key: cord-283862-k6b4vyut authors: bates, carol k.; jackson, jeff; asch, steven title: from the editor’s desk: jgim and covid-19 date: 2020-04-22 journal: j gen intern med doi: 10.1007/s11606-020-05852-9 sha: doc_id: 283862 cord_uid: k6b4vyut nan all of this leads to the question of where jgim can have the most impact. we have expedited some heartfelt pieces in healing arts and some perspectives which as always do not necessarily represent the opinions of the editors-in-chief-though we are not shy in sharing our opinions. we welcome pieces that are not dependent on the changing numbers and in particular manuscripts that set the stage for how we will continue to think about the dilemmas that we will face in the years to come. we have expedited this "from the editor's desk" even though it will not necessarily refer to articles in the same printed issue as has been our habit. so, ironically, if you are reading this in the print issue, we may have evolved our thinking about how best to review covid-19 manuscripts in the meantime. there is one last editorial question that we have revisited because of the pandemic. our team has had some spirited conversations on decisions to publish material that has appeared in other places. we published one paper 1 that referred to another paper in an economics journal ultimately doing so because our readership would otherwise be unlikely to ever hear of this important manuscript. we have rarely published pieces that relate to ahrq monographs, 2 because the monographs reached a limited audience. similarly, we have considered papers on materials that are behind the va firewall and inaccessible to readers who do not work in the va. for covid-19 papers, we have considered the question of whether we should publish material that has also been in the lay press. the value of publications in the lay press that exhort governmental action is obvious. the argument has been made that secondary (and most often later) publication in jgim will give durability through pubmed indexing and the ability to reference these publications in the coming year. editorial guidance on the question of secondary publication comes from the international committee of medical journal editors (icmje). 3 the danger of duplicate/overlapping publication lies in the inadvertent double counting of data and the risk of overweighting of results. while not mentioned in icmje guidance, duplicate publication is also misleading in assessing promotion metrics in the overweighting of a body of work. icmje does have a proviso for public emergencies, stating that "…information with immediate implications for public health should be disseminated without concern that this will preclude subsequent consideration for publication in a journal." therefore, while we recognize the risk that covid-19-themed publications may put forward ideas that have already been disseminated in other settings, we are willing to take this risk and welcome submissions that may fall into that category. finally, a heartfelt thanks to readers working on the front lines. many of you are leading the clinical, educational, and research mission and guiding our healthcare system's response to this crisis. we wish all the best of physical and mental health for all of our readers and their loved ones. stay well. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. the tuskegee study of untreated syphilis: a case study in peripheral trauma with implications for health professionals primary care: the new frontier for reducing admissions icjme recommendations, overlapping publications key: cord-260322-b2493coe authors: mehring, william m.; poksay, andrew; kriege, jesse; prasannappa, rithvik; wang, michael d.; hendel, chris; hochman, michael title: initial experience with a covid-19 web-based patient self-assessment tool date: 2020-06-15 journal: j gen intern med doi: 10.1007/s11606-020-05893-0 sha: doc_id: 260322 cord_uid: b2493coe nan as the covid-19 pandemic spreads, patients experiencing symptoms potentially attributable to the disease require timely assessment. as the disease burden increases, healthcare professionals may increasingly be challenged to meet the demand. automated assessment tools-such as digital self-assessment applications-offer a potential strategy for providing guidance to patients without requiring direct attention from healthcare professionals. 1 to date, several covid-19 self-assessment tools have been released. [2] [3] [4] our team recently developed a web-based covid-19 selfassessment tool, available in english and spanish, offering guidance for patients experiencing potential covid-19 symptoms. 2 based on user input, the tool recommends medical consultation vs. home-care, and provides guidance for preventing infection spread. in this analysis, we describe the results of almost 300,000 digital self-assessments. our tool (available at: https://covidassessment.org/) was developed by a team of clinicians from the usc gehr center for health systems science & innovation, in partnership with the akido labs health information technology partner, using information from the centers for disease control and prevention (cdc) website as a guide. the tool was initially distributed via a lay media article, 2 which led to further distribution through secondary media channels. web analytics software was used to track tool utilization between march 17, 2020, and april 9, 2020. there were 352,257 unique users from 201 countries, of whom 78.9% accessed the tool with a mobile device. users accessed the tool predominately from media outlets like stat news and the los angeles times that linked to the tool, and also via social media outlets like facebook. among 5,611 users who entered optional demographic data (the option to do so was added 2 weeks after the launch), 61% percent were female and the mean age was 39. a total of 276,560 assessments were completed, and users reported symptoms potentially attributable to covid-19 69.6% of the time. among those with symptoms, 80.5% reported mild or moderate symptoms that could likely be managed with home self-care, while 19.5% reported severe symptoms for which our tool recommended immediate medical attention. of those with mild symptoms, 7.1% reported direct exposure to someone with confirmed covid-19; for these users, our tool recommends consideration of telephone consultation with a healthcare professional to determine the need for testing. figure 1 shows the geographic distribution of users in the usa. in our analysis of almost 300,000 digital self-assessments from our covid-19 self-assessment tool, 69.6% of users reported symptoms potentially attributable to covid-19. among users with symptoms, 80.5% had only mild symptoms that likely could be managed with self-care. importantly, we do not have data on user outcomes, and therefore, it is not possible to assess the appropriateness of our tool's recommendations, nor to determine which users actually had covid-19. in another analysis involving 950 users of a different covid-19 self-assessment tool embedded in a health system patient portal, the tool correctly identified 14 of 16 users who visited the emergency room within 48 hours, for a sensitivity of 87.5% (95% ci 61.7-98.5%)." 5 another limitation of our analysis is that the study population received the tool via media sources and therefore represents a convenience sample. nevertheless, the widespread use of our tool highlights the willingness of the public to engage with digital health tools and self-assessment in this time of public health crisis. future research should examine the accuracy and effectiveness of digital self-assessments among those with covid-19 disease, as well as other uses of such technology, such as for triaging directly into telehealth or testing publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. digital technology and covid-19 rapid design and implementation of an integrated patient self-triage and self-scheduling tool for covid-19 quantifying sars-cov-2 transmission suggests epidemic control with digital contact tracing key: cord-284795-0eoyxz78 authors: khetan, aditya k. title: covid-19: why declining biodiversity puts us at greater risk for emerging infectious diseases, and what we can do date: 2020-06-25 journal: j gen intern med doi: 10.1007/s11606-020-05977-x sha: doc_id: 284795 cord_uid: 0eoyxz78 nan those viruses. fruit bats serve as a reservoir for both. with respect to ebola, the fruit bats thrived among the palm oil trees and, when they came into close contact with humans through these plantations, passed on the virus to humans. for nipah, the fruit bats contaminated date palm sap, which was then consumed by humans who thus got infected. given that loss of biodiversity is a primary driver of eid, there is an urgent need for measures to stem this loss. while public health measures, including surveillance of emerging disease hotspots, can be helpful as near-term strategies, they cannot substitute for a long-term solution that conserves biodiversity. in the absence of this, it is likely that public-health capacity will continue to be overwhelmed. human activities that drive loss of biodiversity are also directly tied to climate change and increasing water scarcity. as a result, targeting such activities can lead to a multitude of planetary health-and ipso facto human health-benefits. 5 these activities primarily involve agricultural intensification and expansion, which are the primary drivers of deforestation. human agriculture uses 33% of earth's available land surface, either as cropland (12%) or pasture (21%). it is estimated that between 2000 and 2010, 70% of deforestation was attributable to agricultural land expansion. this agricultural land expansion has mostly been for farming animals (for meat and other animal products such as dairy), soybean production, and palm oil production. 6 further, over 80% of soybean is used to feed animals for meat and is the principal source of protein for farmed animals. soybean demand, therefore, is essentially a surrogate for demand of meat. currently, 40% of calories available from global crop production are either fed to animals or used as biofuels. 5 given the significant contribution of human meat consumption to loss of biodiversity, decreasing such consumption must be recognized as a major priority for decreasing the incidence of eid over the medium to long term. such progress will also result in beneficial effects towards combating climate change, reducing water scarcity, and addressing malnutrition. it is estimated that 25% of global ghg emissions are the result of agriculture, most of it from the farming of animals for human consumption. the water footprint of a serving of meat is 10-20 times the water footprint of a serving of plant foods. decreasing the consumption of meat, therefore, can lead to progress in water conservation. 7 for every gram of protein in beef, 20 g of protein is utilized in feeding the animal. for chickens, the corresponding figure is 4 g. if the world's soybean production were instead utilized to feed humans directly, there would be a several-fold increase in protein availability for a large proportion of humans, whose protein demand is expected to rise with increasing economic prosperity. it is time we-as an interdependent world-recognize that what we eat primarily determines how the planet is used. physicians have historically played a leading role in issues that threaten the survival of our species, such as nuclear warfare. but with food, physicians have taken a narrow view in dietary guidelines and focused on isolating the effect of individual foods or nutrients on human health, ignoring the wider ecosystem which our food habits influence, and are, in turn, influenced by. as the latest pandemic shows, such a narrow view has been counterproductive, and likely will continue to cause significant harm. it is time for us to recognize that food, human health, and the environment are deeply interconnected, and understanding these relationships is vital to our planetary health. global trends in emerging infectious diseases impacts of biodiversity on the emergence and transmission of infectious diseases human influences on biodiversity evolution in action: climate change, biodiversity dynamics and emerging infectious disease safeguarding human health in the anthropocene epoch: report of the rockefeller foundation-lancet commission on planetary health tropical forests were the primary sources of new agricultural land in the 1980s and 1990s country-specific dietary shifts to mitigate climate and water crises key: cord-301399-s2i6qfjn authors: rana, jamal s.; khan, sadiya s.; lloyd-jones, donald m.; sidney, stephen title: changes in mortality in top 10 causes of death from 2011 to 2018 date: 2020-07-23 journal: j gen intern med doi: 10.1007/s11606-020-06070-z sha: doc_id: 301399 cord_uid: s2i6qfjn nan trends in mortality rates due to leading causes of death reflect the medical, psychosocial, and economic well-being of a society, and a historical snapshot of such trends can help inform policies of the future. therefore, we examined changes in the number of deaths and age-adjusted mortality rates (aamr) attributed to the top 10 causes of death between 2011 and 2018, the last year we have data available from the centers for disease control and prevention. we chose 2011 as the start date because of earlier work showing a transition in 2011 in 2 of the top 10 causes of death (heart disease and stroke) from a long-term decline to increasing numbers of deaths since then. 1 the centers for disease control and prevention wide-ranging online data for epidemiologic research (cdc wonder) dataset was used to identify national changes in the number of deaths and aamr due to the top 10 underlying causes of death from january 1, 2011, to december 31, 2018. 2 the population projection was obtained from u.s. census data. 3 as of 2018, the top 3 causes of death were heart disease, cancer, and accidents ( table 1 ). the largest percentage decline for aamr occurred for cancer deaths (− 11.8%), and the greatest increase in aamr occurred for deaths due to alzheimer disease (+ 23.5%). aamr for influenza and pneumonia (− 5.1%) and chronic lower respiratory diseases (− 6.6%) declined. increases in aamr due to accidental deaths (+ 22.8%) and intentional self-harm (suicide) (+ 15.4%) were observed. even though the aamr declined for 7 of the 10 top causes of death, the number of deaths increased for all 10 of the leading causes. this is because the older (age ≥ 65 years) age group grew at a much more rapid rate than that of the younger (age < 65 years) (26.7% vs. 1.7%), while 70% or more of the deaths from 8 of these causes were concentrated in older (age ≥ 65 years) adults ( table 2) . important patterns of change in aamr in the past decade have been previously noted, from stalling of the decline in mortality due to heart disease 1 to decrease in life expectancy attributed to drug overdoses and suicides among young and middle-aged adults. 4 while interventions to prevent and treat coronary heart disease (chd) have been successful, with ageadjusted mortality rate decrease 14.9% in last decade, the worrisome plateau in the decline in heart disease mortality seems to be driven by an increase in mortality for heart failure (20.7%), with majority of deaths due to heart disease happening in the increasing aging population. 5 the largest percent decline during this time period of the study was noted for cancers. according to a recent report, this progress is driven by long-term declines in death rates for the 4 leading cancers, namely lung, colorectal, breast, and prostate cancers. that report also noted that over 2008-2017, reductions slowed for female breast and colorectal cancers and stopped for prostate cancer; in contrast, declines accelerated for lung cancer, which remains the biggest contributor of mortality among cancers. 6 it remains to be seen what the final death toll will be due to covid-19 in 2020. with more than 90,000 deaths by may, it has already surpassed the number of deaths attributed to all but the 6 of the leading causes of deaths in 2018 including influenza and pneumonia, the 8th highest cause of mortality in 2018. due to the direct and myriad of indirect consequences of this pandemic, mortality rankings due to top 10 causes noted in the current report may look very different in 2020. as noted, almost three-quarters of the deaths from 8 of these causes were concentrated in older (age ≥ 65 years) adults. further, the ≥ 65 years population is projected to increase by 39% from 52.4 million in 2018 to 73.1 million in 2030 3 so that the number of deaths from most of the 10 leading causes can be expected to increase unless more effective preventive and therapeutic interventions can be implemented. recent trends in cardiovascular mortality in the united states and public health goals underlying cause of death projected age and sex distribution of the population life expectancy and mortality rates in the united states association between aging of the us population and heart disease mortality from cancer statistics, 2020 publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-322066-m8dphaml authors: kutscher, eric; kladney, mat title: primary care providers: discuss covid-19-related goals of care with your vulnerable patients now date: 2020-05-06 journal: j gen intern med doi: 10.1007/s11606-020-05862-7 sha: doc_id: 322066 cord_uid: m8dphaml nan patients. it is difficult to discuss the possible long-term consequences of intubation because frankly we cannot predict if these complications will occur for each patient. we do not know who will require increased pressures or fio2, resulting in sustained lung injuries. we do not know who will breathe asynchronously with the ventilator, thus requiring increasing doses of sedatives. we do not know who will simply die from their underlying illness, despite mechanical ventilation. we do not know who will survive to extubation, only to ultimately succumb to pneumonia or urosepsis while undergoing rehabilitation. all of these unknowns often result in doctors uncomfortable in talking about risks and benefits of intubation with their patients until it is clear that the patient has progressed to a point of needing respiratory support. and there is, inherently, never a right moment to have this conversation. uniquely, many of the unknowns about intubation are answered with data on covid-19 from other countries. patients often require a prolonged intubation of 10-14 days, and patients who are older, have cardiovascular disease (including hypertension), diabetes, or malignancy have worse outcomes. 1 4 for many in the united states, patients who have died while intubated have been alone and without visitors. 5 for those that do survive, the risk of cachexia and a prolonged recovery is almost inevitable. volunteering as the anonymous doctor on a covid hotline, it was clearly not my role to discuss with these callers whether or not intubation is something they would want. it was instead my role to triage concerns and get people complete medical evaluation if needed. yet, i felt a dissonance: a conversation i felt like i ought to have but could not. in the emergency department, it is not the job of the ed physician to explain intubation to a decompensating patient needing emergent intervention. with thousands of expected cases of covid causing respiratory distress at the same time here in new york city, it is even more unrealistic for us to expect our emergency medicine colleagues to have long nuanced goals of care conversations in the acute setting. this is exacerbated by new visitation policies at most nyc hospitals barring all visitors for adult patients. we as primary care doctors have the privilege of knowing our patients the best. we identify as their doctor and their advocate. through our repeated encounters, our patients learn to trust us, and we learn to trust them. thus, in this time of medical crisis, we must step up to help patients better understand this pandemic. we must reach out to our most vulnerable patients and take advantage of our deep relationships to have difficult conversations. we must ask our patients about their concerns about covid-19, and share information about how to avoid the virus. we must also ask our patients about what medical interventions they would want if they were to contract covid-19 and require respiratory support. we must be clear and transparent in our thoughts and recommendations, tailoring them to each individual, and communicating them with our best intentions to help patients find a path that is right for them. given the data we know about covid-19 and the risks and benefits of intubation, we must use our best medical judgment to help patients understand realistic outcomes and make informed decisions. for many of our conversations, we may not reach a conclusion as to how to best address respiratory support in this pandemic. but by at least opening the conversation and discussing the options, our patients can be active participants in their care. for those who ultimately decide that intubation is outside of their goals, we must help document these wishes through proper legal forums to make sure their desires are respected. the role of the primary care doctor is to partner with our patients to help them find their voice in the medical system. with covid-19, this means having hard conversations with our most vulnerable patients. it means helping many of our beloved patients understand that "do not intubate" is most likely the best choice for them. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) -china clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical characteristics of coronavirus disease 2019 in china opinion: i'm on the front lines. i have no plan for this key: cord-280410-j32tuj5s authors: rose, adam j.; ellen, moriah e. title: covid-related disruption—finding the silver lining date: 2020-08-31 journal: j gen intern med doi: 10.1007/s11606-020-06173-7 sha: doc_id: 280410 cord_uid: j32tuj5s nan c ovid-19 has disrupted healthcare delivery in more ways than we can count. growing evidence shows that many non-covid patients have stayed home with obvious heart attack symptoms rather than coming into the hospital, for fear of catching this has led to patients dying at home, increases in otherwise rare complications such as ventricular wall rupture, 2 and generally to unnecessarily severe complications from events that might have been easily managed under usual circumstances. this pattern has been repeated with strokes and many other acute conditions, 3 where patients have been too afraid to present for needed care. cancer treatment has been delayed or disrupted in many cases, despite valiant efforts by healthcare workers to continue it. screening tests such as colonoscopies have been delayed, which will presumably lead to an excess of late-stage presentations of cancer in the future, plus a backlog of screening tests to be performed later. 4 primary care doctors have not seen some patients in weeks or months, 5 and their chronic conditions are almost certainly becoming less well-controlled over time. covid-19 has not been good for medical care delivery, for patients, or for healthcare workers. or has it? while some (or even many) disruptions have been bad for patients and the healthcare system, others seem to have been helpful. we are aware of several examples of helpful disruptions, which we will briefly describe here. telemedicine has been stymied for years by issues with reimbursement rules-issues that melted away seemingly overnight in the face of covid-19. 6 telemedicine is now poised for rapid growth. evidence will emerge over time about its effectiveness, its place in the healthcare system, and about what it is best-suited to handle-but telemedicine has been freed overnight from many legal constraints on its expansion. overuse of expensive or ineffective therapies has plagued our system for years. 7 however, in light of the current issues of underuse, our recent efforts to rein in overuse seem to belong to another era. while we must remain sanguine about the continued influence of profit motives, and the likely durability of overuse as a problem, overuse may take years to return to what it was. these are only some of the many examples of how covid-19 may have unwittingly helped us to improve our systems. we can only speak about areas with which we happen to be familiar, but we know that the readership of jgim has much wider and varied experience and knowledge. we encourage readers to think about the topic in which they specialize, or the clinic or hospital in which they practice. certainly, readers can furnish many examples of how covid-19 has been bad for care delivery in their area of expertise, their clinic, or their hospital. but with a little imagination, can we also find some examples of things that had been badly in need of a good disruption? perhaps your clinic has changed how it schedules appointments and how it manages the waiting room, to avoid causing large numbers of people to congregate. maybe the new system is terrible and you cannot wait to abandon it. but maybe you have discovered that it actually works better than the system you had in place before. or, that it works better in some ways and worse in others. this could become the basis for efforts to retain what works about the new system, while improving the parts that do not work as well. those of us who deliver care to patients, or study patient care, or help organize patient care certainly have a lot to be depressed and worried about these days. but it is important to see what good may have come out of this as well. healthcare can be so entrenched and so hard to change, and covid-19 may have finally provided just the shake-up some of us needed. indeed, there are so many aspects of our healthcare system that go unexamined, and that we do not even realize ought to change. now, for regrettable reasons, change has come to our healthcare system, sometimes in unpredictable ways. it is up to us to have our eyes open for those changes that may have been unexpectedly good, or helpful-and to refuse to let them slip away quietly. ventricular septal rupture complicating delayed acute myocardial infarction presentation during the covid-19 pandemic evidence for overuse of medical services around the world conflict of interest: the authors do not report any conflicts of interest. key: cord-266266-ekxnn9bo authors: miyawaki, atsushi; hasegawa, kohei; tsugawa, yusuke title: lessons from influenza outbreaks for potential impact of covid-19 outbreak on hospitalizations, ventilator use, and mortality among homeless persons in new york state date: 2020-06-04 journal: j gen intern med doi: 10.1007/s11606-020-05876-1 sha: doc_id: 266266 cord_uid: ekxnn9bo nan increasing numbers of patients infected by covid-19 is raising serious concerns about the potential shortage of hospital beds and ventilators in cities such as new york city. the homeless population is particularly large in urban areas and will become larger given the economic crisis. 