Covid-19 and the Safety Net - Moving from Straining to Sustaining

Regional differences in provider recommendation of HPV vaccines among 13-to-17 year old adolescents from 2019 to 2021

PURPOSE

The prevalence of recommendation of human papillomavirus (HPV) vaccination by health care providers has improved over the last decade. However, research to determine whether the COVID-19 pandemic affected the progress in recommendation among adolescents across the U.S. regions has been limited. Therefore, the present study was conducted to determine if region was associated with provider recommendation of HPV vaccines in 2019-2021 and whether changes in recommendations varied by region.

METHOD

Using a cross-sectional design to examine National Immunization Survey-Teen (2019-2021) data, logistic regression and moderation analyses were performed to model region variation in HPV vaccine recommendations (n = 50,739 respondents).

RESULTS

The odds of recommendation were higher in the Midwest (aOR, 1.17 [95% CI, 1.06-1.29]), and Northeast (aOR, 1.38 [95% CI, 1.23-1.56]) regions than in the South region. Also, the odds of provider recommendation were higher in 2020 (aOR,1.16 [95% CI, 1.03-1.30]) than in 2019. Other variables-sex, age, race/ethnicity, health insurance status, and poverty status-were associated with recommendation of HPV vaccination.

CONCLUSION

Although the improvement in recommendation from 2019 to 2020 is an important public health gain, recommendation in the South still lags behind that in other regions. More efforts are needed to improve HPV vaccination recommendations in this region.

Racial and Ethnic Disparities in Veno-Venous Extracorporeal Membrane Oxygenation Mortality for Patients With Severe COVID-19

Racial/ethnic disparities in mortality were observed during the coronavirus disease-2019 pandemic, but investigations examining the association between race/ethnicity and mortality during extracorporeal membrane oxygenation (ECMO) are limited. We performed a retrospective observational cohort study using the 2020 national inpatient sample. Multivariable logistic regression was used to estimate the odds of mortality in patients of difference race/ethnicity while controlling for confounders. There was a significant association between race/ethnicity and in-hospital mortality ( p < 0.001). Hispanic patients had significantly higher in-hospital mortality compared with White patients (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.16-1.67, p < 0.001). Black patients and patients of other races did not have significantly higher in-hospital mortality compared with White patients (OR = 0.82, 95% CI = 0.66-1.02, p = 0.07 and OR = 1.20, 95% CI = 0.92-1.57, p = 0.18). Other variables that had a significant association with mortality included age, insurance type, Charlson comorbidity index, all patient-refined severity of illness, and receipt of care in a low-volume ECMO center (all p < 0.001). Further studies are needed to understand causes of disparities in ECMO mortality.

Choosing Wisely and Promoting High-Value Care and Staff Safety During the COVID-19 Pandemic in a Large Safety Net System

BACKGROUND AND OBJECTIVES

As the COVID-19 pandemic brought surges of hospitalized patients, it was important to focus on reducing overuse of tests and procedures to not only reduce potential harm to patients but also reduce unnecessary exposure to staff. The objective of this study was to create a Choosing Wisely in COVID-19 list to guide clinicians in practicing high-value care at our health system.

METHODS

A Choosing Wisely in COVID-19 list was developed in October 2020 by an interdisciplinary High Value Care Council at New York City Health + Hospitals, the largest public health system in the United States. The first phase involved gathering areas of overuse from interdisciplinary staff across the system. The second phase used a modified Delphi scoring process asking participants to rate recommendations on a 5-point Likert scale based on criteria of degree of evidence, potential to prevent patient harm, and potential to prevent staff harm.

RESULTS

The top 5 recommendations included avoiding tracheal intubation without trial of noninvasive ventilation (4.4); not placing routine central venous catheters (4.33); avoiding routine daily laboratory tests and batching laboratory draws (4.19); not ordering daily chest radiographs (4.17); and not using bronchodilators in the absence of reactive airway disease (4.13).

CONCLUSION

We successfully developed Choosing Wisely in COVID-19 recommendations that focus on evidence and preventing patient and staff harm in a large safety net system to reduce overuse.

