each change had material and social 'knock on' effects. We identified three main interrelated orderings: Substituting technologies for bodies: Disembodied and dehumanised but feasible; Flow through space: Architectural affordances and one-way traffic; Barriers to flow: Time and technology.

DISCUSSION

Looking at the OSCE through a sociomaterial lens allows us to critically examine the OSCE's essential and complex processes and the restrictions and affordances of the spaces and props within the OSCE. In doing so, we open the possibility of considering alternative ways of doing OSCEs in the future. Moreover, conceptualising the OSCE as a living set of socially (human) and materially (nonhuman) enacted processes changes the social perception of the OSCE and highlights that an OSCE has agency on people, places and things.

Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure: A Randomized Clinical Trial

Importance

Heart failure (HF) affects more than 6 million adults in the US and more than 64 million adults worldwide, with 50% prevalence of depression. Patients and clinicians lack information on which interventions are more effective for depression in HF.

Objective

To compare the effectiveness of behavioral activation psychotherapy (BA) vs antidepressant medication management (MEDS) on patient-centered outcomes inpatients with HF and depression.

Design, Setting, and Participants

This pragmatic randomized comparative effectiveness trial was conducted from 2018 to 2022, including 1-year follow-up, at a not-for-profit academic health system serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participant included inpatients and outpatients diagnosed with HF and depression, and data were analyzed as intention-to-treat. Data were analyzed from 2022 to 2023.

Interventions

BA is an evidence-based manualized treatment for depression, promoting engagement in personalized pleasurable activities selected by patients. MEDS involves the use of an evidence-based collaborative care model with care managers providing coordination with patients, psychiatrists, and primary care physicians to only administer medications.

Main Outcomes and Measures

The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9). Secondary outcomes included physical and mental health-related quality of life (HRQOL), measured using the Short-Form 12-Item version 2 (SF-12); heart failure-specific HRQOL, measured using the Kansas City Cardiomyopathy Questionnaire; caregiver burden, measured with the Caregiver Burden Questionnaire for Heart Failure; emergency department visits; readmissions; days hospitalized; and mortality at 3, 6, and 12 months.

Results

A total of 416 patients (mean [SD] age, 60.71 [15.61] years; 243 [58.41%] male) were enrolled, with 208 patients randomized to BA and 208 patients randomized to MEDS. At baseline, mean (SD) PHQ-9 scores were 14.54 (3.45) in the BA group and 14.31 (3.60) in the MEDS group; both BA and MEDS recipients experienced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months (eg, mean [SD] score at 12 months: BA, 7.62 (5.73); P < .001; MEDS, 7.98 (6.06); P < .001; between-group P = .55). There was no statistically significant difference between BA and MEDS in the primary outcome of PHQ-9 at 6 months (mean [SD] score, 7.53 [5.74] vs 8.09 [6.06]; P = .88). BA recipients, compared with MEDS recipients, experienced small improvement in physical HRQOL at 6 months (mean [SD] SF-12 physical score: 38.82 [11.09] vs 37.12 [10.99]; P = .04), had fewer ED visits (3 months: 38% [95% CI, 14%-55%] reduction; P = .005; 6 months: 30% [95% CI, 14%-40%] reduction; P = .008; 12 months: 27% [95% CI, 15%-38%] reduction; P = .001), and spent fewer days hospitalized (3 months: 17% [95% CI, 8%-25%] reduction; P = .002; 6 months: 19% [95% CI, 13%-25%] reduction; P = .005; 12 months: 36% [95% CI, 32%-40%] reduction; P = .001).

Conclusions and Relevance

In this comparative effectiveness trial of BA and MEDS in patients with HF experiencing depression, both treatments significantly reduced depressive symptoms by nearly 50% with no statistically significant differences between treatments. BA recipients experienced better physical HRQOL, fewer ED visits, and fewer days hospitalized. The study findings suggested that patients with HF could be given the choice between BA or MEDS to ameliorate depression.

Trial Registration

ClinicalTrials.gov Identifier: NCT03688100.