1, 2 they are high-risk of contagious diseases 3 (as shelters and drop-in centers are crowded with an active turnover of people), and the outbreak among this population would negatively impact the health care system's ability to respond to this crisis. however, little is understood how the outbreak of infectious diseases among the homeless population affects health systems' resources (e.g., hospital beds, ventilators) and availability of resources for non-homeless population. to address this knowledge gap, using influenza outbreaks as an example, we investigated health care use among the homeless population hospitalized in new york state. we used the 2007-2012 new york state inpatient database that includes all inpatient discharge records from acute care hospitals. we identified all hospitalizations with primary or secondary diagnosis of influenza (icd-9-cm code 487.xx or 488.xx) from july 2007 to june 2012 (median age 40 years [iqr 6-66]). homeless patients were identified from the homeless status indicator, which was directly reported by hospitals. 4 we calculated monthly trends of hospitalization rates (/1000 person-months) in the homeless and nonh o m e l e s s p o p u l a t i o n s . p o p u l a t i o n e s t i m a t e s (denominator) were derived from the us department of housing and urban development continuum of care data for the homeless population, 1 and the us census bureau data for the non-homeless population. 5 next, we compared the utilization of care and patient outcomes (hospitalization through emergency department [ed], mechanical ventilation use [non-invasive or invasive], and in-hospital death) between homeless versus nonhomeless patients using multivariable modified poisson regression models. we adjusted for patient characteristics and year-month fixed effects. the study was approved by the ucla institutional review board. of the 20,078 patients hospitalized for influenza across 214 hospitals in new york, 1295 (6.4%) were homeless patients. most hospitalizations (99.9%) among homeless individuals were concentrated in ten hospitals. homeless patients experienced a higher rate of hospitalization for influenza than non-homeless persons throughout the observation period (fig. 1) . the difference was particularly salient for the pandemic of h1n1 influenza in 2009: hospitalization rates were 2.9 per 1000 for homeless versus 0.1 per 1000 for non-homeless populations. after adjusting for potential confounders, homeless patients were more likely to be hospitalized from ed (adjusted rate ratio [arr], 1.09; 95% ci 1.04-1.14; p < 0.001) and receive mechanical ventilation (arr, 1.58; 95% ci 1.03-2.43; p = 0.04), compared with non-homeless patients (table 1) . we found no evidence that the inhospital mortality rate differed between homeless and non-homeless populations. using the population-based data, including all hospitalizations for influenza in new york, we found that homeless persons had higher utilization of care compared with non-homeless persons. homeless people experienced a higher hospitalization rate, particularly during a pandemic period and, once hospitalized, a higher rate of mechanical ventilation use. in the midst of covid-19 outbreak, these findings underscore the importance of infection control and prevention of covid-19 among the homeless population (e.g., lower threshold of virus testing, providing temporary housing to improve sanitation, and social/physical distancing 6 ), which will, in turn, save resources of the us health care system for larger populations. our study has limitations. first, it is possible that homeless indicators were under-coded; therefore, their hospitalization rates might have been underestimated. second, our findings may not be generalizable to other states than new york. however, new york is currently struck by the outbreak of covid-19 infections. furthermore, our data represented 16% of the entire us homeless population, 1 and the underlying patterns may be similar across states. coc homeless populations and subpopulations reports united states interagency council on homelessness. opening doors. federal strategic plan to prevent and end homelessness, as amended in infections in the homeless disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions homelessness and the response to emerging infectious disease outbreaks: lessons from sars compliance with ethical standards:the study was approved by the ucla institutional review board. the authors declare that they do not have a conflict of interest. key: cord-332728-72yq43sw authors: flentje, annesa; obedin-maliver, juno; lubensky, micah e.; dastur, zubin; neilands, torsten; lunn, mitchell r. title: depression and anxiety changes among sexual and gender minority people coinciding with onset of covid-19 pandemic date: 2020-06-17 journal: j gen intern med doi: 10.1007/s11606-020-05970-4 sha: doc_id: 332728 cord_uid: 72yq43sw nan with sars-cov-2 recently sweeping the globe, the population is experiencing a group stressor unlike any phenomenon in this country in the last century. how the pandemic experience is related to mental health challenges including anxiety and depression is unknown. numerous factors-such as changes in community function; restriction of activities and social contacts; and fearfulness about the virus, the economic downturn, and food access-may contribute to poorer mental health. marginalized populations, such as sexual and gender minority people (i.e., non-heterosexual people and transgender or gender-expansive people, respectively) may be particularly at risk for adverse impacts of the pandemic due to preexisting economic and health factors. 1 we set out to document changes in depression and anxiety within the pride study, a longitudinal cohort of sexual and gender minority people, a vulnerable population. 2 the pride study, a longitudinal cohort study of sexual and gender minority people, 2 were included if they completed mental health measures in the 2019 annual questionnaire (timepoint 1, june 2019-ongoing at time of data extraction) and in a covid-19 impact ancillary study (timepoint 2, march 23, 2020, through april 19, 2020). paired sample t tests examined changes in depression (9-item patient health questionnaire, phq-9 3 ) and anxiety (7-item generalized anxiety disorder scale, gad-7 4 ) symptoms overall and separately among those who screened positive (phq-9 and gad-7 scores ≥ 10 3, 4 ) and negative (scores < 10) for depression and generalized anxiety disorder at timepoint 1. in total, 2288 participants were included in this study (see table 1 for participant characteristics). depression symptoms increased by a mean phq-9 score of 1.21 (t[2280] = 11.35, p < .001, d = .20) from timepoint 1 to 2. anxiety symptoms increased by a mean gad-7 score we found increases in anxiety and depression coinciding with the covid-19 pandemic onset. increased anxiety and depression symptoms were driven by people who did not have preexisting symptoms consistent with generalized anxiety or depression. while this study was conducted with sexual and gender minority people, the results may be relevant for other vulnerable populations, such as other minority groups. health care providers are advised to check in with patients about stress and to screen for mood and anxiety disorders, even among patients who had no prior history of anxiety or depression. treatment and referrals can include traditional interventions such as individual therapy and medications and may also include covid-19-specific supports implemented on a larger scale (e.g., supportive peer-led groups, mindfulness practice). this study is observational. our finding that individuals with preexisting depression had improved mood from timepoint 1 to 2 may represent regression to the mean and should not be interpreted that these individuals have less depressive symptoms, as they already were experiencing symptoms of depression at timepoint 1. future research will identify who is most at risk for adverse impact. in the interim, we should consider ways to support the mental health of all of our communities during the pandemic, with special care and attention to vulnerable populations. acknowledgments: the pride study is a community-engaged research project that serves and is made possible by lgbtq+ community involvement at multiple points in the research process, including the dissemination of findings. we acknowledge the courage and dedication of the pride study participants for sharing their stories; the careful attention of pridenet participant advisory committee (pac) members for reviewing and improving every study application; and the enthusiastic engagement of pridenet open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/. this includes people who were assigned a sex of birth of male or female, and only gender is reported here; thus, gender minority people may be found in all categories c cisgender is listed here as an identity label. cisgender people can be found in multiple categories and may not endorse this identity label the lives and livelihoods of many in the lgbtq community are at risk amidst the covid-19 crisis. human rights campaign foundation a digital health research platform for community engagement, recruitment, and retention of sexual and gender minority adults in a national longitudinal cohort study-the pride study the phq-9: a new depression diagnostic and severity measure a brief measure for assessing generalized anxiety disorder: the gad-7 key: cord-317440-898r34h2 authors: meiselbach, mark k.; bai, ge; anderson, gerard f. title: charges of covid-19 diagnostic testing and antibody testing across facility types and states date: 2020-09-15 journal: j gen intern med doi: 10.1007/s11606-020-06198-y sha: doc_id: 317440 cord_uid: 898r34h2 nan the high charges for covid-19 testing by some healthcare providers have received broad media and public attention. 1 individual providers determine their own charge, which does not vary with insurance type. 2, 3 the charges for covid-19 testing have important implications for out-of-network plans, uninsured patients, and other payers with little negotiating power. the cares act requires that private plans that do not have a negotiated rate with the provider pay the price publicly listed by the provider for covid-19 testing, which is usually the same as or a percentage of the charge. 4 , 5 providers that have tested uninsured patients can choose to either seek reimbursement from the department of health and human services or bill uninsured patients at a self-determined price, which equals the charge unless the provider offers a discount. therefore, the higher the charge for covid-19 testing, the higher the potential cost exposure of plans without negotiating power and of uninsured patients. nationwide covid-19 testing charges across facility types remain unexplored. in this study, we aim to examine the charges for the most commonly performed covid-19 diagnostic test (cpt code: 87635) and antibody test (cpt code: 86769) across facility types and states. we obtained administrative claims data for covid-19 testing from the covid-19 research database, a pro bono cross-industry collaborative. 6 the sample consisted of 182,149 claims of diagnostic testing (cpt code: 87635, medicare rate $51.31) from 2324 providers in 50 states and dc, and 318,546 claims of antibody testing (cpt code: 86769, medicare rate $42.13) from 764 providers in 46 states and dc. all claims were submitted between march 19 and july 19, 2020. we obtained the state-level diagnostic testing rate, infection rate, and mortality rate, as of july 20, 2020, from the johns hopkins coronavirus resource center. for each test and facility type, we calculated the average charge (total charges divided by total claims and compared across facility types). for each test and state (with more than ten claims), we calculated the average charge and grouped the states into low, medium, and high tertiles. we analyzed the correlation between each state's average testing charge and its covid-19 testing rate (available only for diagnostic testing), infection rate, and mortality rate to understand whether the testing charges were influenced by the demand for the test. for covid-19 diagnostic testing, the mean, median, and standard deviations of charges were $144.06, $100.00 (iqr $67.00-$155.00), and $162.18. the most common facility type was independent laboratories (performed 49.7% of all tests), with an average charge of $140.41 (range $0.01-$14,750.00, iqr $67.00-$100.00), followed by hospital outpatient settings (performed 34.5% of all tests), with an average charge of $168.87 (range $0.01-$2436.00, iqr $94.00-$204.00) (fig. 1, panel a) . for antibody testing, the mean, median, and standard deviations of charges w ere $63.93, $55.00 (iqr $42.13-$55.00), and $48.92. independent laboratories performed 97.2% of all tests, with an average charge of $62.30 (range $4.37-$1515.00; iqr $42.13-$55.00) (fig. 1, (fig. 2) . no statistically significant association (p < 0.05) was found between testing charges and state-level testing rates, infection rates, or mortality rates. a small proportion of covid-19 diagnostic testing and antibody testing services, provided in selected states, had charges that far exceeded the medicare rate. high charges may create financial barriers for some uninsured patients and lead to higher premiums for out-of-network private plans. the results, based on a proportion of all testing claims in the usa, might underestimate the national variation of covid-19 testing charges. the insurance and network status of each claim and the actual prices paid were unavailable. other facilities include ambulatory surgical center, esrd treatment center, federally qualified health center, public health clinic, rural health clinic, skilled nursing facility, telehealth, tribal free-standing clinic, urgent care facility, walk-in retail health clinic, hospital emergency room, and unspecified settings. the data include 165 independent laboratories, 325 hospital outpatient settings, 214 physician offices, and 60 other facilities. the width (degrees) of each slice represents the relative service volume. the radius of each slice represents the average charge. the medicare reimbursement rate is $42.13. mark k. meiselbach, bsc 1 ge bai, phd, cpa 1,3 gerard f. anderson, phd 1,2 a b figure 2 average charges for covid-19 testing, by state. a diagnostic testing (cpt code: 87635), n = 182,149. states that had ten or fewer claims were classified as "no data." the medicare reimbursement rate is $51.31. b antibody testing (cpt code: 86769), n = 318,546. states that had ten or fewer services were classified as "no data." the medicare reimbursement rate is $42.13. two friends in texas were tested for coronavirus variation in the ratio of physician charges to medicare payments by specialty and region diagnostic testing (cpt code: 87635) cpt code: 86769) extreme markup: the fifty us hospitals with the highest charge-to-cost ratios united states congress. h.r.748 -cares act faqs about families first coronavirus response act and coronavirus aid, relief, and economic security act implementation covid-19 research database publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-276026-etj5vpg5 authors: hu, jiun-ruey; wang, margaret; lu, francis title: covid-19 and asian american pacific islanders date: 2020-06-12 journal: j gen intern med doi: 10.1007/s11606-020-05953-5 sha: doc_id: 276026 cord_uid: etj5vpg5 nan current challenges in these communities and helps establish trust. the american psychiatric association's dsm-5 outline for cultural formulation notes that "experiences of racism and discrimination in the larger society may impede establishing trust and safety in the clinical diagnostic encounter. effects may include problems eliciting symptoms, misunderstanding of the cultural and clinical significance of symptoms and behaviors, and difficulty establishing or maintaining the rapport needed for an effective clinical alliance." therefore, the outline calls for the clinician to assess the cultural identity of the individual, cultural conceptualizations of distress, psychosocial stressors, and cultural features of vulnerability and resilience, and cultural features of the relationship between the individual and the clinician. 5 to obtain this information, the general practitioner can use some of the 16 questions in the dsm-5 cultural formulation interview. 5 assess cultural identity by asking, "for you, what are the most important aspects of your background or identity?" assess conceptualizations of distress: "what brings you here today?" and "why do you think this is happening to you? what are the causes of your problem?" similarly, assess psychosocial stressors and cultural features of vulnerability and resilience: "are there any kinds of support that make your problem better, such as support from family, friends, or others?" determine cultural features of the relationship between the individual and the clinician: "have you been concerned about doctors and patients coming from different backgrounds and is there anything that we can do to provide you with the care you need?" the patient is our greatest teacher on their experience. meanwhile, clinicians may find themselves as a witness observing a covid-19-related discriminatory act against a colleague or a patient. the confronting prejudiced response (cpr) model formulates that, in overcoming obstacles to intervening as a bystander, one must recognize the prejudice, perceive it as an emergency, feel a sense of responsibility, and view the benefits as outweighing the costs. 6 although no validated intervention for covid-19-related discrimination exists yet, bystanders may be empowered by current frameworks for bystander intervention, such as from the 4 ds of bystander intervention (distract, delegate, direct, delay) adapted by the american friends service committee to combat racism, to the interrupt, question, acknowledge, educate, echo framework adapted from the southern poverty law center to promote tolerance in teaching. 7 consider the statement "get me a different nurse who does not eat bats. i don't want to get 'kung flu'" using the latter framework. in nonviolent environments where teaching is possible, interrupt: call attention to the fact that an aggression occurred and did not go unnoticed. "let's stop and talk about asians eating bats giving you 'kung flu'." question: ask them to explain why the joke is funny and seek to understand their intentions. "what made you say that?" or "why do you think that?" acknowledge: validate where possible, but set limits. "i understand that you are anxious about catching the virus yourself. however, i do not feel comfortable when you use a term like that." educate: bridge gaps by appealing to evidence. "the virus can infect folks of any race, so we all have to do our part." echo: in group settings, if someone else has interrupted the bias, re-iterate the message and/or thank the first person for speaking up. while there has been an increase in the use of hashtags that encourage violence against chinese people, there has also been a spike in anti-semitic hashtags espousing racist tropes about the virus "being used to kill off large portions of the population." 8 as a medical community, we must make it clear to society that the racist rhetoric of blame threatens mental health and even lives-as we have already seen with the stabbing of the burmese-american family. the scapegoating of minority populations to explain a pandemic should never be acceptable. racism is a determinant of health and should not be overlooked by clinicians. the murders of george floyd and breonna taylor last month are just two reminders of how systemic racism is a national public health crisis. now and when the pandemic abates, we must work to ensure that medicine as a field continues to care for all minority communities. fbi says texas stabbing that targeted asian-american family was hate crime fueled by coronavirus fears. the dallas morning news incidents of coronavirus discrimination structural racism and health inequities in the usa: evidence and interventions. the lancet the poor mental health care of asian americans american psychiatric association. diagnostic and statistical manual of mental disorders, fifth edition the confronting prejudiced responses (cpr) model: applying cpr in organizations how to respond to coronavirus racism. teaching tolerance covid-19 has caused a major spike in anti-chinese and anti-semitic hate speech key: cord-327463-uw3rhkf3 authors: xiao, roy; rathi, vinay k. title: price transparency for covid-19 testing among top us hospitals date: 2020-09-18 journal: j gen intern med doi: 10.1007/s11606-020-06197-z sha: doc_id: 327463 cord_uid: uw3rhkf3 nan on march 27, 2020, congress passed the coronavirus aid, relief, and economic security (cares) act in response to the covid-19 pandemic and its economic repercussions. 1 under the cares act, private insurers are required to cover in vitro diagnostic testing for covid-19 without patient cost sharing or other barriers during the public health emergency. to mitigate the risk of out-of-network billing for insurers that had not already negotiated rates, providers such as hospitals were required to publicly disclose the maximum "cash price" for tests online. of note, this legislation does not prohibit providers from directly billing patients for testing. 2 price transparency may help promote widescale testing as policymakers seek to safely reopen the economy; in the coming months, an estimated 20 million tests per day will be necessary. 3 however, there are reports that some providers may not be complying with price transparency mandates and instead imposing significant financial obligations on patients and payors. 4 we performed a cross-sectional analysis of online covid-19 test price transparency among top us hospitals. we systematically reviewed the public websites of all hospitals in the 2019-2020 u.s. news and world report "best regional hospitals" list to determine whether the following information was available for in vitro covid-19 tests: cash prices (yes/ no), hospital charges (yes/no), test type (molecular/serology/ unspecified; non-mutually exclusive). when available, cash prices represented the maximum amount payable to hospitals for testing by patients or insurers. for hospitals that did not list cash prices, hospital charges represented the maximum payable amount. we collected information from dedicated hospital webpages on covid-19 information, billing/price estimate webpages, public chargemasters, and web searches. for each hospital, we further extracted (as available) the lowest/highest cash prices and hospital charges for each test type. for hospitals that disclosed both cash prices and hospital charges, we estimated the corresponding out-of-network bill balance (defined as the difference between hospital charge minus the cash price) for each type of test offered. we used descriptive statistics to summarize all information. institutional review board approval was not required because this study analyzed publicly available data. all searches were completed between may 25, 2020, and may 29, 2020. we analyzed all data using microsoft excel version 16.37 (microsoft corporation, redmond, wa) and r version 3.6.0 (r foundation for statistical computing, vienna, austria). approximately one-third (n = 181/566; 32.0%) of hospitals disclosed cash prices for in vitro covid-19 testing (fig. 1) ; 181 (32.0%) listed only hospital charges and 204 (36.0%) did not disclose pricing information. among hospitals disclosing cash prices, the median lowest prices for molecular (n = 76) and serology (n = 36) were $67.90 (interquartile range [iqr]: $51.31-$122.75) and $57.00 (iqr: $40.75-$70.00), respectively. the median highest cash price for molecular tests was $100.00 (iqr: $81.60-$157.50) with a maximum cash price of $525.00. among hospitals disclosing only hospital charges, the median lowest charges for molecular (n = 181) and serology (n = 83) were $130.00 (iqr: $100.00-$195.62) and $100.00 (iqr: $65.00-$153.00), respectively. the median highest hospital charge for molecular tests was $153.00 (iqr: $101.31-$250.00) with a maximum hospital charge of $850.00. among hospitals disclosing both cash prices and hospital charges, the median lowest bill balances for molecular (n = 27) and serology (n = 14) were $66.96 (iqr: $7.00-$120.00) and $6.00 (iqr: $6.00-$30.00), respectively. the median highest bill balance for molecular tests was $108.25 (iqr: $10.00-$234.00) with a maximum bill balance of $383.96. our analysis supports concerns about hospital compliance with federal regulations to disclose pricing information for covid-19 testing. these findings may be partially explained by the relatively modest penalties ($300 per day) for noncompliance. 1 to help patients and insurers better understand the price of testing, lawmakers could consider measures such as prohibiting providers from balance billing patients for testing or establishing price ceilings 5 for private insurers using medicare prices as a reference. our study has limitations. we restricted analysis to top us hospitals; thus, our findings are not generalizable to labs or other types of providers (e.g., urgent care centers). furthermore, we may underestimate the overall level of price transparency for covid-19 testing because information may be available through other means, such as phone or point-ofservice inquiries. lessening the financial uncertainties and burdens of covid-19-related care will be critical as many americans face the hardships of recession. adoption of equitable payment policies for testing would be an important step towards protecting patients and public health during the ongoing crisis. figure 1 price transparency for in vitro diagnostic covid-19 testing among 2019-2020 u.s. world and news report best regional hospitals (n = 566). caption: excludes two hospitals that solely offered antigen testing for covid-19. 