Prevalence and Characteristics of Long COVID 7-12 Months After Hospitalization Among Patients From an Urban Safety-Net Hospital: A Pilot Study

Introduction

Little is known about the burden of long COVID among Black and Hispanic patients in the U.S. We surveyed adult patients hospitalized for COVID-19 at John H. Roger, Jr. Hospital of Cook County, a safety-net hospital predominantly serving Black and Hispanic patients in Chicago, for persistent symptoms after hospitalization to assess prevalence and identify risk factors.

Methods

Cross-sectional data were obtained over 6 months after discharge from patients hospitalized at John H. Roger, Jr. Hospital of Cook County who tested positive for SARS-CoV-2 between October 1, 2020 and January 12, 2021. Multivariable logistic regression was used to analyze the associations between patient characteristics and symptom persistence.

Results

Of 145 patients surveyed at a median follow-up period of 255 days (IQR=238-302), 80% were Black or Hispanic, and 50 (34%) reported at least 1 symptom. In multivariable logistic regression, the risk of long COVID was associated with the severity of acute COVID-19 illness, consistent with findings from population-based cohort studies.

Conclusions

Long COVID prevalence remains high 7 months to a year after an initial illness in a majority Black and Hispanic hospitalized cohort. There is a long-term and ongoing need to assess and address the burden of long COVID, especially among minority communities disproportionately affected by acute COVID-19.

Disseminating oral health educational content and evaluating its use on non-dental safety net clinic websites

OBJECTIVES

Safety net clinics (SNC) provide healthcare to vulnerable populations and SNC websites are an important information source. In North Carolina (NC), all 100 counties are Dental Health Professional Shortage Areas, yet 91 of 317 SNCs are non-dental (ND-SNC). Our goals were to: (1) assess the presence and type of oral health (OH) information on ND-SNC websites; (2) develop and distribute an OH education webpage to ND-SNCs and track its use.

METHODS

The website search function was used with common dental terms to evaluate the presence of OH content on each ND-SNC website. Key representatives from ND-SNCs were surveyed to assess patient care and willingness to implement an OH webpage. Webpage topics included oral hygiene and a map of NC dentists that provide services to low-income patients. Google Analytics was used to track consumer webpage engagement including acquisition source (AS), average time on page (AT), and unique page views (UPV).

RESULTS

Of the 91 ND-SNCs websites, none contained OH education; 15% had information about nearby dental providers. For the 40 ND-SNCs using our webpage, January-December 2022, the primary AS for new webpage users was referrals; 72.5% of users visited directly from ND-SNC websites. Statewide AT was 2 min and 30 s (SD = 58 s), 2.88 times longer than the 52-s threshold marketing experts use to establish genuine user engagement. There were 1364 UPVs statewide for 2022.

CONCLUSION

Our results suggest a need for OH education content on ND-SNC websites, as users are searching for and engaging with this information.

Protection of gender health and fight against gender violence during the COVID-19 pandemic: the experience of our street clinic in a disadvantaged suburb of Rome Metropolitan City

OBJECT

In this study, we evaluated health, social inequalities and risk to gender violence of women living in a disadvantaged degraded suburb of Rome Metropolitan City, during COVID-19 pandemic.

METHODS

The study included 779 women referring to primary care services of Medicina Solidale Institute for gynecological/breast examinations (209), medical and support aid for the children (383) and COVID-19 test execution (187).

RESULTS

The data show that most women (68%) were unemployed or had an irregular job. The request of support varied depending on the ethnicity: while healthcare support was requested mostly by African female community, the COVID-19 test, mandatory for public transportation and work, was a need of the east-european community. Both these communities referred to Medical Solidale primary care service for the healthcare and food/clothing support for their children. It is interesting to note that the requests from the Italian women community was elevated in terms of personal healthcare, support for the children and COVID-19 test execution. The access to the national health system (NHS) resulted a complex administrative procedure despite the original social-ethnic communities. The vast majority of women lacked awareness of their crucial role for supporting the family entity, while inadequacy was commonly reported.