Barriers to, and enablers of, paramedics responding to suspected or confirmed COVID-19 cases: An integrative review

BACKGROUND

The coronavirus pandemic (COVID-19) has focused attention on healthcare workers' concerns about working during a pandemic, yet research on the effect of the pandemic specifically on paramedics is lacking. This literature review aims to critically examine the current knowledge of paramedics' experience of barriers to, and enablers of, responding to suspected or confirmed COVID-19 cases.

METHODS

An integrative review was undertaken using articles found by a systematic search of four research databases. Inclusion criteria included paramedics or emergency medical technicians who had experience of barriers or enablers responding to patients during the coronavirus pandemic.

RESULTS

Nine articles met the inclusion and exclusion criteria. Barriers included communication and poor leadership, fear of infection to self and family, frequent changes in guidelines and inconsistencies across agencies, stress/burnout, and concerns with personal protective equipment. Enablers included job security, perceived social support, solidarity with other paramedics, and use of modern technologies for communication.

CONCLUSIONS

There are unique experiences of working during the COVID-19 pandemic in the prehospital environment. Particular challenges occurred with leadership, communication within the organisation and between agencies, and working in an unpredictable environment.

Delivering COVID self-tests through GetaKit.ca: Creating testing access during a pandemic

OBJECTIVES

To determine the real-world outcomes associated with using the GetaKit.ca website to distribute COVID self-tests to persons with risk factors, with a focus on facilitating testing for persons who are Black, Indigenous, or of Colour (BIPOC).

METHODS

GetaKit was an open cohort observational study to distribute free self-tests, starting with HIV self-testings and then adding the Lucira Check-It® COVID self-test. Participants would register on our website and complete a risk assessment, which would calculate their need for each type of testing.

RESULTS

Focusing on the COVID self-tests, from September to December 2021 (with targeted outreach in winter 2022), we distributed 6474 COVID self-tests to 3653 persons through 4161 unique orders, of which 47% came from BIPOC participants. Compared to white participants, BIPOC participants were more likely to have been a contact of COVID but less likely to be vaccinated. As well, 69% of results were reported back via the GetaKit.ca website, with 5.3% of these being positive. The positivity rate for our 3653 participants was 9.6%.

CONCLUSIONS

Delivering COVID self-tests via our website provided tests to BIPOC communities and yielded positivity rates that matched local COVID testing centres. This highlights the utility of such systems for delivering testing during future pandemics.

Analyzing the changing relationship between personal consumption and suicide mortality during COVID-19 pandemic in Japan, using governmental and personal consumption transaction databases

During the early stages of the ongoing COVID-19 pandemic, suicides did not increase in most countries/regions. Japan, however, was an exception to this, reporting increased numbers of female suicides with no changes in male suicide. To explore the trends of increasing suicides, the fluctuations of personal consumption (as an indicator of lifestyle) and standardized suicide death rate (SDR) disaggregated by age, sex, and prefecture, were determined using a linear mixed-effect model. Additionally, fixed effects of personal consumption on SDR during the pandemic were also analyzed using hierarchical linear regression models with robust standard errors. During the first wave of the pandemic, SDR for both sexes decreased slightly but increased during the second half of 2020. SDR of females younger than 70 years old and males younger than 40 years old continued to increase throughout 2021, whereas SDR for other ages of both sexes did not increase. Personal consumption expenditures on out-of-home recreations (travel agencies, pubs, and hotels) and internet/mobile communication expenses decreased, but expenditures on home-based recreations (contents distribution) increased during the pandemic. Increased expenditures on internet/mobile communication were related to increasing SDR of both sexes. Increasing expenditures on content distributions were related to increasing females' SDR without affecting that of males. Decreasing expenditures on pubs were related to increasing SDR of both sexes in the non-metropolitan region. These findings suggest that transformed individual lifestyles, extended time at home with a decreased outing for contact with others, contributed to the progression of isolation as a risk of suicide. Unexpectedly, increasing compensatory contact with others using internet/mobile communication enhanced isolation resulting in increased suicide risk.