3548 -cares act congress said covid-19 tests should be free -but who's paying? kaiser health new roadmap to pandemic resilience: massive scale testing, tracing, and supported isolation (ttsi) as the path to pandemic resilience for a free society most coronavirus tests cost about $100. why did one cost $2,315? the new york times how the cares act affects covid-19 test pricing data access and responsibility: dr. xiao had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. key: cord-347454-zs909ldm authors: depuccio, matthew j.; di tosto, gennaro; walker, daniel m.; mcalearney, ann scheck title: patients’ perceptions about medical record privacy and security: implications for withholding of information during the covid-19 pandemic date: 2020-07-31 journal: j gen intern med doi: 10.1007/s11606-020-05998-6 sha: doc_id: 347454 cord_uid: zs909ldm nan some patients may withhold relevant medical information from their provider because of concerns about the security and privacy of their information, or about how their information will be used. 1 with increasing reliance on telemedicine and telehealth tools (e.g., patient portals) in response to the coronavirus disease 2019 (covid-19) pandemic, this issue may be particularly problematic. as withholding information can compromise providers' ability to deliver appropriate care, the accuracy of public health surveillance system data, and even population health efforts to mitigate the spread of covid-19, we need to understand how patients' concerns about the privacy and security of their medical information may lead to information-withholding behaviors. data for the present study came from a survey administered to patients hospitalized at a large academic medical center (amc) enrolled in a pragmatic randomized controlled trial (rct). 2 the rct studied the relationship between inpatient portal use and patients' care experience. one survey section asked about patients' attitudes toward use of health information technology, including their perceptions about information security risks and privacy. these questions were adapted from the national cancer institute's health information technology national trends survey. the institutional review board of the amc approved this study. the dependent variable for this study was the answer to the question "have you ever kept information from your healthcare provider because you were concerned about the privacy or security of your medical record?" (yes/no). on the basis of previous research, 3 we included four independent variables derived from answers to questions about medical information privacy and security: 1. "if your medical information is sent electronically from one health provider to another, how concerned are you that an unauthorized person will see it?" 2. "how confident are you that you have some say in who is allowed to collect, use, and share your medical information?" 3. "how confident are you that safeguards (including the use of technology) are in place to protect your medical records from being seen by people who aren't permitted to see them?" 4. "how interested are you in exchanging medical information electronically with a healthcare provider?" a multivariable logistic regression model was used to test the relationship of the independent variables with informationwithholding behavior, adjusting for patient demographics. table 1 summarizes patient characteristics and survey responses of our study participants. results of our regression analysis ( table 2) show that for patients who were concerned that their medical information would be compromised if it was sent electronically between providers, the odds of withholding information from their provider was three times that of patients without concerns. conversely, for patients who were confident about the privacy of their medical information, the odds of keeping information from their provider was approximately half of those who were not confident. black patients were generally more likely to withhold information compared with white patients. patients who were older, married, employed, and in good mental health and who had healthcare coverage were less likely to keep information from their provider. similar to previous research conducted in the general population, 3, 4 our findings suggest that many hospitalized patients are concerned about who has access to their medical information, and we found an association between these concerns and patients' reported information-withholding behavior. while these findings were limited to the perceptions of patients from a single amc, they are nonetheless important for providers to consider given relaxation of health insurance portability and accountability act (hipaa) protections in response to covid-19. specifically, the u.s. office for civil rights has granted business associates (e.g., healthcare clearinghouses) the ability to make good-faith disclosures of personal medical information for public health activities as long as the patient is informed within 10 days. 5 in order to protect against potential adverse impacts of this rule on disclosure, providers likely need to reinforce technological safeguards, such as secure and encrypted communication, and clearly communicate about how patients' medical information is accessed, stored, and used in order to honor patient privacy preferences 6 and potentially address patients' concerns in this area. monitoring the impact of these changes on patients' information-withholding behavior will be critical to ensure providers have the appropriate information to enable delivery of high-quality care. *definitions for each variable can be found in table 1 putting the focus back on the patient: how privacy concerns affect personal health information sharing intentions high touch and high tech (ht2) proposal: transforming patient engagement throughout the continuum of care by engaging patients with portal technology at the bedside concern about security and privacy, and perceived control over collection and use of health information are related to withholding of health information from healthcare providers trust me, i'm a doctor: examining changes in how privacy concerns affect patient withholding behavior notification of enforcement discretion under hipaa to allow uses and disclosures of protected health information by business associates for public health and health oversight activities in response to covid-19 (45 cfr parts 160 and 164) ethical practice in telehealth and telemedicine the authors wish to thank alice gaughan, conflict of interest: the authors declare that they do not have a conflict of interest.disclaimer: while this research was funded by the agency for healthcare research and quality, the study sponsor had no involvement in the collection, analysis, or interpretation of data; in the writing of this manuscript; or in the decision to submit the manuscript for publication. key: cord-259952-58q4ma92 authors: ganson, kyle t.; weiser, sheri d.; tsai, alexander c.; nagata, jason m. title: associations between anxiety and depression symptoms and medical care avoidance during covid-19 date: 2020-09-01 journal: j gen intern med doi: 10.1007/s11606-020-06156-8 sha: doc_id: 259952 cord_uid: 58q4ma92 nan since the outbreak of the novel coronavirus disease 2019 (covid-19) pandemic, emergency health care utilization has acutely declined by 23% for heart attacks, 20% for strokes, and 10% for hyperglycemic crises. 1 ambulatory visits have also declined by nearly 60%. 2 the lack of health care utilization is concerning as it may result in significant medical complications resulting from untreated medical problems. 1 little is known about what is driving these declines in health care utilization. a study from italy suggested that fear of covid-19 infection may be one such factor. 3 recent research has documented pervasive anxiety and depression during the covid-19 pandemic. 4, 5 we conducted this study to estimate the association between mental health symptoms and medical care avoidance among us adults. we analyzed data from june 11-june 16, 2020, of the weekly, cross-sectional household pulse survey (hps; n = 73,472) which is conducted by the us census bureau in collaboration with five other federal agencies to produce data on the social and economic impacts of covid-19 among adults in the usa. the hps questionnaire was reviewed by independent experts at the center for behavioral science methods, as well as the demographic directorate and subject matter representatives from the five partner federal agencies. to gather the sample, hps used the census bureau's master address file as the primary sampling frame to collect responses from a large sample that is sufficient for the anticipated low responses rates. the census bureau used the online platform qualtrics as the primary data collection method. see the census bureau website (https://www.census.gov/ householdpulsedata) for more information and access to publicly available data. we fitted modified multivariable poisson regression models to estimate the associations between four mental health symptoms (nervous, anxious, or on edge; not being able to stop or control worrying; little interest or pleasure in doing things; feeling down, depressed, or hopeless) in the past 7 days and medical care avoidance (delayed medical care; needed non-coronavirus medical care but did not get it) due to the coronavirus pandemic in the past 4 weeks. the use of robust estimates of variance permits straightforward interpretation of the exponentiated regression coefficients as risk ratios. we adjusted for potential confounding by age, sex, race/ethnicity, income, education, employment loss, and marital status. nonresponse sample weighing was applied. analyses were conducted using stata 15.1. demographic and descriptive results are displayed in table 1 . individuals who experience all four symptoms of anxiety and depression had higher adjusted relative risk ratios of delayed medical care and not receiving needed non-coronavirus medical care, after adjustment for potential confounders (table 2) . individuals who were nervous, anxious, or on edge in the past 7 days had the highest adjusted relative risk ratio of delayed medical care (1.95, 95% ci 1.83-2.09) and the highest adjusted relative risk ratio of not receiving needed non-coronavirus medical care (2.08, 95% ci 1.93-2.25). in this population-based study of us adults from june 11-16, 2020, we show that mental health symptoms are strongly correlated with medical care avoidance amidst the covid-19 pandemic. our results revealed significantly higher adjusted relative risk ratios of medical care avoidance among us adults who experience common symptoms of anxiety and depression. importantly, our results show that individuals who experience these symptoms are more likely to avoid seeking non-coronavirus medical care despite needing it, which is concerning as delayed medical care may result in significant adverse short-and long-term health outcomes for many conditions. 1 our results provide support for accurate and effective translation of knowledge to the public about the risks and benefits of seeking needed medical care during the ongoing covid-19 pandemic. of particular importance is the expansion of health insurance policies to cover telehealth services 6 and continued efforts to implement telehealth services to address non-emergency medical concerns. additionally, a continued increase in telepsychiatry and telemental health services is needed to assist us adults in managing mental health symptoms for the duration of the covid-19 pandemic. , the modified poisson model permits interpretation of the exponentiated regression coefficients as risk ratios rather than incidence rate ratios. june 11-june 16, 2020 †"at any time in the last 4 weeks, did you delay getting medical care because of the coronavirus pandemic?" ‡"at any time in the last 4 weeks, did you need medical care for something other than coronavirus, but did not get it because of the coronavirus pandemic?" § "over the last 7 days, how often have you been bothered by the following problems ... feeling nervous, anxious, or on edge?" ‖ "over the last 7 days, how often have you been bothered by the following problems ... not being able to stop or control worrying?" ¶ "over the last 7 days, how often have you been bothered by ... having little interest or pleasure in doing things?" # "over the last 7 days, how often have you been bothered by ... feeling down, depressed, or hopeless?" potential indirect effects of the covid-19 pandemic on use of emergency departments for acute life-threatening conditions -united states the impact of the covid-19 pandemic on outpatient visits: a rebound emerges. the commonwealth fund delayed access or provision of care in italy resulting from fear of covid-19 covid-19 and mental health: a review of the existing literature the outbreak of covid-19 coronavirus and its impact on global mental health telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) we would like to thank samuel benabou for providing editorial assistance. key: cord-355851-t8xh6327 authors: goodman, christopher w.; brett, allan s. title: accessibility of virtual visits for urgent care among us hospitals: a descriptive analysis date: 2020-05-18 journal: j gen intern med doi: 10.1007/s11606-020-05888-x sha: doc_id: 355851 cord_uid: t8xh6327 nan complex regulations and limited reimbursement have hindered telehealth. 1 however, increasing experience with telehealth during the covid-19 crisis represents an opportunity to facilitate its use more generally after this crisis. 2 while telehealth has the potential to expand access to care, disparities in access are an ongoing concern. 3 many hospitals now offer real-time "virtual visits" for common urgent care through their websites, which offer an opportunity to assess the accessibility of a typical telehealth service. 4 we assembled a geographically representative sample of 170 hospitals in the usa, according to previously published methodology. 5 in brief, we selected hospitals according to an algorithm that involved gross receipts, geographic diversity, and bed size; at least one hospital in each state was included. hospitals are often part of multi-hospital systems with web portals for the entire network of hospitals. in our estimation, websites of sampled hospitals represented about 1200 hospitals, one-fifth of all us hospitals. many hospitals have begun offering virtual visits for urgent care with real-time connectivity through their websites. we chose to focus on virtual urgent care with both audio and visual connectivity. hospitals used different names for these services such as "e-visits," "virtual urgent care," and "virtual visits." we included links to primary care visits if the website clearly indicated quick access for urgent care. we excluded other versions of urgent care including online algorithms (e.g., "symptom checkers") or audio-only services. we examined hospital websites and their virtual visit sites, focusing on three accessibility characteristics: general availability, language accommodations, and affordability. general availability included the presence or absence of virtual visits and relevant exclusions. navigation started from the main hospital system website, with attempts to proceed logically to virtual urgent care, or "virtual visits." if that failed, a separate search was conducted with the hospital's name and "virtual visits." we included virtual visits with real-time, audio-visual connectivity for urgent care. websites were accessed march 23-april 2, 2020. table 1 ); however, restrictions were common: about onefifth of virtual visits were not publicly accessible. even among hospitals with publicly accessible virtual visits, further limitations included geographic limitations (i.e., accessing care across state lines) and exclusions for chronic health conditions. ease of navigation was variable. some virtual visit links were advertised on the main page, while others required more thorough searches. language accessibility was poor. among hospitals with virtual visits, 31% made language accommodations easily identifiable on navigation (usually only spanish translation). only 1 hospital clearly noted interpreter options for virtual visits. most hospitals charged a flat fee for virtual visits (median charge, $49). payment was usually required upfront; no hospital made accommodations for ability to pay (although 16% temporarily waived fees in relation to covid-19). virtual visits were not easily or equitably accessible; in general, navigation of hospital websites was challenging. most hospitals required navigation in english, and only one clearly offered interpreter services, which are considered best practice and legally required. exclusions for new patients or patients with chronic medical conditions suggest that clinicians and hospitals may be hesitant to care for new or complex patients without physical examinations; however, such exclusions favor healthier, insured patients. the requirement of up-front payment, albeit modest, reinforces bias towards higher income patients. other limitations such as the reading level of websites and internet bandwidth requirements were not assessed and deserve further investigation. broadband access is a welldescribed limitation for rural and low-income communities. 6 the pattern that emerges in this survey is all too familiar: access favors generally healthy, well-off, english-speaking patients. we suspect this pattern results from a combination of telehealth policy constraints (e.g., limited reimbursement) and neglect on the part of clinicians and hospitals. public policy committee of the american college of physicians. policy recommendations to guide the use of telemedicine in primary care settings: an american college of physicians position paper virtually perfect? telemedicine for covid-19 telemedicine 2020 and the next decade in-person health care as option b charity care characteristics and expenditures among us tax-exempt hospitals in 2016 broadband access as a public health issue: the role of law in expanding broadband access and connecting underserved communities for better health outcomes publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. charges transparent 72 (73%) accommodations for low income || 0 *restrictions included the following: access only for "established" patients, exclusion of patients on federal insurance programs, and requirement to purchase additional telehealth equipment †generally, geographic limitations were state-based, requiring the patient to be physically located in a given state at the time of the visit ‡some websites alluded directly or indirectly to excluding patients with chronic conditions; however, language was often too vague to allow formal quantitation § language support included hospitals with any link or visual aid that indicated translation of the website or interpretation of virtual visits || while none of the hospital websites made general accommodations for income status, 16 hospitals waived fees temporarily due to covid-19 or specifically for visits related to covid-19 key: cord-339533-r0qsqjus authors: mein, stephen a title: covid-19 and health disparities: the reality of “the great equalizer” date: 2020-05-14 journal: j gen intern med doi: 10.1007/s11606-020-05880-5 sha: doc_id: 339533 cord_uid: r0qsqjus nan f rom government officials to mainstream media and even celebrities, coronavirus disease 2019 (covid-19) has been touted as "the great equalizer." it is a disease that transcends wealth, fame, prestige, or age. we are all at risk. the statement highlights our vulnerability as part of a society that lacks any immunity to the novel virus. however, it also inaccurately assumes that we will all be equally affected by it. history has shown that this will not be the case. pandemics have the unique ability to amplify existing health inequalities, disproportionately affecting socially disadvantaged groups, including racial and ethnic minorities and low-income populations. during the 2009 h1n1 influenza pandemic, minority groups had higher rates of serious infection requiring hospitalizations compared with non-minority groups. 1 similarly, during the 1918 "spanish" influenza pandemic, racial minorities had both higher all-cause mortality and influenza mortality rates compared with caucasians. 2 early data from covid-19 hot spots around the country are beginning to tell a similar story. in new york, now the epicenter of the outbreak, predominantly black and hispanic neighborhoods are seeing higher numbers of cases and fatalities. hispanic and black patients currently make up 34% and 28% of all fatalities in new york city despite only comprising 29% and 22% of the population, respectively. concurrently, deaths among whites are at 27% of all cases despite constituting 32% of the population. 3 similar findings are being reported in other parts of the country as well. data from michigan shows both higher percentages of cases (33% vs 24%) and deaths (40% vs 30%) in blacks compared with whites even though blacks only account for 14% of the population. 4 the consistency of outcomes from pandemics spanning decades reveals deep underlying truths about health disparities. racial and ethnic minorities are at both a higher risk of contracting covid-19 and suffering worse outcomes. chief strategies for minimizing the spread of a pandemic include early detection, isolation of confirmed cases, and social distancing. across the country, states have implemented shelter-in-place orders, requesting citizens to remain at home and limiting non-essential services. additionally, infected individuals are instructed to quarantine at home if well enough to do so. while these steps are necessary to "flatten the curve" and reduce transmission of covid-19 and the strain on healthcare facilities, the recommendations inadvertently preferentially harm the socially disadvantaged. longstanding inequalities have placed a greater proportion of racial and ethnic minority populations near or below the federal poverty line. low-income groups are more likely to work in the service industry doing jobs that reduce their ability to work from home and historically lack sick leave. 5 they are also more commonly single-income families, and a greater dependence on their income may leave them continuing jobs that place them at a higher risk of contracting covid-19. 5 conversely, government regulation that stops all non-essential services leads to higher unemployment rates among this population, evidenced by the recent dramatic rise in first time unemployment claims. unemployment comes with a loss of employer-based health insurance leaving a population with already lower rates of insurance even more vulnerable. 5, 6 low-income populations are more likely to live in crowded conditions and rely on public transportation, both of which limit their ability to successfully social distance. 6 minority groups also more commonly speak another language, impeding their ability to obtain information and also delaying care and reducing the quality of care they receive. 5, 6 once infected, racial and ethnic minorities are at a greater risk of increased disease severity. it is well known that comorbidities are associated with more severe influenza illness. 6 initial studies from china have shown a similar pattern with covid-19. hypertension, diabetes, coronary artery disease, chronic obstructive lung disease, and chronic kidney disease have all been associated with increased mortality. 7 previous epidemiological studies have consistently shown many of these conditions to be more prevalent in racial/ethnic minorities, likely contributing to the worse health outcomes seen from covid-19. 2 the current pandemic is highlighting the health disparities that already exist within our communities. steps must be taken to better understand and mitigate this complex crisis. first, the issue needs to be better identified. until recently, there has been minimal comprehensive demographic data reported from the centers for disease control and prevention (cdc) or other governing bodies around the racial/ethnic characteristics of patients infected with covid-19. many people, including those in the medical field as well as politicians, are now calling for more transparency around this topic. once this data becomes more widely available, it will need to be strategically leveraged in order to improve the care of these patients. specifically, it should shape our allocation of resources to ensure that there is sufficient screening and treatment of covid-19 in resource limited settings that have higher proportions of racial and ethnic minorities. finally, as a vaccine becomes available, vaccination strategies could worsen disparities. 6 historically, racial and ethnic groups have had suboptimal influenza vaccination rates, particularly among young adults. 2, 6 a vaccine response to covid-19 might include large-scale vaccination clinics or delivery through primary care offices. both would require patients to seek vaccination and thus may accentuate the problem and widen differences in vaccination rates. 2 grassroots vaccine campaigns that meet people in their communities through mobile health centers or clinics at nontraditional sites like shelters will need to be utilized. it will be important to engage local and trusted partners with both the development and implementation of these programs. health disparities have long plagued our country and greatly impacted racial and ethnic minorities. covid-19 is already showing signs of accentuating these disparities. while covid-19 places everyone in this country at risk, it is not "the great equalizer." it will continue to preferentially affect the socially disadvantaged. it is our responsibility as the medical community to work to identify and alter these outcomes for our patients. centers for disease control and prevention. information on 2009 h1n1 impact by race and ethnicity protection of racial/ethnic minority populations during an influenza pandemic new york state department of health. nysdoh covid-19 tracker coronavirus: michigan data racial disparities in exposure, susceptibility, and access to health care in the us h1n1 influenza pandemic pandemic influenza planning in the united states from a health disparities perspective. emerg infect dis clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study key: cord-267114-tvoi6a7q authors: abdus, salam title: financial burdens of out-of-pocket prescription drug expenditures under high-deductible health plans date: 2020-09-18 journal: j gen intern med doi: 10.1007/s11606-020-06226-x sha: doc_id: 267114 cord_uid: tvoi6a7q nan the costs of prescription drugs increased significantly in the usa over the past few years. 1 the prevalence of high-deductible health plans (hdhps) also increased steadily over the last two decades. 