CONCLUSIONS

This study confirms a critical condition for women living in disadvantaged neighborhoods, whose vulnerability is further worsened by the limited access to primary care assistance with serious consequences for health and quality of life. Prevention and treatment, especially for the most vulnerable subjects, should be a priority for the public health system.

Many Intensive Care Units Were Overloaded While Nearby Hospitals Had Excess Capacity During The COVID-19 Pandemic

Strained hospital capacity is associated with adverse patient outcomes. Anecdotal evidence suggests that during the COVID-19 pandemic in the US, some hospitals experienced capacity constraints while others in the same market had surplus capacity, a phenomenon known as "load imbalance." Our study evaluated the prevalence of intensive care unit load imbalance and the characteristics of hospitals most likely to be over capacity while other nearby hospitals were under capacity. Of the 290 hospital referral regions (HRRs) analyzed, 154 (53.1 percent) experienced load imbalance during the study period. HRRs experiencing the most imbalance had higher proportions of Black residents. Hospitals with the highest Medicaid patient shares and Black Medicare patient shares were significantly more likely to be over capacity, while other hospitals in their market were under capacity. Our findings highlight that hospital load imbalance was common during the COVID-19 pandemic. Policies to coordinate transfers may decrease strain during periods of high demand and ease the burden on hospitals that serve a higher proportion of patients from racial minority groups.

Evaluation of COVID-19 vaccine implementation in a large safety net health system

Objectives

To evaluate rapid COVID-19 vaccine clinic implementation from January-April 2021 in the Los Angeles County Department of Health Services (LACDHS), the second-largest US safety net health system. During initial vaccine clinic implementation, LACDHS vaccinated 59,898 outpatients, 69% of whom were Latinx (exceeding the LA County Latinx population of 46%). LACDHS is a unique safety net setting to evaluate rapid vaccine implementation due to system size, geographic breadth, language/racial/ethnic diversity, limited health staffing resources, and socioeconomic complexity of patients.

Methods

Implementation factors were assessed through semi-structured interviews of staff from all twelve LACDHS vaccine clinics from August-November 2021 using the Consolidated Framework for Implementation Research (CFIR) and themes analyzed using rapid qualitative analysis.

Results

Of 40 potential participants, 25 health professionals completed an interview (27% clinical providers/medical directors, 23% pharmacist, 15% nursing staff, and 35% other). Qualitative analysis of participant interviews yielded ten narrative themes. Implementation facilitators included bidirectional communication between system leadership and clinics, multidisciplinary leadership and operations teams, expanded use of standing orders, teamwork culture, use of active and passive communication structures, and development of patient-centered engagement strategies. Barriers to implementation included vaccine scarcity, underestimation of resources needed for patient outreach, and numerous process challenges encountered.

Conclusion

Previous studies focused on robust advance planning as a facilitator and understaffing and high staff turnover as barriers to implementation in safety net health systems. This study found facilitators that can mitigate lack of advance planning and staffing challenges present during public health emergencies such as the COVID-19 pandemic. The ten identified themes may inform future implementations in safety net health systems.

Collateral Impacts of the COVID-19 Pandemic: The New York City Experience

OBJECTIVE

To adapt an existing surveillance system to monitor the collateral impacts of the COVID-19 pandemic on health outcomes in New York City across 6 domains: access to care, chronic disease, sexual/reproductive health, food/economic insecurity, mental/behavioral health, and environmental health.

DESIGN

Epidemiologic assessment. Public health surveillance system.

SETTING

New York City.

PARTICIPANTS

New York City residents.

MAIN OUTCOME MEASURES

We monitored approximately 30 indicators, compiling data from 2006 to 2022. Sources of data include clinic visits, surveillance surveys, vital statistics, emergency department visits, lead and diabetes registries, Medicaid claims, and public benefit enrollment.