Discontinuation of Health Interventions Among Brazilian Older Adults During the Covid-19 Pandemic: REMOBILIZE Study

The objective of this study was to analyze changes in access to health interventions during the pandemic among Brazilian older adults and to investigate the factors associated with social and health inequalities. We conducted an online survey with Brazilian adults aged 60  +  years between May and June 2020. A multidimensional questionnaire was used to investigate access to health interventions during the pandemic and associated factors. Of 1482 participants, 56.5% reported health care before the pandemic, and 36.4% discontinued it during the pandemic. The discontinuation rate was 64.4% (95% CI 61.1-67.6). Participants with higher educational level (nine or more years of education: OR 0.34; 95% CI 0.17-0.70) and higher income (eight or more times the minimum wage: OR 0.54; 95% CI 0.36-0.81) were associated with less probability of discontinuation. Presenting multimorbidity (OR: 1.42; 95% CI 1.06-1.90) and polypharmacy (OR: 0.61; 95% CI 0.46-0.81) were associated with discontinuity in health interventions. Our study showed that structural health inequities in access to health care shaped the rates of discontinuation in health care interventions during the COVID-19 pandemic. Strategic actions should be set up to actively monitor socially vulnerable older adults and strengthen community-based services to mitigate the discontinuation of health care interventions.

"Beyond Just a Supplement": Administrators' Visions for the Future of Virtual Primary Care Services

PURPOSE

The COVID-19 pandemic resulted in unprecedented adoption and implementation of virtual primary care services, and little is known about whether and how virtual care services will be provided after the pandemic ends. We aim to identify how administrators at health care organizations perceive the future of virtual primary care services.

METHODS

In March-April of 2021, we conducted semistructured qualitative phone interviews with administrators at 17 health care organizations that ranged from multi-state nonfederal delivery systems to single-site primary care practices. Organizations differed in size, structure, ownership, and geography. We explore how health care administrators anticipate their organization will offer virtual primary care services after the COVID-19 pandemic subsides.

RESULTS

All interviewed administrators expected virtual primary care services to persist after the pandemic. We categorize expected impact of future virtual services as limited (n = 4); targeted to a narrow set of clinical encounters (n = 5); and a major shift in primary care delivery (n = 8). The underlying motivation expressed by administrators for providing virtual care services was to remain financially stable and competitive. This motivation can be seen in the 3 main goals described for their anticipated use of virtual services: (1) optimizing medical services; (2) enhancing the patient experience; and (3) increasing loyalty among patients.

CONCLUSIONS

Health care organizations are considering how virtual primary care services can be used to improve patient outcomes, access to care, and convenience of care. To implement and sustain virtual primary care services, health care organizations will need long-term support from regulators and payers.

The effect of the COVID-19 pandemic on severe asthma care in Europe: will care change for good?

Background

The coronavirus disease 2019 (COVID-19) pandemic has put pressure on healthcare services, forcing the reorganisation of traditional care pathways. We investigated how physicians taking care of severe asthma patients in Europe reorganised care, and how these changes affected patient satisfaction, asthma control and future care.

Methods

In this European-wide cross-sectional study, patient surveys were sent to patients with a physician-diagnosis of severe asthma, and physician surveys to severe asthma specialists between November 2020 and May 2021.

Results

1101 patients and 268 physicians from 16 European countries contributed to the study. Common physician-reported changes in severe asthma care included use of video/phone consultations (46%), reduced availability of physicians (43%) and change to home-administered biologics (38%). Change to phone/video consultations was reported in 45% of patients, of whom 79% were satisfied or very satisfied with this change. Of 709 patients on biologics, 24% experienced changes in biologic care, of whom 92% were changed to home-administered biologics and of these 62% were satisfied or very satisfied with this change. Only 2% reported worsening asthma symptoms associated with changes in biologic care. Many physicians expect continued implementation of video/phone consultations (41%) and home administration of biologics (52%).

Conclusions

Change to video/phone consultations and home administration of biologics was common in severe asthma care during the COVID-19 pandemic and was associated with high satisfaction levels in most but not all cases. Many physicians expect these changes to continue in future severe asthma care, though satisfaction levels may change after the pandemic.