2 since hdhp enrollees may face the full cost of their initial purchases of prescription drugs, increases in the prices of prescription drugs are likely to have a significant impact on hdhp enrollees. prior research examined total out-of-pocket health care expenditure burdens of hdhp enrollees. 3, 4 little is known, however, about the burdens of out-of-pocket prescription drug expenditures in particular. this study examines financial burdens of out-of-pocket prescription drug expenditures across different levels of deductibles. the study focuses on low-income adults (family income less than 250% of federal poverty level) with multiple, prevalent chronic conditions, who are more likely to be constrained by their resources and use more prescription drugs. data for this analysis come from 2012-2017 medical expenditure panel survey household component (meps-hc). the sample was restricted to adults ages 19 to 64 who were enrolled in employer-sponsored health insurance plans throughout the year. data was pooled across multiple years given the small sample size of the subpopulation of lowincome adults with multiple chronic conditions. the following self-reported chronic conditions were identified: diabetes, asthma, hypertension, arthritis, heart disease, cancer, chronic bronchitis, stroke, and emphysema. following the literature, financial burden of prescription drugs was calculated as annual family out-of-pocket prescription drug spending divided by annual family disposable (after-tax) income, and 10-percent burden (out-of-pocket prescription drug spending exceeding 10 percent of disposable income) was used as a measure of high burden. 5 health plans were classified into three categories-high-deductible (deductible levels exceeded the internal revenue service threshold for high-deductible plans), low-deductible (deductibles were below the internal revenue service threshold), and no-deductible health plans. two-tailed t tests were used for making comparisons. among all adults (n = 39,421), the prevalence of 10-percent prescription drug burden was 1.2% or lower for any deductible group (table 1) . among low-income adults (n = 7,510), the prevalence of 10-percent burden for high-and low-deductible enrollees was 5.0% (p < .01) and 3.1% (p < .01), respectively, compared with 1.6% among no-deductible enrollees. among low-income adults with two or more chronic conditions (n = 1,354), the high burden rate for the high-deductible group, at 14.3%, was higher than that for the no-deductible group at 5.5% (p < .05). among low-income adults with multiple chronic conditions, high-deductible enrollees were more likely than the no-deductible enrollees to have a 10-percent burden from brand name drugs alone (11.5% versus 3.2%, p < .05), but the differences in the prevalence of 10-percent burden from generic drugs alone across deductible groups were not statistically significant (table 2) . among low-income adults with employer-sponsored insurance who had multiple chronic conditions and were enrolled in high-deductible plans, about 14.3% had family out-ofpocket prescription drug expenditures exceeding 10 percent of family disposable income. while out-of-pocket costs for prescription drugs have decreased in recent years, 1 the results of this study suggest that for low-income adults with multiple chronic conditions who are enrolled in employer-sponsored high-deductible plans, out-of-pocket prescription drug costs may still result in significant financial hardships. as brand name drugs tend to be expensive, it is not surprising that the differences in financial burdens across deductible levels are coming primarily from out-of-pocket spending on brand name drugs. the coronavirus pandemic may further exacerbate the financial burdens of prescription drugs in numerous ways. for example, utilization of prescription drugs for mental health may increase 6 , which may affect the out-of-pocket costs for those in high-deductible health plans in particular. also, loss using the self-reported priority conditions in meps hc, the following diagnosed conditions were identified: diabetes, asthma, hypertension, arthritis, heart disease, cancer, chronic bronchitis, stroke, and emphysema. adults who reported having ever been diagnosed with coronary heart disease, angina, myocardial infarction, or any other kind of heart condition or heart disease were defined as having heart disease. adults who reported having ever been diagnosed with asthma and who reported they still had asthma or had an asthma attack in the past 12 months were defined as having asthma. adults who reported being diagnosed with high blood pressure on two or more occasions were defined as having hypertension † base group *,**,***statistically significantly different, based on two-sample t tests, from the no-deductible plan enrollees at the 5%, 1%, or 0.1%, respectively the sample comprised adults ages 19 to 64 who were enrolled in employer-sponsored health insurance plans and no other coverage throughout the year fpl, federal poverty level using the self-reported priority conditions in meps hc, the following diagnosed conditions were identified: diabetes, asthma, hypertension, arthritis, heart diseases, cancer, chronic bronchitis, stroke, and emphysema. adults who reported having ever been diagnosed with coronary heart disease, angina, myocardial infarction, or any other kind of heart condition or heart disease were defined as having heart disease. adults who reported having ever been diagnosed with asthma and who reported they still had asthma or had an asthma attack in the past 12 months were defined as having asthma. adults who reported being diagnosed with high blood pressure on two or more occasions were defined as having hypertension out-of-pocket expenditures on brand name drugs and generic drugs add up to total out-of-pocket prescription drugs expenditures a family was defined as health insurance eligibility units (hieus), which comprised adults, their spouses, and co-residing children under 19. disposable family income was defined as after-tax family income (income taxes, social security taxes, and medicare taxes using the web-based version of the national bureau of economic research taxsim model) † base group *statistically significantly different, based on two-sample t tests, from the no-deductible plan enrollees at the 5% of jobs may not only change the composition of adults with access to employer-sponsored insurance but also reduce family income. the impact might be worse for those with chronic conditions as they could be at higher risk of developing serious illness from coronavirus. the estimates from this study can be used as a baseline to compare with later estimates, once data on household prescription drugs use and income during the pandemic becomes available. the key takeaway point of this paper for general internists is that for patients with chronic conditions, who are more likely to use prescription drugs, outof-pocket costs of prescription drugs could be really burdensome if they are enrolled in high-deductible plans. medicine use and spending in the u.s.: a review of 2017 and outlook to 2022 kaiser family foundation and health research and educational trust, employer health benefits survey financial burden of employer-sponsored highdeductible health plans for low-income adults with chronic health conditions health insurance deductibles and their associations with out-of-pocket spending and affordability barriers among us adults with chronic conditions the financial burden from prescription drugs has declined recently for the nonelderly, although it's still high for many prescriptions for antidepressants, anti-anxiety, antiinsomnia drugs jumps 21% post covid-19. fierce healthcare key: cord-283917-jumgb0hs authors: li, hang long; cheung, bernard m. y. title: the proportion of adult americans at risk of severe covid-19 illness date: 2020-10-26 journal: j gen intern med doi: 10.1007/s11606-020-06325-9 sha: doc_id: 283917 cord_uid: jumgb0hs nan the covid-19 pandemic has affected more than 23 million people worldwide, including 5.6 million americans. because of these numbers, identifying the population(s) at risk is important. the us centers for disease control and prevention (cdc) announced on july 17, 2020, that conditions including obesity, diabetes mellitus (dm), chronic kidney disease (ckd), heart disease, and chronic obstructive pulmonary disease (copd) are well-established risk factors predisposing individuals to severe illness from covid-19. 1 other probable risk factors with less robust evidence include asthma and hypertension. we aimed to estimate the proportion of adult americans at risk from severe covid-19 illness. in this analysis, participants in the united states national health and nutrition examination survey (nhanes) 2011-2016 2 aged ≥ 20 years were included. pregnant participants and those with missing relevant laboratory/examination/selfreported data were excluded. the prevalence and 95% confidence intervals (95% ci) of established risk factors (obesity, dm, ckd, heart disease, and copd), probable risk factors (asthma, stroke, hypertension, taking immunosuppressive agents, and liver disease), and any risk factors (established or probable risk factors) were calculated. subgroups according to age (< 50 and ≥ 50 years), sex, ethnicity, education, and income level were compared. data analysis was performed using the r statistical package "survey" (version 3.6.3). altogether, 7744 nhanes participants with a mean age of 49.5 years were included (table 1) . overall, the prevalence of having ≥ 1 established, probable, or any risk factor were 58.9% (95% ci 56.7-61.0), 55.5% (95% ci 53.2-58.0), and 73.7% (95% ci 71.6-76.0), respectively (table 2) . obesity was the most common established risk factor (41.0%), followed by dm (24.0%) and ckd (18.4%). hypertension was the most common probable risk factor (50.1%), followed by asthma (8.9%) and stroke (3.6%). obesity and hypertension were consistently the leading risk factors in both age groups: the prevalence of obesity and hypertension in the younger age group were 38.9% and 31.1%, respectively, whereas in the older age group, 43.0% and 68.4% had obesity and hypertension, respectively. older participants were more likely to have ≥ 1 any risk factor; 86.2% of people aged ≥ 50 years had ≥ 1 any risk factor, compared to 60.9% in people aged < 50 years (p < 0.001). whereas obesity was almost equally common in the young and the old, dm, ckd, heart disease, copd, stroke, and hypertension were all much more common in people aged 50 years or older. there were minor differences in the percentage of people with ≥ 1 established and ≥ 1 any risk factor according to sex, ethnicity, education, and income level, but the percentages remained around 60% and 75%, respectively. non-hispanic asian appeared to have a lower risk. this is the first study to estimate the proportion of the americans in the general population at risk from severe covid-19 illness using data from a nationally representative survey. alarmingly, three-quarters of adult americans are at risk. covid-19 is a threat to people across all age groups, sexes, ethnicities, education, and income levels. consequently, the three-quarters of adult americans at risk should stay at home as much as possible during a pandemic. they should observe strict social distancing and personal hygiene measures, such as face covering and hand disinfection. 3 they should have priority access to masks, viral tests, treatment facilities, drugs, and vaccines. 4 our study shows that obesity and hypertension are the leading risk factors for severe covid-19 illness, especially in those aged < 50 years. those at risk should seriously consider lifestyle modifications, including weight control, healthy diet, alcohol moderation, smoking cessation, and regular physical activity. these can also alleviate other risk factors including dm, ckd, and asthma, and help reduce the adverse psychological consequences of social distancing. 5 a limitation of nhanes is the reliance on self-reported medical history that might cause underestimation of risk factors. moreover, we have not included cancer as it is highly heterogeneous, or less common conditions such as sickle cell anemia and post-transplant immunodeficiency. in conclusion, an alarming three-quarters of americans are at increased risk of severe covid-19 illness. obesity and hypertension are the leading risk factors. individuals with increased risk should strictly follow social distancing and personal hygiene measures and adopt lifestyle modifications. data are presented as weighted mean ± standard error, or weighted percentage (95% confidence interval) dm, diabetes mellitus; ckd, chronic kidney disease; copd, chronic obstructive pulmonary disease p values for age group comparison were obtained by multivariate logistic regression, adjusted for sex and ethnicity, where appropriate, or by chisquare test, where appropriate obesity was defined as body mass index (bmi) ≥ 30 kg/m 2 dm was defined as (1) answered "yes" to "(other than during pregnancy), have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?" or (2) glycosylated hemoglobin ≥ 6.5%, or (3) fasting glucose ≥ 126 mg/dl heart disease was defined as answering "yes" to any of the questions below: (1) "has a doctor or other health professional ever told you that you had congestive heart failure?" or (2) "has a doctor or other health professional ever told you that you had coronary heart disease?" or (3) "has a doctor or other health professional ever told you that you had a heart attack (also called myocardial infarction)?" ckd was defined as (1) answering "yes" to "have you ever been told by a doctor or other health professional that you had weak or failing kidney?" or (2) estimated glomerular filtration rate (egfr) < 60 ml/min/1.73 m 2 using the chronic kidney disease epidemiology collaboration (ckd -epi) equation, or (3) urine albumincreatinine ratio ≥ 30 mg/g copd was defined as answering "yes" to either of the questions below: (1) "has a doctor or other health professional ever told you that you had emphysema?" or (2) "has a doctor or other health professional ever told you that you had chronic bronchitis?" asthma was defined as answering "yes" to both of the questions below: (1) "has a doctor or other health professional ever told you that you have asthma?" and (2) "do you still have asthma?" stroke was defined as answering "yes" to the question "has a doctor or other health professional ever told you that you have asthma?" liver disease was defined as answering "yes" to both of the questions below: (1) "has a doctor or other health professional ever told you that you had any kind of liver condition?" and (2) "do you still have a liver condition?" hypertension was defined as (1) having at least three of the blood pressure measurements on the day of examination as ≥ 130 mmhg for systolic measurement or ≥ 80 mmhg for diastolic measurement, or (2) answering "yes" to "have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?" publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. covid-19) people who need to take extra precautions physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis ethics and covid-19: resource allocation and priority-setting the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention conflict of interest: the authors declare that they do not have a conflict of interest. key: cord-348026-t1jkeu3d authors: ruhnke, gregory w. title: physician supply during the coronavirus disease 2019 (covid-19) crisis: the role of hazard pay date: 2020-06-10 journal: j gen intern med doi: 10.1007/s11606-020-05931-x sha: doc_id: 348026 cord_uid: t1jkeu3d nan t he coronavirus disease 2019 (covid-19) crisis has pushed the limits of our health care infrastructure, including the labor components of health system capacity, given the increasing incidence of clinically significant nosocomial infection with health care workers becoming exposed, infected, and overworked. the options for rapidly increasing the physician labor supply include physicians working outside their typical area of practice (e.g., shifting their site of work to the emergency room or inpatient units), retired physicians re-entering the workforce, substitution through alternative advanced practice providers (such as nurse practitioners and physician assistants), and early graduation of medical students. rapid licensure of retired physicians has received a great deal of media attention. many medical schools have encouraged their students to consider early graduation to work within their hospital system as interns. this has the advantage of immediately providing skilled, trained physicians who, based on demographic characteristics, are generally at low risk of deleterious outcomes in the event of either a community-acquired or health careassociated covid-19 infection. since the case fatality rate of covid-19 patients over age 60 ranges from 3.5 to 20.2%, physicians returning to work from retirement may create a substantial number of covid-19-related deaths (and increase ventilator demand) as a result of in-hospital transmission. such a migration of older physicians into the hospital setting would be extremely concerning-in one of the original case series, of those infected, 29% were health care workers. 1 there are other reasons to consider early graduation of medical students as a viable source of physician supply to meet mutual needs. according to one study of 16,394 internal medicine residents in 2008-2009, average educational debt was greater than $100,000 and $200,000 among 40.2% and 13.6%, respectively. 2 a study of 3083 graduating family medicine residents found that 58% reported having > $150,000 in educational debt and 26% reported having > $250,000. 3 debt indeed creates a dramatic financial burden on physicians-in-training and those early in their careers, making highly compensated employment opportunities extremely valuable. compensating differentials such as hazard pay have historically been applied to compensate workers for tasks that are either risky or particularly arduous. 4 underlying the theory of such differentials are the assumptions that workers must be aware of the hazards present, be averse to those hazards, and have alternative job options. these assumptions are based on the ethical avoidance of coercion and the principle that the choice to seek hazard pay should reflect a utility-maximizing rational decision based on complete and symmetric information. although the covid-19 pandemic has raised the issue of hazard pay for those who provide "essential" services that may require an exposure risk, only 26% of surveyed employers indicated they are planning to provide hazard pay. 5 compensating wage differentials for medical students willing to graduate early may maximize their personal utility while ameliorating the physician shortage during the current crisis. from a societal perspective, this would optimize allocation of low-risk physician labor capacity. most internal medicine residents are paid between $50,000 and $60,000 per year. if they voluntarily started residency early and received substantial hazard pay, this would allow them to significantly reduce their educational debt. a large debt burden has been associated with trainee choice of more lucrative specialty fields of medicine, 6 as well as a propensity to moonlight and reduced likelihood of seeking a career in academic medicine. 7 as a result, hazard pay offered to medical students willing to risk exposure to covid-19 now may reduce their debt burden and potentiate the creation of more primary care physicians, a dearth of whom has been a significant health policy concern. since moonlighting during graduate medical education exacerbates trainees' sleep deprivation while diminishing their educational focus, a medical student graduating early in 2020 to provide a societal good while earning hazard pay may have numerous benefits. in addition to graduating medical students, younger physicians have significant debt burdens and financial pressures. many newly constructed covid-19 units are staffed by physicians who have recently completed training, although anecdotal evidence suggests they are not receiving adequate compensation differentials, consistent with the non-physician data cited above. requests from medical center leadership for low-risk (i.e., younger) physicians, perhaps with subtle pressure, to work in such units without appropriate compensation is ethically suspect, and may in some cases be tantamount to coercion. it is important to acknowledge that many health care institutions are facing budgetary hardships for a variety of reasons due to this pandemic, which may pose considerable barriers to financing compensation differentials. however, there are several ways in which hazard pay might be financed based on local considerations and institutional structures: (a) small compulsory contributions from physicians (perhaps exempting those required to take unpaid furloughs) at a given institution not caring for covid-19 patients by choice or due to risk factors for bad outcomes if infected; (b) public funding, such as the coronavirus preparedness and response supplemental appropriations act of 2020; and (c) private foundations offering funding for covid-19 response efforts. hazard pay could of course be considered for all physicians risking their health to care for infected patients. also, a corollary consideration beyond the scope of this piece is supplementary life insurance for all health care workers who succumb to a covid-19 infection. however, the focus of this viewpoint is to propose an economically efficient method of bringing physicians to the bedside who would otherwise not be caring for covid-19 patients. offering an incentive to those willing and/or able to risk infection is ethically preferable to subtly or explicitly coercing junior physicians to take risks against their will without a reward. ethical dilemmas around compensating differentials most often center on workers' comprehension of the hazards present, as well as their magnitude. 4 on the one hand, graduating medical students should be sufficiently intelligent and welltrained to understand that the choice to graduate early for the public good includes both the opportunity costs of their alternative plans and the risks of covid-19 exposure. the risk of exposure, transmission, and clinically significant infection is difficult even for the centers for disease control and prevention to quantify, primarily because of imprecise estimates regarding the proportion of cases that result from asymptomatic carriers. however, regardless of the uncertainty of risk estimates among medical students voluntarily graduating early, the risks to older physicians re-entering practice from retirement is clearly substantial. a significant compensation differential for those at low risk of deleterious outcomes voluntarily working at the front lines is far more acceptable from economic and ethical perspectives than the alternatives. these include subtle coercion without compensation, forcing physicians to work outside their usual scope of practice, or utilizing the services of older physicians, whose work-related exposure may markedly increase the burden on an alreadyoverwhelmed health care system. intelligent and judicious use of hazard pay models has the potential to maximize aggregate societal welfare. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china quality of life, burnout, educational debt, and medical knowledge among internal medicine residents over half of graduating family medicine residents report more than $150,000 in educational debt hazard pay in unsafe jobs: theory, evidence, and policy implications payback time: the associations of debt and income with medical student career choice anesthesiology residents' medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey key: cord-270876-kul6bs3w authors: morris, nathaniel p. title: virtual visits and the future of no-shows date: 2020-06-08 journal: j gen intern med doi: 10.1007/s11606-020-05948-2 sha: doc_id: 270876 cord_uid: kul6bs3w nan the patient's finger approaches the screen. the screen goes black as his face and the interior of his car disappears. i had never completed a clinic appointment with a patient in a parked car until a few weeks ago. now, as our clinic shifts to virtual visits amid the coronavirus disease 2019 (covid-19) pandemic, i find myself routinely talking with patients in their cars, their closets, and their backyards. at first, these virtual visits seemed awkward and clunky. patients shouted into their smartphones, and i shouted at my computer as we tried to hear one another. i couldn't help but notice patients' belongings strewn in their backseats, the coats hanging over them, and the neighborhoods around them. then i realized something startling. despite these logistical issues, i couldn't recall the last time i had a no-show. no-shows, or when patients miss healthcare appointments, are the underbelly of medicine. estimates of outpatient noshow rates vary widely, with healthcare institutions reporting rates between 9 and 76% in recent years. [1] [2] [3] [4] in 2008, the veterans health administration reported approximately 3.1 million (12%) no-shows out of 26.5 million scheduled outpatient appointments and an estimated annual cost of 564 million from the total number of unused appointments. 1 no-shows can lead to disruptions in patient-clinician relationships, interruptions in pharmacotherapy, lack of testing follow-up, greater utilization of higher levels of care, psychological stress, and other adverse outcomes for patients. clinics can introduce measures, such as pre-appointment phone or text reminders, that may decrease no-show rates. however, in-person clinic visits still pose obstacles that can be challenging, if not insurmountable, for patients. in addition to keeping track of appointment locations and timing, patients and families may need to travel lengthy distances to clinics, which may entail taking public transportation, finding a ride, driving, walking, or a combination of modes of travel. upon arrival, patients may need to find and pay for parking, find the right clinic, find the right waiting room, and check in at the front desk. then, patients may sit and wait, often with prolonged delays, until someone brings them to a patient room. support staff might ask basic questions or take vitals, but then patients may wait for longer periods until their clinicians arrive at the appointments. after completing their visits, which may last just minutes, patients then return to the waiting room, check out, and complete the whole process in reverse. other factors, including disabilities and language barriers, may make it harder for patients to attend in-person visits. a study from ireland of over 200 patients at general surgery clinics in 2018 estimated that one-way travel from home to clinic and waiting for a clinician took 1 h 44 min on average. 