RESULTS

We observed disruptions across most indicators including more than 50% decrease in emergency department usage early in the pandemic, which rebounded to prepandemic levels by late 2021, changes in reporting levels of probable anxiety and depression, and worsening birth outcomes for mothers who identified as Asian/Pacific Islander or Black. Data are processed in SAS and analyzed using the R Surveillance package to detect possible inflections. Data are updated monthly to an internal Tableau Dashboard and shared with agency leadership.

CONCLUSIONS

As the COVID-19 pandemic continues into its third year, public health priorities are returning to addressing non-COVID-19-related diseases and conditions, their collateral impacts, and postpandemic recovery needs. Substantial work is needed to return even to a suboptimal baseline across multiple health topic areas. Our surveillance framework offers a valuable starting place to effectively allocate resources, develop interventions, and issue public communications.

Perceived barriers to cervical cancer screening and motivators for at-home human papillomavirus self-sampling during the COVID-19 pandemic: Results from a telephone survey

Home-based self-sample human papillomavirus (HPV) testing may be an alternative for women who do not attend clinic-based cervical cancer screening. We assessed barriers to care and motivators to use at-home HPV self-sampling kits during the COVID-19 pandemic as part of a randomized controlled trial evaluating kit effectiveness. Participants were women, aged 30-65 years and underscreened for cervical cancer in a safety-net healthcare system. We conducted telephone surveys in English/Spanish among a subgroup of trial participants, assessed differences between groups and determined statistical significance at p<0.05. Over half of 233 survey participants reported clinic-based screening (Pap) is uncomfortable (67.8%), embarrassing (52.4%), and discomfort seeing male providers (63.1%). The latter two factors were significantly more prevalent among Spanish versus English speakers (66.4% vs 30% and 69.9 vs 52.2%, respectively, p<0.01). Most women who completed the kit found Pap more embarrassing (69.3%), stressful (55.6%) and less convenient (55.6%) than the kit. The first factor was more prevalent among Spanish versus English speakers (79.6% vs 53.38%, p<0.05). The COVID-19 pandemic influenced most (59.5%) to participate in the trial due to fear of COVID, difficulty making appointments and ease of using kits. HPV self-sampling kits may reduce barriers among underscreened women in a safety-net system.

Public Health Workforce Gaps, Impacts, and Improvement Strategies from COVID-19

The public health workforce has been instrumental in protecting residents against population health threats. The COVID-19 pandemic has highlighted the importance of the public health workforce and exposed gaps in the workforce. Public health practitioners nationwide are still coming to understand these gaps, impacts, and lessons learned from the pandemic. This study aimed to explore Minnesota's local public health practitioners' perceptions of public health workforce gaps, the impacts of these workforce gaps, and the lessons learned in light of the COVID-19 pandemic. We conducted seven concurrent focus groups with members of the Local Public Health Association of Minnesota (LPHA; n = 55) using a semi-structured focus group guide and a survey of the local agencies (n = 70/72 respondents, 97% response rate). Focus group recordings were transcribed verbatim and analyzed using deductive and inductive coding (in vivo coding, descriptive coding), followed by thematic analysis. The quantitative data were analyzed using descriptive analyses and were integrated with the qualitative data. Participants indicated experiencing many workforce gaps, workforce gaps impacts, and described improvement strategies. Overall, many of the workforce gaps and impacts resulting from COVID-19 discussed by practitioners in Minnesota are observed in other areas across the nation, making the findings relevant to public health workforce nationally.

The Impact of COVID-19 Pandemic on Scientific Research: an Upcoming New Wave?

The coronavirus disease (COVID)-19 pandemic continues to have an impact on health care. A potential new wave can be foreseen concerning the impact of the pandemic on medical research and literature. We focused our attention on journals belonging to "Medicine, General and Internal" Clarivate™ category and "Q1" journal impact factor quartile. We found that since January 2020, 9621 papers regarding COVID-19 have been published in these journals. This occurred at the expense of non-COVID-19-related scientific papers as most journals did not increase the total number of their published articles. Thus, our analysis may outlook a new potential scientific wave related to COVID-19, in addition to the clinical ones, possibly delaying the improvement in the quality of care for other diseases in the next years.