2 by allowing patients to remotely attend appointments through audiovisual applications, virtual visits bring promise for decreasing outpatient no-shows. patients can attend virtual visits from anywhere, including their homes, their workplaces, or even their parked cars, decreasing the burdens of making it to in-person appointments. in a 2016 survey of 218 patients who missed primary care appointments, 15 (7%) reported problems with transportation, and 82 (38%) reported either forgetting or not knowing about the appointment. 5 since virtual visits already involve electronic applications and messaging for setup, these systems can integrate automated reminders, such as email or mobile notifications, to enhance appointment attendance. patients can log in at the start times of their visits or when their clinicians are ready, which may reduce unnecessary waiting. a 2017 randomized trial of 195 patients with parkinson's disease found home virtual visits saved patients a median of 88 min and 38 miles compared with usual care. 6 in addition to convenience, patients may prefer virtual visits for other reasons, such as increased access to virtual interpreters or privacy around potentially sensitive topics. for instance, some patients might hesitate to walk into clinics with signs for psychiatry or addiction treatment, but they might be willing to virtually meet with a clinician to discuss these health concerns. virtual visits are not be a universal solution for no-shows. patients with limited socioeconomic resources, limited internet access, ognitive impairment, or other physical disabilities might not be able to use digital technologies required for virtual visits. some patients might have difficulty accessing separate spaces for speaking privately with clinicians during virtual visits. in-person appointments will be necessary for some patients with medical needs that virtual visits cannot adequately address and, in addition, patients might opt not to participate in virtual visits, for example, due to preferences for in-person appointments or concerns about digital privacy. in the study of general surgery outpatients from 2018, 123 (55%) of 223 patients reported they would prefer in-person appointments over virtual ones, even when accounting for the time and cost of coming to in-person appointments. 2 patients and clinicians might struggle with setting up the technology needed for virtual visits, which might waste time and resources. if virtual visits require less investment for patients to attend, or if patients believe that virtual no-shows are less disruptive to health systems, patients may be more likely to miss these appointments. finally, virtual visits might not change attendance if patients would not come anyways due to poor relationships with clinicians or mistrust of healthcare. in the 2016 survey of patients who missed primary care appointments, 9 (4%) of 218 reported not coming due to negative experiences with their physicians or the practice. 5 more research is needed to clarify how virtual visits influence no-show rates. for example, a 2019 study from canada of home virtual visits for 75 patients at a stroke prevention clinic reported a no-show rate of 2 (3%) out of 81 appointments, but the study did not include comparisons of no-show rates for in-person clinic visits. 7 at a 2019 conference, researchers reported preliminary findings from a randomized trial of 108 patients receiving follow-up after hospitalization for heart failure; virtual visits were associated with a greater than 30% reduction in no-show rates compared with in-person visits, although this association did not reach statistical significance. 3 the covid-19 pandemic may prompt a shift in outpatient care toward virtual visits for the foreseeable future, and noshow rates are far from the only outcomes that need further study during this transition. health professionals and patients are facing uncertainties about their comfort with virtual visits, best practices for using these technologies, when in-person visits may be necessary, and the effectiveness of virtual visits compared with usual care. still, as social distancing efforts seek to keep people apart, perhaps this pandemic might help health professionals better recognize the everyday obstacles, from transportation burdens to wait times, that prevent patients from making it to appointments. whether during a pandemic or not, simply connecting with our patients, and maintaining our relationships with them, may be what matters most. seeing patients in their parked cars may not be a perfect way of providing care. but isn't it better than patients not coming at all? audit of veterans health administration's efforts to reduce unused outpatient appointments potential benefits and drawbacks of virtual clinics in general surgery: pilot cross-sectional questionnaire study virtual visits versus inperson visits and appointment no-show rates prevalence, predictors and economic consequences of no-shows why do patients miss their appointments at primary care clinics? national randomized controlled trial of virtual house calls for parkinson disease home virtual visits for outpatient followup stroke care: cross-sectional study key: cord-332729-f1e334g0 authors: shah, nirav r.; lai, debbie; wang, c. jason title: an impact-oriented approach to epidemiological modeling date: 2020-09-21 journal: j gen intern med doi: 10.1007/s11606-020-06230-1 sha: doc_id: 332729 cord_uid: f1e334g0 nan t he covid-19 pandemic has propelled epidemiological modeling into the public and political consciousness, beyond the strict purview of scientific and public health experts. models have emerged as crucial tools for decisionmakers, with calls for government-mandated non-pharmaceutical interventions (npis) such as stay-at-home orders to be based on data-driven thresholds such as case numbers and transmission rates. 1 and it goes both ways: data drives use of npis, which then affect models in an iterative process. meanwhile, the outputs of covid-19 models have become a subject of public fixation and mainstay of media headlines. there is a growing body of evidence supporting the efficacy of npis such as shelter-in-place and mask-wearing, which are affected by the extent of the public's buy-in and compliance. studies have shown that npis averted a 67× increase in cases in china by february 29, 2020, and even lax compliance can reduce transmission by as much as 25%. 2 other studies suggest that suppression will minimally require social distancing by the entire population. 3 under such circumstances, public awareness and consensus become paramount, particularly in the usa, where societal and cultural norms may limit imposed lockdowns akin to those that occurred in wuhan and other parts of china. thus, there emerges an unprecedented need to build a shared understanding of the disease, not just among experts and policymakers but also for the public. those who develop epidemiological models are no longer only creating specialty tools, but consumer products as well, and thus face a new, non-traditional, set of considerations. we propose that this requires an impact-oriented approach, i.e., what is the cumulative impact of their models upon the public? we call this impact-oriented modeling. traditionally, epidemiological models have been valued for their ability to inform decision-makers who possess prior knowledge of disease management. 4 in the wake of the h1n1 pandemic in 2009, the world health organization (who) convened a mathematical modeling network of public health experts and academics. 5 the centers for disease control and prevention (cdc) recently added policy development as a sixth item in its list of the major tasks of epidemiology in public health, but there remains no mention of the impact on the general public. 6 impact-oriented modeling values more than accuracy, which remains non-negotiable. beyond simply the outputs of such a model, consideration must be given to the presentation of these outputs, including design, visualization, and supporting content, all of which affect the utility, user experience, downstream policy, and, ultimately, impact. to this end, we outline a set of 8 key considerations for impact modeling. though these eight considerations will not be easily met in totality, we recommend incorporating as many possible into modeling for the covid-19 pandemic ( table 1 ). 1. agility: is the data and model providing timely information? the fast-changing nature of covid-19 highlights the need for models to reflect the most recent information, which may differ drastically from recent, prior information. with covid-19, journalists have become an active source not only of news but also of data. the new york times' repository of covid-19 cases (available at https://github.com/nytimes/covid-19-data), collected by reporters who monitor news conferences, analyze data releases, and seek clarification from public officials, is updated daily and is among the best sources of this fundamental metric. 2. responsiveness: do the data and model respond to new evidence? not only do models allow the public and decisionmakers to react to data, but the models themselves should also react to data in an iterative fashion. a feedback loop of action-information-reaction should drive models to continuously evolve, along with covid-19 and our knowledge of it. for instance, on may 4, 2020, over five weeks after it first launched on march 26, the institute for health metrics and evaluation (ihme) pivoted from a poorly-performing curve-fitting model drawing on prior death reporting, to a traditional seir model (available at https://covid19. healthdata.org/), which led to a substantial increase in forecasted covid-19 deaths and more accurate outputs. 3. transparency: are the data and model's mechanisms and data sources publicly available for fact-checking and validation? this issue has already been raised in the field of machine learning, where the plethora of options likewise renders the task of selection difficult. in the absence of perfect knowledge and the presence of myriad approaches, open-source models and databases enable users of these models to make more informed choices between models and data sources. they also enable the validation of models and data sources, which is critical not only for verifying the accuracy, but for enabling iteration and improvement. for instance, the covid act now (can) model is fully open-source, along with its data inputs (available at https://covidactnow.org). the mechanisms of its models, its assumptions, and references, are made publicly available. 6 this enables the public and experts to escalate questions and concerns that have enabled the model to be refined, such as by ingesting more accurate data. 4. usability: can the data and model be used easily, effectively, and efficiently? intuitively, we know that when users are not able to easily access and use a product, they are less likely to continue using it. developers of consumer products are thus familiar with the need to consider user expectations, desires, and requirements. 7 covid-19 models may benefit from doing the same. for example, user research, a common component in the development of consumer products, may become increasingly important in order to better understand the barriers that prospective users of epidemiological models face. 5. accessibility: can the data and model be understood and used by a broad audience, irrespective of scientific, technical, and other capabilities? the majority of the usa has not received training in epidemiology or data science. elderly populations that are more vulnerable to infection typically have less experience using technology. as progress containing the virus depends on the cumulative behavior of millions of individuals, a broad understanding of a model results in success or failure, and hence, models must use language and visuals that forgo specialized jargon and excessive complexity. 6. universality: do data and the model draw on inputs that are defined and measured consistently across geographies? given the unprecedented nature of covid-19, countries, states, counties and cities depend upon learning from each other, and what happens across artificial political boundaries matters across a region. standardization and consistency of data across regions can enable this. for example, the covid tracking project is an open-source initiative of the atlantic and provides one of the most complete data sets available about covid-19 in the usa (available at https:// covidtracking.com/). 7. adaptability: can the model be modified and adapted? in particular, efforts to provide useful covid-19 data for the usa have run into the following quandary: even as the implementation of tactical strategies exists primarily at the local level, it is also at the local level that the big data required to feed epidemiological models becomes most difficult to obtain. it may be that the models most easily customized by cities and counties will be those that have the greatest impact. the covid-19 hospital impact model for epidemics (chime) model allows for custom inputs, such as estimates of the regional population, hospital market share, and currently hospitalized covid-19 patients, in order to assist local officials with hospital capacity planning (available at https://penn-chime.phl.io/). 8. actionability: does the model reflect current government policies? given the role of epidemiological models in shaping public discourse and behavior, there is a responsibility to also inform actionability. models that fail to do so may contribute to anxiety, confusion, or even actions that violate federal, state, or local regulations. on the other hand, models that clearly communicate the actionable implications of their outputs can contribute to a positive rather than a negative impact. both the new york times and georgetown university's center for global health, science, and security (available at https://covidamp.org/) have begun to collect data on covid-19 policies by state and effective dates, including shelter-in-place and reopening orders. to our knowledge, no data source or model currently fulfills all the considerations that we have set forth. these eight considerations may enable covid-19 data and models to become better harbingers of actionable, behavior-changing, and even life-saving information; to bridge the gap between scientific public health expertise and mainstream, layperson are the data and model's mechanisms and data sources publicly available for fact-checking and validation? 4 usability can the data and model be used easily, effectively, and efficiently? 5 accessibility can the data and model be understood and used by a broad audience, irrespective of scientific, technical, and other capabilities? 6 universality does the data and model draw on inputs that are defined and measured consistently? 7 adaptability can the model be easily modified and adapted? 8 actionability are there clear calls-to-action that reflect current government policies? knowledge; and to generate more positive impact than noise. as the british statistician george box said, "all models are wrong. but some are useful." wrong but useful -what covid-19 epidemiologic models can and cannot tell us effect of non-pharmaceutical interventions to contain covid-19 in china impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand a proposal for standardized evaluation of epidemiological models. developing the theory and practice of epidemiological forecasting (delphi) world health organization. mathematical modelling of the pandemic h1n1 third edition: an introduction to applied epidemiology and biostatistics. the centers for disease control and prevention using websites to engage consumers in managing their health and healthcare key: cord-304839-lesa5u2n authors: jiang, fang; deng, liehua; zhang, liangqing; cai, yin; cheung, chi wai; xia, zhengyuan title: review of the clinical characteristics of coronavirus disease 2019 (covid-19) date: 2020-03-04 journal: j gen intern med doi: 10.1007/s11606-020-05762-w sha: doc_id: 304839 cord_uid: lesa5u2n in late december 2019, a cluster of cases with 2019 novel coronavirus pneumonia (sars-cov-2) in wuhan, china, aroused worldwide concern. previous studies have reported epidemiological and clinical characteristics of coronavirus disease 2019 (covid-19). the purpose of this brief review is to summarize those published studies as of late february 2020 on the clinical features, symptoms, complications, and treatments of covid-19 and help provide guidance for frontline medical staff in the clinical management of this outbreak. in december 31, 2019, hospitals reported a cluster of cases with pneumonia of unknown cause in wuhan, hubei, china, attracting great attention nationally and worldwide. 1 on january 1, 2020, wuhan public health authorities shut down the huanan seafood wholesale market, where wild and live animals were sold, due to a suspected link with the outbreak. on january 7, 2020, researchers rapidly isolated a novel coronavirus (sars-cov-2, also referred to as 2019-ncov) from confirmed infected pneumonia patients. real-time reverse transcription polymerase chain reaction (rt-pcr) and next-generation sequencing were used to characterize it. 2 on january 23, 2020, owing to the large flow of people during the chinese spring festival, public transport was suspended in wuhan and, eventually, in all the cities in hubei province to reduce the risk of further transmission. the number of rt-pcr-confirmed cases has increased rapidly. on january 30, 2020, the world health organization (who) declared covid-19 (as it would be officially known as of february 11) to be a public health emergency of international concern (pheic) and declared an epidemic. as of february 24, 2020, 80,239 cases were confirmed worldwide causing 2700 deaths. mainland china, and especially hubei province, has borne the brunt of the epidemic, reporting 77,780 cases. outside of mainland china, 33 countries have reported 2549 confirmed infections and 34 fatalities. 3 we reviewed the published clinical features, symptoms, complications, and treatments of patients with covid-19 to help health workers around the world combat the current outbreak. we searched pubmed for all published articles regarding covid-19 up to february 19, 2020. keywords used were "covid-19," "2019 novel coronavirus," "sars-cov-2," "2019-ncov," "wuhan coronavirus," and "wuhan seafood market pneumonia virus." after careful screening, six published articles with confirmed cases were identified and included in this review. the summary of included clinical studies is shown in table 1 . huang et al. 4 first reported clinical features of 41 patients confirmed to be infected with covid-19 on january 2, 2020, which include 13 icu cases and 28 non-icu cases. more than half of the cases (66%) had been exposed to the huanan seafood wholesale market. almost all the patients had bilateral lung ground glass opacity on computed tomography imaging. the initial symptoms included fever (98%), cough (76%), dyspnea (55%), myalgia or fatigue (44%), sputum production (28%), headache (8%), hemoptysis (5%), and diarrhea (3%). only one patient did not present fever in the early stage of disease. twelve (29%) cases progressed to acute respiratory distress syndrome (ards), 5 (12%) had acute cardiac injury, 3 (7%) had acute kidney injury (aki), and 3 (7%) had shock. at the data cutoff date, 28 (68%) patients were discharged and 6 (15%) had died. on january 20, 2020, chen et al. 5 reported 99 cases with sars-cov-2-infected pneumonia. this case series revealed that older males with comorbidities as a result of weaker immune function were the most susceptible to covid-19 incidence. the symptoms, complications, and treatments in this study were similar to the previous published study by huang and colleagues. 4 at the data cutoff date, 31 (31%) were discharged and 11 (11%) died, and 57 (58%) of the patients table 1 summary of included clinical studies to date author huang et al. 4 chen et al. 5 li et al. 6 song et al. 7 chen et al. 8 wang et al. 9 study setting were still hospitalized. a study of li et al. 6 reported on 425 covid-19 cases in wuhan confirmed between january 1 and 22, 2020. the mean incubation period was 5.2 days, with the 95th percentile of the distribution at 12.5 days, though uncertainty remains. two subsequent studies confirmed the pattern of signs and symptoms. 7, 8 at the time of this writing, the most recent published case series 9 of 138 confirmed cases included 36 requiring intensive care by the data cutoff date of february 3, 2020. it also found the common presenting symptoms of fever (136, 99%), fatigue (96, 70%), and dry cough (82, 59%), though there were two patients who did not present any signs of fever at the onset of illness. a higher proportion of cases presented with gastrointestinal symptoms including diarrhea and nausea (14, 10%) than in previous series. forty-seven (34%) were discharged while 6 (4%) died, while the remainder were still hospitalized. the organ failure complications were similar to the original studies. taken together, these studies indicate the main clinical manifestations of covid-19 are fever (90% or more), cough (around 75%), and dyspnea (up to 50%). a small but significant subset has gastrointestinal symptoms. preliminary estimates of case fatality, likely to fall as better early diagnostic efforts come into play, is about 2%, mostly due to ards, aki, and myocardial injury. coronaviruses are widespread in humans and several other vertebrates and cause respiratory, enteric, hepatic, and neurologic diseases. notably, the severe acute respiratory syndrome coronavirus (sars-cov) in 2003 and middle east respiratory syndrome coronavirus (mers-cov) in 2012 have caused human epidemics. comparison with the current virus shows several significant differences and similarities. both mers-cov and sars-cov have much higher case fatality rates (40% and 10%, respectively). though the current sars-cov-2 shares 79% of its genome with sars-cov, it appears to be much more transmissible. 10 both sars-covs enter the cell via the angiotensinconverting enzyme 2 (ace2) receptor. 11, 12 the sars-cov-2 first predominantly infects lower airways and binds to ace2 on alveolar epithelial cells. both viruses are potent inducers of inflammatory cytokines. the "cytokine storm" or "cytokine cascade" is the postulated mechanism for organ damage. the virus activates immune cells and induces the secretion of inflammatory cytokines and chemokines into pulmonary vascular endothelial cells. the preliminary estimate of r0 (the expected number of cases directly produced by one person in a population susceptible to author huang et al. 4 chen et al. 5 li et al. 6 song et al. 7 chen et al. 8 wang et al. 9 invasive mechanical ventilation and ecmo, na not applicable, aki acute kidney injury, ards acute respiratory distress syndrome, crrt continuous renal replacement therapy, ecmo extracorporeal membrane oxygenation, imv invasive mechanical ventilation, niv noninvasive ventilation infection) for covid-19 is 2.2 (95% ci, 1.4 to 3.9). 6 fomites are suspected as the main source of infectious particles, though some uncertainty remains. other coronaviruses have been shown to persist for days on uncleaned surfaces. 10 additionally, sars-cov-2 rna was detected in the stool specimen in a person who had symptoms while the serum specimen tested negative. 13 recently, sars-cov-2 was isolated from a swab sample of a confirmed patient's feces by chinese researchers, 14 indicating the potential for fecal-oral transmission. studies have shown effective person-to-person transmission of 2019-ncov even in the presence of isolation efforts in medical facilities. 15, 16 a case series of nine infected pregnant women did not reveal evidence of third trimester vertical transmission after cesarian section. 17 transmission in health settings is a very serious threat. the most recent case series reported 57 (41%) of 138 patients were infected hospital settings, including 40 (29%) medical staff. 9 while further study is needed, it appears that asymptomatic persons are also potential sources of 2019-ncov infection. 18, 19 handwashing is the mainstay of viral control. contact isolation gear such as masks, gowns, and gloves are also recommended. transmission via ocular surface is possible, 20 so eye protection should also be used. several efforts to develop vaccines are underway, but the who estimates it will take 18 months for the covid-19 vaccines to be available. 21 at present, most treatment is symptomatic and supportive, though anti-inflammatory and antiviral treatments have been employed. supportive treatment for complicated patients has included continuous renal replacement therapy (crrt), invasive mechanical ventilation, and even extracorporeal membrane oxygenation (ecmo). no specific antiviral drugs have been confirmed effective. the first reported patient with 2019-ncov infection in the usa was treated with remdesivir, 13 and others have used antiretrovirals like ritonavir, with trials of both in progress. 22 a recent study conducted by the "front-line" health care providers combating covid-19 in wuhan indicated that systemic corticosteroid treatment did not show significant benefit. 23 baricitinib has been suggested as a potential drug for the treatment in the hope that it might reduce the process of both virus invasion and inflammation. 24 despite some diversity in initial symptoms, most covid-19 patients have fever and respiratory symptoms. for now, travel history to epidemic areas is important to the diagnosis and should be obtained on all patients with flu-like syndromes. if positive, timely referral to the public health authorities for testing is crucial. frontline medical staff are at risk and should employ protective measures. treatment is mainly supportive and symptomatic, though trials of vaccines and antivirals are underway. healthcare providers should follow subsequent reports as the situation will likely change rapidly. a novel coronavirus outbreak of global health concern a novel coronavirus from patients with pneumonia in china world health organization clinical features of patients infected with 2019 novel coronavirus in wuhan epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia emerging coronavirus 2019-ncov pneumonia analysis of clinical features of 29 patients with 2019 novel coronavirus pneumonia clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan sars and mers: recent insights into emerging coronaviruses a pneumonia outbreak associated with a new coronavirus of probable bat origin receptor recognition by novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars first case of 2019 novel coronavirus in the united states chinese researchers isolate novel coronavirus strain from feces importation and human-to-human transmission of a novel coronavirus in vietnam a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records transmission of 2019-ncov infection from an asymptomatic contact in germany evidence of sars-cov-2 infection in returning travelers from wuhan, china 2019-ncov transmission through the ocular surface must not be ignored who says vaccines against novel coronavirus 18 months away, pushes global research a randomized, open-label, blank-controlled trial for the efficacy and safety of lopinavir-ritonavir and interferon-alpha 2b in hospitalization patients with novel coronavirus infection. available from www.chictr.org. cn/showprojen.aspx?proj=48684 clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province baricitinib as potential treatment for 2019-ncov acute respiratory disease key: cord-325181-d2cqarep authors: kusner, jonathan; mitchell, andreas; kenney, bevin; reiger, sheridan f. title: an underused treatment strategy: voter enfranchisement date: 2020-10-19 journal: j gen intern med doi: 10.1007/s11606-020-06286-z sha: doc_id: 325181 cord_uid: d2cqarep nan o n november 3, 2020, the usa faces a unique election. this election will occur amidst a historically divided nation confronting a global pandemic and a steepening economic recession, while a national movement for racial justice wages on during an election cycle with a presidential incumbent who was recently impeached. providers at community health centers (chcs) are facing unique challenges in this landscape, serving as essential workers themselves while looking for ways to support some of the most vulnerable patients in the nation-many of whom bear the greatest burden of covid-19, economic recession, and racial injustice, but whose voices are also often left out of the national political conversation. [1] [2] [3] [4] there has never been a more important time for chcs to amplify the voices of their patients through healthcare-sponsored non-partisan voter registration. the connection between healthcare and voter enfranchisement has been understudied, leading many healthcare professionals to be uncomfortable with offering voter registration services to their patients. voter suppression, the act of limiting the ability of eligible citizens to vote, brings the connection between healthcare and voting into stark relief. chcs often serve populations that are the targets of voter suppression efforts: 4 the young, those with lower socioeconomic status, and racial and ethnic minorities. 2, [5] [6] [7] [8] well-documented voter suppression targeted at these populations is particularly concerning in light of evidence that these populations demonstrate political preferences that differ from unsuppressed dominant voter groups. 9 medicaid expansion is an important example that illustrates this. across the usa, there are dramatic differences in opinions of medicaid according to race, with people of color having more favorable opinions of medicaid compared to whites. 9 states with voting barriers that disproportionately affect people of color tended to be those states that rejected medicaid expansion. 2, 9, 10 one startling example is alabama, in which two-thirds of the population that would benefit from medicaid expansion (44% of whom identify as black) were not registered to vote. 9, 11 although any healthcare institution may offer voter registration services to patients, chcs are particularly well positioned to offer these services in light of the demographic overlap between populations that chcs serve and those targeted by disenfranchisement efforts. social determinants of health (sdoh) are shaped by political systems and economic and social policies. 12, 13 these domains have traditionally been understood to exist outside of health professionals' medical obligations. however, recurrent public and private sector failures that have negatively impacted health like the water crisis in flint, michigan, our nation's disorganized response to the covid-19 pandemic, and the epidemic of police and gun violence in the usa have made it more obvious that sdoh significantly impact the health and wellness of communities. 3 in recognition of this, many public health and medical professionals have advocated for physicians and hospitals to take an active role in addressing sdoh. 14, 15 given the demands on physicians' time and attention, many others have been remained hesitant about physicians' role in addressing sdoh. 16 non-partisan voter registration has emerged as an important middle path. directing patients to healthcare-based voter registration is one activity that allows healthcare professionals to elevate the voices of their patients to inform solutions to sdoh in a way that integrates with current healthcare work flows. [17] [18] [19] [20] healthcare-based non-partisan voter registration does not require physicians and other healthcare professionals to become voter registration experts nor does it involve these individuals sitting down one-on-one with patients to register them to vote. voter registration will take many forms, depending on clinic and institutional work flows, layouts, and resource commitments, but in all of these cases, healthcare professionals are asked to simply direct patients to highquality resources, sponsored by their institution or clinic, which then take over the process of registering individuals to vote. the concept and implementation of a non-partisan voter registration drive within chcs is not novel and has been reported by liggett 2018. 18, 19 chcs are not the only clinical setting where voter registration should take place. national legislation empowers any office providing public assistance, like medicaid services, to register voters. in spite of these initiatives taking various forms, there are several best practices that are transferable between voter registration efforts, along with many free online resources that can facilitate this work, some of which we will highlight here. by way of best practice, any healthcare-associated voter registration initiative must be strictly non-partisan with a goal of general civic participation and without any intention of specific partisan gain. to remain non-partisan, specific details of candidates, policy, or issues should not be discussed. patients can instead be referred to resources, like vote411.org, which compile ballot related information in a non-partisan manner. all efforts should be geared toward participation in the electoral process according to safe voting practices. sadly, due to past voter suppression efforts, which have occurred along specific demographic lines, contemporary voter enfranchisement efforts are often critiqued as partisan initiatives. the partisan appearance of contemporary voter enfranchisement efforts speaks more strongly to the goals of historic and ongoing voter suppression than it does to the intent of proparticipation, non-partisan initiatives. we believe that healthcare workers should not remain complicit in continued voter disenfranchisement out of concern for partisan optics. voter suppression in the usa is particularly durable because its solution, voter enfranchisement, is easily misrepresented as a partisan initiative. we believe critics should instead ask why so many citizens within a single party have gone so long without political voice. 2, 5-7, 10, 21 in addition to non-partisan commitment, voter readiness efforts should unobtrusively engage any and every eligible voter no matter their demographics, broadly defined. this is typically best performed by including site-based materials, like posters and informational fliers in addition to in-person engagement. the design of any healthcare-based voter registration initiative should include the perspective and support of clinic administrators, front office staff, healthcare providers of all professions, and patient advocates in order to ensure sustainability, respect for all, and noninterference with daily patterns of work. even with explicit support and energetic buy-in from all of the appropriate groups, voter registration initiatives can be sporadic, lack follow-up, and fail to cultivate an institutional culture of patient empowerment. one strategy to combat this is through the formation of an institutional action plan (iap) created in partnership between all relevant stakeholders. such action plans have been popularized by initiatives within higher education, namely students learn students vote (slsv). outlines and examples for iaps can be found at the slsv website here: https://www.studentslearnstudentsvote.org/sample-campus-plans. guided by an iap, voter registration efforts can be further facilitated by high-quality online resources, many of which are available at no cost. for further support, national voter registration day partners with organizations of any size and within any sector to provide resources and guidance on establishing voter registration infrastructure. they encourage potential partners to explore their website for more information: https://nationalvoterregistrationday. org/. two other organizations have demonstrated outstanding leadership in voter registration resource development. vote. org (https://www.vote.org/) provides free seamless online voter registration, vote by mail application, election reminders, registration confirmation, and many other services tailored to anywhere in the usa. their platform is free to use and allows for high-level data collection which can assist quality improvement efforts. voter (https://vot-er.org/) is a nonpartisan voter readiness initiative that specifically seeks to engage healthcare professionals in "inviting (patient) voices into the democratic process." to facilitate this, they offer their health democracy kit, which allows healthcare providers to direct patients to an online voter registration platform that walks patients through voter registration in a state-specific manner. voter will provide healthy democracy kits to healthcare institutions free of charge. in order to investigate the feasibility of healthcare-based voter registration, we conducted a month-long voter registration intervention at a chc in boston, ma from october 24, 2017, to november 11, 2017 . the chc that was chosen for this project had a patient population that was 84% hispanic or latino, 14% reported graduating from college, and 25% reported food insecurity. this project was implemented in three phases: administrative approval, volunteer recruitment and training, and voter registration. we obtained approval for this project and its study by the chc leadership and patient advisory board, as well as the harvard office of human research administration institutional review board. this registration initiative was staffed by bilingual (english and spanish-speaking) volunteers who were recruited through local health professions schools. the league of women voters, a non-partisan national civic engagement organization, trained volunteers in voter registration. we equipped volunteers with ma-based online voter registration resources (https://www. sec.state.ma.us/ovr/). encouragingly, although 88.3% of eligible individuals were already registered to vote, we were able to complete voter registration for 41 other individuals throughout the month. our experience demonstrated how easily healthcare-based non-partisan voter registration can be coordinated and offered to patients in a way that does not burden providers or interrupt clinic work flows. ours is only one experience but we hope that it may serve as an example of how non-partisan voter registration may be offered as a healthcare sponsored service to individuals in one's community. healthcare professionals around the usa are grappling with their role in our evolving healthcare and social environments. although political engagement has previously been expunged from the healthcare environment, there are strong links between healthcare and voting. these links make it apparent that healthcare providers and institutions have a role to play at the interface of health and voting. healthcaresponsored non-partisan voter registration is one activity that has been shown to be feasible within a healthcare setting, is well aligned with the goals of healthcare professionals to improve the health and wellness of their communities, and advances patient-centered care through the elevation of patients' voices to inform healthcare solutions. high-quality resources are freely available to healthcare providers and institutions to implement non-partisan voter registration. as the links between healthcare, sdoh, and voting continue to emerge, we believe that those in healthcare will increasingly recognize their responsibility to elevate the voices of their patients: voting is the standard of care. the fullest look yet at the racial inequity of coronavirus widening the lens on voter suppression from calculating lost votes to fighting for effective voting rights the social determinants of health: it's time to consider the causes of the causes changes in demographics of patients seen at federally qualified health centers new voting restrictions in america. www.brennancenter.org accepted photo identification and different subgroups in the eligible voter population, state of texas supreme court won't restore 'golden week' voting in ohio north carolina state conference of the naacp health care policy is undermined by voting barriers passive voter suppression the kaiser family foundation state health facts. data source: the centers for disease control and prevention (cdc), national vital statistics reports (nvsr) closing the gap in a generation: health equity through action on the social determinants of health social capital as a health determinant: how is it measured? policy res div strateg policy dir popul public heal branch hospitals' obligations to address social determinants of health the health gap: doctors and the social determinants of health the role of physicians in addressing social determinants ofhealth voting and the role of physicians results of a voter registration project at 2 family medicine residency clinics in the voter registration and engagement in an adolescent and young adult primary care clinic do doctors vote? voter identification laws and the suppression of minority votes key: cord-330368-rk31cwl4 authors: bowden, kasey; burnham, ellen l.; keniston, angela; levin, dimitriy; limes, julia; persoff, jason; thurman, lindsay; burden, marisha title: harnessing the power of hospitalists in operational disaster planning: covid-19 date: 2020-07-13 journal: j gen intern med doi: 10.1007/s11606-020-05952-6 sha: doc_id: 330368 cord_uid: rk31cwl4 hospitalists are well poised to serve in key leadership roles and in frontline care in particular when facing a pandemic such as the sars-cov-2 (covid-19) infection. much of the disaster planning in hospitals around the country addresses overcrowded emergency departments and decompressing these locations; however, in the case of covid-19, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by a large influx of patients needing high-level medical care. in a matter of days, our division of hospital medicine, in partnership with our hospital, health system, and academic institution, was able to modify and deploy existing disaster plans to quickly care for an influx of medically complex patients. we describe a scaled approach to managing hospitalist clinical operations during the covid-19 pandemic. on december 31, 2019, chinese officials informed the world health organization of a "mysterious pneumonia" affecting 41 patients, all tied to the huanan wholesale seafood market. 1, 2 later identified as sars-cov-2 (covid-19), covid-19 would soon unfold into a pandemic impacting frontline responders across the world. [3] [4] [5] overburdened providers and healthcare systems would soon surface in china, italy, and eventually the usa. 6 hospitalists have been at the forefront of the covid-19 response, helping to lead frontline work, orchestrating complex and dynamic clinical operational plans, and partnering with clinicians and leaders from many different specialties. [7] [8] [9] much of the hospital disaster planning in the usa focuses on rapid intake of a large number of trauma patients in response to a time-limited event such as a natural disaster or a mass casualty incident. prior pandemics such as the influenza h1n1 epidemic in 2009 directed attention to the importance of emergency preparedness for potentially large pandemics but failed to motivate sustained attention in the wake of a successful vaccine. in that context, covid-19 was primed to overwhelm intensive care units, emergency departments, and medical wards. starting with preparedness models outlined by persoff et al., 10 frank et al., 8 the chest consensus statement, 11, 12 and our existing disaster plans, we developed a modified framework for hospital operations management and staffing, anticipating a massive influx of acutely ill, medically complex, and highly contagious patients with covid-19. using best practices in disaster planning, we developed a working framework for the management of the covid-19 pandemic (fig. 1) . crucial to successfully addressing this challenge was collaboration: forming effective partnerships and information sharing across multiple groups. recognizing the imminent influx of a novel patient population, capacity building became an early priority-and became a guiding principle of the framework. in typical disaster planning, net new providers are brought in as quickly as possible; however, when caring for patients with a highly contagious virus, the potential risks associated with bringing multiple new providers into the hospital also needed to be balanced. therefore, plans were devised to maximize the workforce already in the hospital, thereby limiting the need to call in additional providers until necessary. utilizing knowledge from italy and china, it was anticipated that the workforce could also become overwhelmed by illness related to exposures from patient care or other caregiving issues indirectly related to the virus (e.g., child care due to school closures). [13] [14] [15] [16] containment thus became a guiding principle to build systems that limited the number of providers exposed to highly contagious patient care environments. backup call (i.e., jeopardy) became a last option to preserve the number of providers available to cover for those with illness or caregiving duties. the last guiding principle was conscientiousness of resources (people, systems, and cost), knowing that any plan needed sustainability, particularly since successfully flattening the curve would mean prolonging the plateau and thus prolongation of the surge of covid-19 patients over time. in tier one, the capacity of all hospital medicine teams including teaching and non-teaching teams was increased above the usual census targets although still within the guidelines set forth by the accreditation council for graduate medical education. coverage for the afternoon hours to help with increased cross-cover was deployed as moonlighting. as elective surgeries were delayed or canceled, declines in patient volumes occurred, contributing to additional capacity on our internal medicine consult services and other specialty services such as hospitalist-led medical oncology teams where declines in patient volumes were also seen. services such as family medicine and pulmonary critical care became fluid partners with hospital medicine offering collective surge capacity with each team willing to flex to the other service(s) should the need arise. a powerful and experienced advanced practice provider (app) workforce was key to the tier 1 plan allowing teams to flex to higher volumes while maximizing efficiency and patient throughput. physician-app teams at our institution typically manage around 14 to 16 patients together given the complexity of our patients. as part of our surge plan, our apps could see patients independently (with physician back up as needed), pushing the team census to 20 patients (and up to 25) on each team if needed, while not requiring an individual clinician to care for overwhelming and potentially unsafe number of patients. staffing protocols and clinical care algorithms for admission and discharge of patients with covid-19 also helped to facilitate these models which might not otherwise be possible with more typical medicine patients. experienced hospitalist physicians and apps were prioritized to these teams. because of the potential for a significant increase in admissions and cross-cover for evening and nights, times that are typically more sparsely staffed, additional providers were needed to cover those shifts when the patient numbers surged. an urgent moonlighting model harnessing apps, physicians, and residents (when available) was built. to increase capacity while limiting the number of providers in the hospital, strategies were developed for remote patient care from home. for example, triagist work (admission flow and census management) was converted to a home-based service. onsite modified visit protocols were developed for inpatient visits when a physical exam was not expected to change management. providers were able to visit patients using hipaa-compliant video chat platforms. modified visits were deployed as a mechanism to decrease provider exposure to covid-19 and to conserve personal protective equipment (ppe), in particular for consulting services and teaching teams to limit the number of providers entering the room. for disaster preparedness prior to covid-19, some hospitalist providers had received specific training in the handling of special pathogens and donning/doffing procedures. while our team had a small number of highly trained hospitalists to work with special pathogens, it was apparent that, given the scale of the covid-19 pandemic, those teams would be quickly overloaded. thus, a hybrid approach was developed with dedicated covid-19 teams staffed by a small group of providers that could be scaled as real-time learning and training occurred. patients with covid-19 or suspicion for covid-19 were geographically cohorted, initially to one unit and one team, and then scaled as patient volumes increased. we partnered with our nursing colleagues to build these expert units and leveraged our electronic health record for enhanced communication strategies (i.e., secure chat platforms) to mitigate the constraints of ppe donning and doffing on communication. the implementation of tier 1 increased our team's ability to care for an additional~40 general medical patients with a net increase in general medicine capacity of 16% without bringing in additional providers for day teams. in tier 2, much of the focus was on modifying existing services and flexing teams to the areas of greatest need. as icu volumes grew, the intensive care unit volumes began to outgrow the floor volumes and hospitalist attendings and apps were flexed to the icu teams. team members received just-in-time education with support from critical care experts. because surgical volumes remained low, hospitalist consult teams were further consolidated and those providers were flexed to the icu. concurrently, family medicine team expanded their inpatient capacity by taking advantage of lower outpatient clinic volumes and partnering with obstetrics and gynecology (ob/gyn) to offload obstetric patients to ob/gyn teams. subspecialists and outpatient general internist volunteers were called in to supervise housestaff teams to allow additional hospitalists to function as icu providers. just-intime educational sessions were developed along with shared resources from groups across the country to train volunteer providers who had not recently worked in the inpatient setting. tier 2 allowed for a net capacity increase of at least 100 general medical patients (or a net increase of 45% of regular medicine volume from baseline) with added ability to provide care to critically ill covid patients. as an example, each newly added provider could then care for upwards of 16 patients if needed and already existing consult services (and other specialty services) could then care for similar numbers given the substantial decrease in surgical volumes. in tier 3, we planned to utilize jeopardy call (i.e., back up providers that we already had in place) plus an additional layers of volunteer clinicians within and external to the hospital system. app providers from across the campus were surveyed and placed into a pool of providers who could be flexed to medical and intensive care unit services as needed. we had over 100 physician volunteers sign up from within our system and had additional app providers external to our division ready and willing to help cover our services. because we have a centralized office of advanced practice with close ties to our apps across the health system, the office was able to orchestrate a robust back up pool quickly. while we did not have to implement tier 3, based upon responses to our tier 2 plan, we believe this represents a feasible surge model. in all, the three tiers would allow for the care of at least 460 medically ill patients with an approximate 100% or greater increase in capacity from baseline to care for general medical patients. operations leadership team built a forum to have daily huddles with hospital command center leadership, icu leadership, and the designated covid-19 team lead for the week. staffing and flex plans were developed and deployed in real-time during the huddles and any specific issues that were raised were addressed. this allowed the clinicians who were on service to relay concerns with minimal interruption of clinical work. calls with the department of medicine leadership including the chair, division heads for infectious disease, hospital medicine, and pulmonary were held daily. updates to the division were consolidated into a nightly email to help streamline the flow of information, provide concise and consistent messaging, and limit the quantity of emails going out to the staff. question and answer virtual townhalls were held with the entire division twice a week. hospital medicine and critical care teams held frequent calls each week with nursing leadership to plan for staffing needs and to anticipate how various units of the hospital along with nursing staffing as well as other ancillary staffing would be managed. data strategies. the division of hospital medicine data and analytics team developed three key reports: (1) a daily census report summarizing the number of patients with covid by location and by need (ventilator utilization, extracorporeal membrane oxygenation); (2) an operational report with the number of admissions, discharges, length of stay, icu transfers, and readmissions; (3) an ehr-based report with specific patient information for the leadership team. reports (1) and (2) were sent to leadership daily. to understand what scenarios would create high-capacity situations with more patients than patient to provider ratios could safely take care of, a forecasting tool was developed. using this model, high-capacity situations with reduced ability to flex up were predicted to be most likely to occur when hospital and clinic operations began to return to normal while the covid-19 patient volumes were still high (table 1) . sustainability. this plan is meant to help guide when a shortterm, unexpected need arises and is not meant to replace appropriate medium to longer term staffing solutions. as with any surge plan, ensuring sustainability is key. our model allows for a temporary increased workload in a pandemic situation where patients have a single uniting illness and the surge is expected to be short-term. with reduced volumes of other patients in our healthcare system, we were able to utilize space, providers, and ancillary services usually dedicated to other forms of medical/surgical care. generalizability. we work at a large, urban academic hospital with multiple hospitals within the system. while our plan has seemingly been successful at our institution, it is likely modifications would need to be considered at other sites and thus, this report hopefully serves as a guide/menu of options for hospitals and their hospital systems to consider. hospitalist groups across the country have assumed numerous roles during the covid-19 pandemic, from frontline providers to operational leaders for their groups, hospitals, and health systems. we have provided a framework that maximizes providers within the hospital while also taking advantage of a wide array of the clinician workforce, minimizing exposures as well as maximizing clinician groups who might not otherwise be as involved in inpatient care. a comprehensive timeline of the new coronavirus pandemic, from china's first covid-19 case to the present a new coronavirus associated with human respiratory disease in china covid-19 -navigating the uncharted first case of 2019 novel coronavirus in the united states a novel coronavirus from patients with pneumonia in china how to surge to face sars-cov-2 outbreak. lessons learned from lumbardy pediatric hospital medicine management, staffing, and well-being in the face of covid-19 the role of hospitalists in biocontainment units: a perspective hospital medicine management in the time of covid-19: preparing for a sprint and a marathon the role of hospital medicine in emergency preparedness: a framework for hospitalist leadership in disaster preparedness, response, and recovery surge capacity logistics: care of the critically ill and injured during pandemics and disasters: chest consensus statement surge capacity principles: care of the critically ill and injured during pandemics and disasters: chest consensus statement impact of school closures for covid-19 on the us health-care workforce and net mortality: a modelling study heroes of sars: professional roles and ethics of health care workers risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (covid-19) in china conflict of interest: the authors declare that they do not have a conflict of interest. key: cord-002095-47dbqu2r authors: al-helou, georges; anklesaria, zafia; kohlwes, jeffrey; ahari, jalil; dhaliwal, gurpreet title: when the illness goes off script—an exercise in clinical reasoning date: 2016-03-14 journal: j gen intern med doi: 10.1007/s11606-016-3632-3 sha: doc_id: 2095 cord_uid: 47dbqu2r nan i n this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion. a 49 year-old man with hypothyroidism presented to the emergency department with fever, malaise, and a nonproductive cough for 3 days. he denied headaches, nausea, abdominal, back, or chest pain. his only medication was levothyroxine. he lived in california, but was visiting the northeast united states when he became ill. he denied any recent travel outside the country. he denied tobacco use and illicit drug use; he occasionally drank alcohol. he was in a monogamous heterosexual relationship and was employed in the film industry. the patient is a middle-aged man with hypothyroidism presenting with acute fever and cough. acute fever and cough are usually caused by a viral or bacterial upper or lower respiratory tract infection. his recent travel to the northeast united states brings to mind tickborne infections, although most such pathogens do not cause pneumonitis. cough can be seen with anaplasmosis, erlichiosis, babesiosis, and the pneumonic form of tularemia. his residence in california puts him at risk for pulmonary coccidiomycosis. illness scripts are an adaptation from cognitive psychology's script theory. in script theory, individuals use their prior knowledge to contextualize new experiences. the clinician triggers the illness scripts of familiar diseases such as viral or bacterial respiratory infections and tick-borne infections to compare to his problem representation. he uses geographic clues to consider less fitting conditions, but will likely only give them serious thought if the emerging data set deviates from his more common scripts. 1 in the emergency department, the temperature was 39.7 degrees celsius, heart rate was 107 beats per minute, blood pressure was 110/63 mmhg, respiratory rate was 24 breaths per minute, and his oxygen saturation was 95 % on 3 liters of nasal cannula oxygen. he was in moderate distress. there were several 1 cm firm, mobile, non-tender cervical lymph nodes and a 2 cm left axillary lymph node. he had crackles in the bilateral mid-lung fields. heart, abdominal, and neurologic examinations were normal. there was a diffuse non-blanching maculo-papular rash on the trunk with petechiae ( fig. 1) . he has signs of systemic inflammation which may arise from infection, autoimmunity, or malignancy. scattered lymphadenopathy can be explained by all three categories of disease, but sepsis is the acute concern. his cough, bilateral crackles, and hypoxia signal a diffuse parenchymal lung process; most commonly this will be a bacterial pneumonia. fever and rash is often caused by viral exanthems such as epstein barr virus (ebv), cytomegalovirus (cmv), and acute human immunodeficiency virus (hiv); while each causes lymphadenopathy and fever, primary pulmonary disease is unusual. acute influenza frequently leads to pneumonia, but rash is not characteristic. bacterial infections like endocarditis, meningococcemia, and rocky mountain spotted fever all warrant early consideration with fever and a diffuse petechial rash, although he does not have any epidemiologic risk factors for these conditions. a bacterial pneumonia with bacteremia could cause cutaneous vasculitis, but scattered lymphadenopathy is not part of that picture. while disseminated endemic fungal infections can cause fever, rash, lymphadenopathy, and pulmonary disease, an acute presentation with widespread skin lesions would be more likely in an immunocompromised patient. the rash does not have the typical appearance or pain of stevens-johnson syndrome/toxic epidermal necrolysis, but environmental and medication exposures should be queried nonetheless. sarcoidosis affects each of the involved organs in this case, but is usually more indolent. vasculitis and other autoimmune conditions like systemic lupus erythematosus (sle) and antineutrophil cytoplasmic antibody (anca)-associated diseases are possible but less likely. the same could be said for malignancy, which rarely presents with this degree of acuity, save for aggressive hematologic cancers. using sirs physiology as a starting point, the discussant builds an analytic framework around three categories (infection, autoimmunity, malignancy). the clinician outlines a broad differential diagnosis after an early focus on lifethreatening illnesses (pneumosepsis). this broad framework creates the scaffolding to access appropriate illness scripts as the case unfolds. rapid improvement with antibiotics will support the common disease (e.g., pneumosepsis). if the patient gets sicker, the clinician has already considered other diagnostic possibilities, which will facilitate the evaluation of a broad range of potential illness scripts. laboratory testing revealed a white blood cell count of 4000/μl (25 % neutrophils, 25 % bands, 15 % lymphocytes, and 30 % monocytes), hemoglobin of 13.8 g/dl, and platelets of 78,000/μl. sodium was 132 mmol/l, blood urea nitrogen 28 mg/dl, and creatinine 1.5 mg/dl. the rest of the electrolytes were normal. international normalized ratio (inr) was 1.7, partial thromboplastin time (ptt) 35.7 seconds, albumin 2.5 g/dl, total protein 4.7 g/dl, total bilirubin 2.2 mg/dl, direct bilirubin 1.1 mg/dl, aspartate transaminase 65 u/l, alanine transaminase 58 u/l, alkaline phosphatase 63 u/l. arterial blood gas showed ph of 7.39, partial pressure of co2 of 29 mmhg, and partial pressure of o2 of 100 mmhg on 6 l of oxygen by nasal cannula. chest x-ray showed bilateral hilar fullness with clear lung fields. the combination of thrombocytopenia and coagulopathy points to either liver dysfunction or disseminated intravascular coagulation (dic). the patient has liver function test abnormalities and hypoalbuminemia, but lacks risk factors or physical exam findings of chronic liver disease. the low albumin is likely a negative acute phase reactant phenomenon. monocytosis is non-specific. it can be a prominent feature of myeloid disorders, particularly chronic myelomonocytic leukemia. the rash, modest hepatitis, and pancytopenia could signal early leukemic infiltration of the skin, liver, and bone marrow. acute promyelocytic leukemia is the form of leukemia most associated with dic. the bilateral hilar fullness implies hilar lymphadenopathy, which can be seen in sarcoidosis, pulmonary infections such as tuberculosis or fungal pneumonia, and malignancy (including lymphoma). he has clear lung fields on chest x-ray with marked hypoxia, which always raises the question of pulmonary embolus; however, the bilateral mid-lung crackles suggests a parenchymal disorder that has yet to appear on imaging studies. the summary of the patient's acute problems includes fever, hypotension, hypoxia, lymphadenopathy, disseminated rash, leukopenia, thrombocytopenia, acute kidney injury, mild hepatitis, and probable dic. sepsis remains the leading concern, but non-bacterial infections, acute hematologic malignancy, and sarcoidosis are important contenders. as the amount of data increases, the clinician triggers many more illness scripts. none are a perfect match, so he discusses the pros and cons of each possibility to prioritize the differential diagnosis. typical clinical reasoning is often built upon the problem representation (pr), a one-line synopsis of the important characteristics of a case. this is followed by accessing illness scripts that match the important information from the pr. 2 in this complex case, the clinician reverses the standard process by accessing many illness scripts and then summarizes the case again to refocus the differential diagnosis. restatement of the pr is a useful strategy in complex cases to focus on the key clinical elements and hone the differential diagnosis as new information becomes available. computed tomography (ct) of the chest revealed prominent mediastinal lymph nodes, right middle lobe bronchial wall thickening, and nonspecific nodular interstitial ground-glass opacities in both bases (fig. 2) . the intra-thoracic lymphadenopathy, bronchial wall thickening, and interstitial lung disease is compatible with sarcoidosis. although a virus is more likely than bacteria to cause a rash, hepatitis, or pancytopenia, these are not common features of the common lower respiratory tract viral pathogens. lymphangitic spread of a lymphoma, leukemia, or carcinoma is plausible. lymph node biopsy (axillary or intra-thoracic) will be informative. intravenous fluid, vancomycin, meropenem, doxycycline, and azithromycin were administered. the patient remained febrile and developed worsening respiratory failure requiring mechanical ventilation. a repeat chest x-ray showed bilateral diffuse infiltrates consistent with acute respiratory distress syndrome (ards). norepinephrine, epinephrine, and vasopressin were administered for hypotension. he became anuric and continuous veno-venous hemodialysis was initiated. he began to bleed from his venipuncture sites and developed ischemia of his fingers and toes. labs revealed worsening thrombocytopenia (platelets 7,000/ul) and neutropenia (absolute neutrophil count of 800/ul). his inr was 2.1, ptt was 56 seconds, and fibrinogen was 120 mg/dl (reference range: 150-400 mg/dl). blood, sputum, and urine cultures grew no organisms. a respiratory viral panel, hiv antibody test, and urine antigen tests for legionella and streptococcus were negative. the rapid deterioration of his hemodynamics, respiratory status, kidney function, bone marrow, and coagulation system indicates a severe systemic inflammatory response. he is appropriately being treated for sepsis, but extensive laboratory data does not implicate a pathogen. with travel to the northeast us, i would still consider tick-borne pathogens that can occasionally cause fulminant sepsis, including anaplasmosis, erlichiosis, and babesiosis. the first two should have been treated by the doxycycline. babesiosis is diagnosed by microscopy, serology, or polymerase chain reaction, but is less likely given the normal hemoglobin. the lack of documented infection warrants examination of non-infectious processes that mimic severe sepsis. rapidly progressive hematologic malignancies such as acute leukemia and lymphoma (including cutaneous t cell lymphomas) can present with fevers and multiorgan failure. aggressive forms of mastocytosis may be characterized by widespread organ invasion, cutaneous involvement, and hypotension, but the characteristic flushing and gastrointestinal complaints are absent. in the autoimmune spectrum, sarcoidosis is less likely because of acuity and extent of multiorgan failure. however, those same features make catastrophic antiphospholipid syndrome and anca-associated disorders plausible. although his deterioration is likely a progression of the underlying disease, we must also consider if treatments might be responsible. for instance, could his shock be an anaphylactic reaction to one of his multiple antibiotics? as the patient is deteriorating, the clinician returns to the less common conditions he considered earlier in the context of sirs. this represents clinical bpre-planning^and enables the clinician to take the next steps quickly when initial therapies fail. as his clinical thinking evolved from pneumosepsis to pseudosepsis, he considers rarer diseases in an efficient yet constrained manner that focuses testing rather than using a shotgun approach. blood smears showed rare schistocytes but no evidence of malaria, ehrlichia, or babesiosis. an ehrlichia polymerase chain reaction and a rickettsia antibody panel were negative. a serum lactate dehydrogenase (ldh) was 1300 u/l, and serum ferritin was 2000 ng/ml. a ct of the abdomen revealed mesenteric and retroperitoneal lymphadenopathy and mild splenomegaly. high dose vasopressor medications were continued, and stress dose steroids were added empirically due to refractory hypotension. he was subsequently weaned off vasopressors but remained intubated and febrile. his rash spontaneously resolved on icu day 2. this information has not radically shifted the differential diagnosis or the relevant categories of disease. it is hard to know if steroids can be credited for the restoration of hemodynamic stability given simultaneous treatment with antibiotics. the problem representation is now fever, hypotension (resolved), diffuse pulmonary infiltrates, widespread lymphadenopathy, disseminated rash (resolved), leukopenia, thrombocytopenia, dic, severe aki, and mild hepatitis with no evident infection. in the absence of evidence of infection or autoimmunity, malignancy becomes the leading concern. acute promyelocytic leukemia (apl) is an important consideration with his dic, but the absence of peripheral blasts is unusual. given the widespread lymphadenopathy, elevated ldh, and mild splenomegaly, an aggressive lymphoma is probable. metastatic carcinoma of unknown primary could also cause lymphadenopathy and invade multiple organs. hemophagocytic lymphohistiocytosis (hlh) is characterized by multi-organ involvement, cytopenias, splenomegaly, and fevers. since these findings are seen in many other conditions, testing for criterion-based data that are more specific to hlh, including elevated il2r level, hypertriglyceridemia, low nk activity, or a bone marrow biopsy demonstrating hemophagocytosis, is often necessary to make the diagnosis. hlh in adults is usually secondary to infection, autoimmunity, or malignancy. often the distinction between aggressive lymphoma and hlh is blurred, but i suspect his condition resides somewhere along that spectrum. the patient fulfilled five diagnostic criteria for hlh: fevers, splenomegaly, cytopenias, hyperferritinemia, and hypofibrinogenemia or hypertriglyceridemia (510 mg/dl); the interleukin-2 receptor level (soluble cd25) was also elevated at 9,196 pg/ml (normal range 5-400 pg/ml). (table 1) the diffuse lymphadenopathy raised suspicion for autoimmunity or malignancy as an underlying etiology of his hlh. an axillary lymph node biopsy showed cells that were markedly positive for cd1a and s100 staining (fig. 3) , consistent with langerhans cell histiocytosis (lch). there was no evidence of a lymphoma or hemophagocytosis, and cultures were negative. there was no evidence of histiocytosis elsewhere in the body; there were no lytic bony lesions, pulmonary nodules or cysts, or findings of central nervous system disease (e.g., diabetes insipidus). he was diagnosed with lymphadenopathic lch 4 which precipitated an inflammatory reaction culminating in hlh. the patient was treated with etoposide and dexamethasone for hlh and defervesced within a few days. his organ failure and coagulopathy improved, although he sustained digital necrosis (presumably from dic and vasopressor treatment) requiring amputations of six fingers. he required prolonged mechanical ventilation. he was discharged to a rehabilitation facility where he regained strength over the next 3 months and then returned home. he has returned to his job, and no relapse has occurred in the 18 months since discharge. this patient had one rare disease-hemophagocytic lymphohistiocytosis (hlh)-caused by another rare disease, langerhans cell histiocytosis (lch). it is impossible to have an illness script for every bzebra^diagnosis. a better strategy is to have intimate knowledge of common diseases in order to easily recognize deviations from these familiar scripts. it is the mismatch between common illness scripts (pleural) 5 and a patient's presentation that prompts diagnosticians to consider rare diseases. clinicians typically have well-developed illness scripts for common conditions. for example, pneumonia would typically be conceptualized as a febrile illness with a cough and chest xray infiltrate that improves with antibiotics. with experience, clinicians see many variations of pneumonia, including cases that lack fever or even chest x-ray infiltrates. experience also allows the clinician to recognize an unexpected data point as more than a variation, but instead as a deviation that invites consideration of other diagnoses. for example, unilateral hilar lymphadenopathy can be seen in lobar pneumonia, but symmetric, bilateral hilar lymphadenopathy is too unusual for pneumonia and will invite consideration of sarcoidosis, which can also present as a fever, cough, and infiltrate. power (a, b) . these cells stained positive for s100 (c) and cd1a (d) to diagnose a rare disorder, a clinician does not need to know its complete illness script. the key is to know when to think about rare conditions. in this case, an early or presumptive diagnosis of hlh would have been inappropriate due to the extremely low base-rate of this disease. the clinicians knew the illness script for pneumosepsis, patiently worked under this assumption, and ultimately recognized deviations from this script. the inflammatory response was not controlled with antibiotics and no source of infection was identified, so attention turned from sepsis to sepsis mimickers. rare diseases such as hlh were considered only after the discussant found irreconcilable mismatches with the illness scripts of more common conditions. this process of identifying incongruities prompted the clinicians to request consultations and perform additional diagnostic tests. solving challenging cases is ultimately a test of clinicians' knowledge of common diseases, not rare ones. when clinicians know the illness scripts of common diseases well enough to recognize telltale deviations from the norm, they can trigger the consideration of rare conditions and request help from colleagues and other resources that will ultimately lead to a diagnosis. 1) hlh is a rare syndrome of marked immune activation that can mimic sepsis. hlh may be triggered by infection, neoplasms, autoimmune disorders, or genetic mutations. 5 2) lch is a clonal proliferation of mononuclear phagocytic cells (histiocytes). lch can be local and asymptomatic, or it can involve multiple organs. it can present as sirs and even shock. 6, 7 the most common sites of involvement are the skin, bones, lungs, liver, spleen, teeth, gums, and central nervous system (manifesting as diabetes insipidus). 6 -8 3) reports have linked lch and hlh. the pathogenesis is still unknown, but it is suspected that macrophage activation through t-cell activation and cytokine release plays an important role in the pathophysiology. 9 a 22-year-old woman with abdominal pain a 43-year-old woman with abdominal pain and fever how i treat hemophagocytic lymphohistiocytosis lymph node involvement by langerhans cell histiocytosis: a clinicopathologic and immunohistochemical study of 20 cases adult haemophagocytic syndrome report from the international registry of the histiocyte society langerhans cell histiocytosis-clinical and epidemiological aspects cell-specific gene expression in langerhans cell histiocytosis lesions reveals a distinct profile compared with epidermal langerhans cells macrophage activation and hemophagocytic syndrome in langerhans cell histiocytosis: report of 30 cases key: cord-339701-j0sr3ifq authors: mikami, takahisa; miyashita, hirotaka; yamada, takayuki; harrington, matthew; steinberg, daniel; dunn, andrew; siau, evan title: risk factors for mortality in patients with covid-19 in new york city date: 2020-06-30 journal: j gen intern med doi: 10.1007/s11606-020-05983-z sha: doc_id: 339701 cord_uid: j0sr3ifq background: new york city emerged as an epicenter of the coronavirus disease 2019 (covid-19) pandemic. objective: to describe the clinical characteristics and risk factors associated with mortality in a large patient population in the usa. design: retrospective cohort study. participants: 6493 patients who had laboratory-confirmed covid-19 with clinical outcomes between march 13 and april 17, 2020, who were seen in one of the 8 hospitals and/or over 400 ambulatory practices in the new york city metropolitan area main measures: clinical characteristics and risk factors associated with in-hospital mortality. key results: a total of 858 of 6493 (13.2%) patients in our total cohort died: 52/2785 (1.9%) ambulatory patients and 806/3708 (21.7%) hospitalized patients. cox proportional hazard regression modeling showed an increased risk of in-hospital mortality associated with age older than 50 years (hazard ratio [hr] 2.34, ci 1.47–3.71), systolic blood pressure less than 90 mmhg (hr 1.38, ci 1.06–1.80), a respiratory rate greater than 24 per min (hr 1.43, ci 1.13–1.83), peripheral oxygen saturation less than 92% (hr 2.12, ci 1.56–2.88), estimated glomerular filtration rate less than 60 ml/min/1.73m(2) (hr 1.80, ci 1.60–2.02), il-6 greater than 100 pg/ml (hr 1.50, ci 1.12–2.03), d-dimer greater than 2 mcg/ml (hr 1.19, ci 1.02–1.39), and troponin greater than 0.03 ng/ml (hr 1.40, ci 1.23–1.62). decreased risk of in-hospital mortality was associated with female sex (hr 0.84, ci 0.77–0.90), african american race (hr 0.78 ci 0.65–0.95), and hydroxychloroquine use (hr 0.53, ci 0.41–0.67). conclusions: among patients with covid-19, older age, male sex, hypotension, tachypnea, hypoxia, impaired renal function, elevated d-dimer, and elevated troponin were associated with increased in-hospital mortality and hydroxychloroquine use was associated with decreased in-hospital mortality. electronic supplementary material: the online version of this article (10.1007/s11606-020-05983-z) contains supplementary material, which is available to authorized users. the coronavirus disease 2019 (covid-19) is a pandemic that has impacted medical systems, societies, and economies worldwide. the first case of covid-19, caused by severe acute respiratory syndrome 2 virus (sars-cov-2) 1 , was reported in china in december 2019 2 . the virus has spread globally at a rapid pace, resulting in more than 2 million confirmed cases as of april 17, 2020 3 . in recent weeks, new york city has emerged as an epicenter of the pandemic, with over 120,000 confirmed cases and over 13,000 deaths due to confirmed or probable covid-19 death as of april 17, 2020 4 . studies of the clinical characteristics and epidemiologic characteristics of covid-19 have been conducted in countries experiencing outbreaks earlier than the usa [5] [6] [7] [8] [9] [10] [11] . large-scale observational data of the clinical characteristics and outcomes of covid-19 in the population of the usa are scarce. in this study, we describe the clinical characteristics of covid-19 in ambulatory and inpatient settings and identify risk factors associated with mortality in hospitalized patients. a multicenter retrospective cohort study of patients with covid-19 patients was conducted using the medical records of the mount sinai health system, a large urban health system of 8 hospitals and more than four hundred ambulatory practices in the new york city metropolitan area. patients with a positive sars-cov-2 test result and an encounter with a healthcare provider for covid-19 between march 12 and april 17, 2020, were included in this study. a confirmed case of covid-19 was defined as a positive result on reversetranscriptase-polymerase-chain-reaction (rt-pcr) assay of nasopharyngeal swab specimens. the study population was dichotomized into ambulatory and hospitalized groups. the former included patients whose encounter was an office visit, electronic supplementary material the online version of this article (https://doi.org/10.1007/s11606-020-05983-z) contains supplementary material, which is available to authorized users. emergency department (ed) visit, or telehealth/telemedicine. inpatients and ambulatory patients who were subsequently admitted to the hospital were included in the hospitalized group. both groups were further subdivided into survivors and non-survivors. ambulatory non-survivors were patients who had expired prior to presentation to the ed, who had expired in the ed prior to admission to the hospital units, or who had an office or telemedicine encounter and were later found out to be deceased. ambulatory survivors included all other ambulatory patients. hospitalized non-survivors were patients who had expired as of april 17, 2020 . hospitalized survivors were patients who had been discharged home or to other facilities as of april 17, 2020 . icahn school of medicine at mount sinai has waived informed consent and institutional review board approval because the study used a de-identified database. the following covariates were extracted from the database: patients' age, sex, ethnicity, race, smoking status, vital signs including temperature, peripheral oxygen saturation (spo 2 ), heart rate, respiratory rate (rr), blood pressure (bp), body mass index (bmi), and laboratory results including white blood cell count (wbc), d-dimer, interleukin-6 (il-6), hemoglobin, estimated glomerular filtration rate (egfr), alanine aminotransferase (alt), aspartate aminotransferase (ast), c-reactive protein (crp), procalcitonin, ferritin, lactate dehydrogenase (ldh), fibrinogen (fbg), interleukin-6 (il-6), comorbidities, and treatments. continuous variables were reported as median with interquartile range. categorical variables were expressed as proportions. temporary changes of vital signs and laboratory values in survivors and non-survivors for the first 14 days after admission were assessed. to illustrate the risk associated with changes in the continuous variables, including vital signs and laboratory values, multivariate generalized additive models were used to calculate the odds ratio (or) for mortality, with each median value set as a reference (i.e., or = 1). the hazard ratio (hr) of each variable for mortality risk was assessed using univariate cox proportional hazard regression model. to account for missing data values for laboratory results, we introduced multiple imputation, which is a procedure used to replace missing values with other plausible values by creating multiple filling-in patterns to avert bias caused by missing data. using the dataset with imputed values, univariate and multivariate cox model were fit to calculate hr. the multivariate cox model was adjusted for the following variables assessed in the univariate cox model: patients' age, sex, race, cigarette use history, past medical history of asthma, hypertension, diabetes, or cancer, systolic bp, rr, spo 2 , bmi, initial laboratory values (lymphocyte proportion, d-dimer, il-6), and hydroxychloroquine use. for this cox regression analysis, we excluded variables from the univariable analysis if their between-group differences were not significant, if the number of events was too small to calculate hazard ratios, or if they had collinearity with other significant values. each hospital was considered by the clustering term in the cox proportional hazard model analysis where the clustering effect associated with hospitals was accounted for by the robust sandwich estimator. preliminary confirmation of predictability of the cox proportional hazard model demonstrated the area under the curve (auc) to be 0.808 (95% ci, 0.790-0.825, supplementary figure 1 ). to investigate the effect of hydroxychloroquine while addressing the imbalance among treatment groups, we introduced inverse probability weighting (iptw) based on propensity scoring to control for observed differences in baseline characteristics between treatment group and control group. iptw was calculated based on the same variables as used in the cox regression models, except for hydroxychloroquine use. we then fitted an iptw-adjusted cox with doubly robust methods. survival curves with stratification for hydroxychloroquine were constructed using the kaplan-meier method. all statistical analyses were performed using version 3.6.2 of the r programming language (r project for statistical computing; r foundation). the median age was 47 years old in the ambulatory group (iqr 34 to 60) and 66 years old in the hospitalized group (iqr 55 to 78). 858 patients died (13.2%): 52 patients in the ambulatory group (1.9%) and 806 patients in the hospitalized group (21.7%). among ambulatory patients, 69% were emergency room encounters without hospital admission, 18.2% were office-based encounters, and 1.4% were telemedicine encounters. compared with that of ambulatory patients, a higher proportion of hospitalized patients were older, were male, or had a history of cigarette use. hospitalized patients were more likely clinical characteristics of the 2014 survivors and 806 nonsurvivors in the hospitalized group are shown in table 2 (supplementary table 1 for the ambulatory group). the median number of days to discharge for survivors was 5 days (iqr, 3 to 9 days). the median number of days to death for non-survivors was also 5 days (iqr, 3 to 9 days). compared with survivors, non-survivors were older and the higher proportion were male. non-survivors were more likely to have a history of cigarette use and coexisting medical conditions including copd, hypertension, dm, and ckd. temporal changes of vital signs and laboratory values in survivors and non-survivors during hospitalization are shown in figure 1 . throughout hospitalization, non-survivors had higher heart rate and respiratory rate and lower oxygen saturation compared with survivors. initial laboratory findings of non-survivors demonstrated higher wbc count and higher levels of d-dimer, il-6, ast, crp, procalcitonin, ferritin, ldh, fibrinogen, and troponin. throughout hospitalization, non-survivors had higher wbc count, neutrophil proportion, ldh, and ferritin levels, and lower egfr and lymphocyte proportion. non-survivors also had higher levels of crp, ddimer, and il-6 in the first week of hospitalization. non-survivors showed a marked increase in ldh, crp, d-dimer, ast, alt, and procalcitonin on day 1 after admission. both groups had a trend of decreasing hemoglobin levels and increasing platelet counts during hospitalization; however, a more pronounced decrease in hemoglobin levels was seen in non-survivors, while an increase in platelet counts was greater for survivors. the generalized additive models demonstrated correlations between laboratory values and increased odds of in-hospital mortality which are similar to the difference observed between hospitalized survivors and non-survivors (supplementary figure 3) . the majority of hospitalized patients received hydroxychloroquine (74.6% of survivors and 71.3% of non-survivors) and azithromycin (67.4% of survivors and 71.3% of non-survivors). fewer hospitalized patients received other medications such as remdesivir, anakinra, tocilizumab, or sarilumab ( table 2 ). the majority of ambulatory patients did not receive hydroxychloroquine or azithromycin. kaplan-meier estimate showed lower mortality in hospitalized patients who received hydroxychloroquine (log rank p value < 0.001) (supplementary figure 4) . the results of multivariate cox proportional hazard regression models are shown in table 3 (univariate models are shown in supplementary table 6 ). of 3708 hospitalized patients, 888 patients remained hospitalized as of april 7 and were not included in the analysis. in the multivariate analysis, factors associated with a higher risk of in-hospital mortality included age over 50, systolic blood pressure less than 90 mmhg, a respiratory rate greater than 24 per min, spo 2 less than 92%, egfr less than 60 ml/min/1.73m 2 , il-6 greater than 100 pg/ (continued on next page) ml (6.5 times upper limit of normal [uln]), d-dimer greater than 2 mcg/ml (4 times uln), and troponin greater than 0.03 ng/ml. factors associated with a lower risk of in-hospital mortality included female sex, african american race, and hydroxychloroquine use. the adjustment with iptw did not lead to a significant change in the hr of hydroxychloroquine (without iptw: hr 0.53, ci 0.41-0.67; with iptw: hr 0.53, ci 0.41-0.68). we report a large retrospective cohort study of both ambulatory and hospitalized patients with covid-19 from across the new york city metropolitan area. the clinical characteristics described here represent the first large retrospective cohort study from the us population in a city at the epicenter of the pandemic. early reports showed that covid-19 had a mortality rate among all confirmed cases of 2% 12 which is significantly lower compared with that of 34% with mers 13 and 10% with sars 14 . the mortality rate in hospitalized patients reported previously ranged from 4 to 28% 2, 7-9, 11 . the mortality rate of 25.9% among hospitalized patients in our study may be explained by more severe disease in our total cohort, by a different reporting method, or by geographic variation. we identified several risk factors associated with mortality in hospitalized patients with covid-19 that have been previously reported including older age and male sex. we report additional risk factors associated with in-hospital mortality including low sbp, tachypnea, low spo 2 , low egfr, and higher levels of il-6, d-dimer, and troponin levels. the severity of coronavirus infection in humans has been previously described to increase during viral clearance suggesting pathogenicity arising from host immune response 15 . our study confirmed again that older patients with covid-19 hospitalization are at significantly higher risk of mortality. we did not observe any independent association between inhospital mortality and some of the common coexisting medical conditions including hypertension, diabetes, or cancer. however, using calculated gfr as a surrogate for ckd, we observed that decreased renal function was a risk factor for inhospital mortality, a finding that is consistent with previous studies 16 . il-6 and other pro-inflammatory cytokines production are felt to be due to immune dysregulation rather than normal 17, 18 . our findings are consistent with this theory, and we observed elevated il-6 as an independent prognostic risk factor, with higher levels in nonsurvivors. in hospitalized patients, we saw fluctuating il-6 levels, with a significant increase seen on day 1 of admission and an increasing level trend that was more pronounced in non-survivors. thrombocytosis was associated with disease activity in sars and was thought to be secondary to the direct effect of the virus or effect of inflammatory cytokines 19 . we observed a greater thrombocytosis during hospitalization in survivors than in non-survivors. a previous study of il-6 in primates revealed that there is a dose-dependent response of thrombocytosis induced by il-6 20 . the discrepancy between high il-6 levels and lack of thrombocytosis in non-survivors could be explained by endothelial damage and subsequent platelet consumption from viral infection, impaired platelet release from megakaryocytes in the lung, or direct impairment of hematopoiesis 21 . this may suggest that the absence of reactive thrombocytosis may portend a poor response to sars-cov-2 infection. elevated d-dimer in covid-19 patients has been described previously 22, 23 . we report in this study its independent association with an increased risk of in-hospital mortality. abnormal d-dimer alone is non-specific; however, the higher elevation in non-survivors suggests that coagulopathy, particularly disseminated intravascular coagulation (dic), may contribute to mortality in covid-19. one of the functional receptors for pathogenic human coronavirus such as sars-cov is angiotensinconverting enzyme 2 (ace2) 24 , and these receptors are expressed in heart tissues 25 . this suggests that sars-cov-2 virus could directly affect the heart. similar to the previous finding that showed an association of cardiac injury and a higher risk of in-hospital mortality 26 , we observed elevated troponin levels in hospitalized patients as a risk factor for increased mortality. hydroxychloroquine is an analog of chloroquine, a widely used anti-malarial with immunomodulatory effects 27 . in vitro studies have shown that hydroxychloroquine has activity against sars-cov-2 28 sars-cov-2 with hydroxychloroquine use 32 . we attempted to adjust for all known confounders between the groups who did and did not receive hydroxychloroquine using multivariate regression analyses and the iptw method, which revealed that hydroxychloroquine use was associated with decreased risk of in-hospital mortality. due to the inherent limitations of our retrospective study design, there was no conclusive determination on the efficacy of hydroxychloroquine in patients with covid-19. more robust studies such as randomized clinical trials are needed. our study has several limitations. first, we have no longterm follow up data for ambulatory and discharged patients; hence, the clinical outcome observed may not be reflective of the true eventual outcome, particularly in the ambulatory group. second, we have patients who remained hospitalized at the time of our analyses and did not have our outcomes, such as discharge or mortality, and were excluded for our comparison of survivors and non-survivors. third, due to limitations and local testing policy during the study duration, there are an unknown number of patients who were not diagnosed with covid-19 because of a lack of severe symptoms and/or hospitalization. fourth, we are not able to adjust for unknown confounders that may affect the true treatment effect. these limitations prevent any definitive conclusions on the efficacy of any treatment. in this retrospective study of over 6000 ambulatory and hospitalized patients with covid-19 in the new york city metropolitan area, age, male sex, tachypnea, low systolic blood pressure, low peripheral oxygen saturation, impaired renal function, elevated il-6, elevated d-dimer, and elevated troponin were found to be risk factors for mortality. hydroxychloroquine use was associated with decreased mortality. a pneumonia outbreak associated with a new coronavirus of probable bat origin clinical features of patients infected with 2019 novel coronavirus in wuhan world health organization. coronavirus disease (covid-19) pandemic covid-19 data baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region clinical characteristics of coronavirus disease 2019 in china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan clinical findings in a group of patients infected with the 2019 novel coronavirus (sars-cov-2) outside of wuhan, china: retrospective case series clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention middle east respiratory syndrome coronavirus world health organization. cumulative number of reported probable cases of severe acute respiratory syndrome (sars) coronaviruses post-sars: update on replication and pathogenesis chronic kidney disease is associated with severe coronavirus disease 2019 (covid-19) infection interferon and cytokine responses to sars-coronavirus infection immunopathogenesis of coronavirus infections: implications for sars haematological manifestations in patients with severe acute respiratory syndrome: retrospective analysis in vivo effects of recombinant human interleukin-6 in primates: stimulated production of platelets thrombocytopenia in patients with severe acute respiratory syndrome (review) prominent changes in blood coagulation of patients with sars-cov-2 infection d-dimer is associated with severity of coronavirus disease 2019: a pooled analysis regulation of ace2 in cardiac myocytes and fibroblasts association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan in vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (covid-19) efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial. medrxiv no evidence of clinical efficacy of hydroxychloroquine in patients hospitalized for covid-19 infection with oxygen requirement: results of a study using routinely collected data to emulate a target trial hydroxychloroquine in patients with covid-19: an open-label, randomized, controlled trial. medrxiv we thank the mount sinai data warehouse team for the covid-19 database, and norihiro inoue md, phd, hiroki ueyama md, satoshi miyashita md, misato nagumo md, and mizuho asada phd for giving us critical comments and input. authors' roles: tm and es had the idea for and designed the study and had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. tm and es drafted the paper. tm, es, hm, and ty did the analysis, and all authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. tm and es collected the data. all authors agree to the accuracy or integrity of any part of the work are appropriately investigated and resolved. informed consent was waived because of the de-identified and retrospective nature of the data. we confirm that we have read the journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. the authors declare that they do not have a conflict of interest. key: cord-337120-irpm5g7g authors: lee, bruce y. title: the role of internists during epidemics, outbreaks, and bioterrorist attacks date: 2007-01-13 journal: j gen intern med doi: 10.1007/s11606-006-0030-2 sha: doc_id: 337120 cord_uid: irpm5g7g internists are well-positioned to play significant roles in recognizing and responding to epidemics, outbreaks, and bioterrorist attacks. they see large numbers of patients with various health problems and may be the patients’ only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. therefore, internists must understand early warning signs of different bioterrorist and infectious agents, proper reporting channels and measures, various ways that they can assist the public health response, and roles of different local, state, and federal agencies. in addition, it is important to understand effects of a public health disaster on clinic operations and relevant legal consequences. during the past half decade, well-publicized events, including the anthrax mail attacks, 1 hurricane katrina, 2 and severe acute respiratory syndrome (sars) 3, 4 have reminded us that epidemics, disease outbreaks, bioterrorist attacks, and natural disasters can occur. although there is debate over when and how they may happen, there is little question that such events could have significant and far-reaching health, social, and economic consequences. moreover, smaller outbreaks, such as influenza and west nile virus, 5 occur with greater regularity. internists can play vital roles in identifying, responding to, and containing bioterrorist attacks and disease outbreaks if they understand their role in these events. internists may be among the first to recognize clues that a problem is occurring, especially as initial signs and symptoms may be subtle or mimic common disorders, prompting victims to contact their primary care physicians, rather than go to emergency departments. 6 furthermore, internists' broad range of medical knowledge, experience, and skills make them uniquely qualified to diagnose and treat a variety of potential health problems. internists are also well-positioned to work with various health care personnel and services during a disaster. therefore, internists must understand early warning signs of bioterrorist and infectious agents, proper reporting channels and measures, and ways that they can help contain and treat the consequences of epidemics, outbreaks, and attacks. during its initial stages, an attack, epidemic, or outbreak may not be obvious. depending on the agent and its mode of transmission, the population density, and the population's access to health care, it can be days or even weeks before anyone can recognize the problem. as the early response may be crucial in containing the problem and minimizing resultant morbidity and mortality, efforts have been made to develop biosurveillance systems to detect outbreaks and attacks. [7] [8] [9] these systems collect pertinent data (e.g., pharmacy drug sales, emergency department visit chief complaints, and air samples) and search for irregularities that suggest a problem is occurring. however, these systems are by no means foolproof because they only look for a finite set of clues, do not cover every part of the united states, and may provide equivocal information. moreover, there could be delays between the point that biosurveillance systems detect suspicious patterns and when the public health system responds. therefore, internists might be the first to become aware of a problem and pivotal in initiating the public health response. internists see large numbers of patients with various health problems and may be the patients' only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. so they could be the first to report attacks or outbreaks and initiate public health response. indeed, there are examples of "astute" clinicians being the first to recognize epidemic or bioterrorist attacks (e.g., the 1999 new york city west nile outbreak, 5 the 2001 anthrax attack cases, 10, 11 and the 2003 sars epidemic in vietnam 12 ). in some cases, bioterrorist and infectious agents cause distinctive signs and symptoms. 13, 14 for example, of the 10 inhalational anthrax cases in the 2001 attacks, all had fever, chills, lethargy, and chest x-ray abnormalities. seven had mediastinal widening, and 8 had pleural effusions. all but 1 had elevated liver transaminases. a combination of these findings is highly suspicious for inhalational anthrax, especially in a young, otherwise healthy patient and/or when a patient initially experiences nonspecific influenza-like symptoms followed first by a brief period of apparent recovery, and then, by an abrupt resurgence of more severe symptoms. 15 however, in a majority of cases, early symptoms are vague and readily mistaken for more common upper respiratory infections (e.g., influenza, plague, tularemia, and staphylococcal enterotoxin b) or viral gastroenteritis (e.g., hepatitis a, cryptosporidium, and salmonella). therefore, in addition to looking for specific symptoms, internists should remain vigilant about general trends and patient flow in their clinics. 16 any of the following may be the only sign that an attack or outbreak has occurred 17 21, 22 and rabbits in tularemia outbreaks 23 ); 5. physicians or other clinic staff becoming ill after coming into contact with patients (e.g., the 2003 sars epidemic 4 ); 6. a patient's health rapidly deteriorates out of proportion to the presenting symptoms and diagnosis (e.g., a 30-yearold non-immunocompromised patient dying of pneumonia is rare); 7. an unusual number of patients fail to respond to treatments. an internist's index of suspicion should be even higher when bioterrorism or epidemic alerts are issued. internists must be prepared to address a wide range of physical, psychological, and social consequences of public health disasters. patients may be injured by either a public health disaster or the ensuing mass panic. in addition, internists may have to function as emergency physicians when emergency departments are overcrowded or unavailable. specifically, internists must be prepared to: 1. treat the exposed and infected. different organ systems can be affected (e.g., meningitis from inhalational anthrax, sepsis from typhoidal tularemia, and pneumonia from influenza), so complete examinations are important. websites providing extensive treatment and prophylaxis information include the center for disease control and prevention (cdc) (http://www.bt.cdc.gov/), food and drug administration (fda) (http://www.fda.gov/cder/drugprepare/default.htm), department of health and human services (http://www.hhs.gov/disasters/index.shtml), and national library of medicine (http://www.nlm.nih.gov/ medlineplus/biodefenseandbioterrorism.html); 2. administer prophylaxis to the exposed but not the infected. determining exposure can be difficult as patients may claim that they have been exposed. in a large-scale epidemic or attack, public health officials may set up temporary stations for mass vaccination and prophylaxis. however, many patients may still appear at clinics requesting prophylaxis; 3. triage who gets treated in a large outbreak/attack. internists will have to prioritize who should receive treatment, especially when necessary resources and skilled manpower are limited. knowing when and how to ration treatments can be challenging, particularly in chaotic conditions. although internists may feel compelled to acquiesce to every patient's needs, their primary responsibility in public health emergencies is the public. 24 while clear guidelines have not been established and rationing decisions are rather controversial, certain groups such as essential personnel (e.g., health care workers, police, fire fighters, and other individuals integral in responding to a public health disaster) should receive priority. essential personnel are needed to prevent more casualties and fatalities and could spread contagious diseases to many other people; 4. treat mental health consequences. public health disasters can result in significantly increased mental health problems including anxiety, depression, and posttraumatic stress disorders. [25] [26] [27] [28] evidence suggests that even people who witness, hear, or read about a disaster can be affected. 29, 30 shortages of mental health professionals in a disaster often require internists to handle patients' mental health issues. 31-35 5. treat comorbidity exacerbations. evidence suggests that undue environmental stresses can exacerbate comorbidities such as heart disease and respiratory disease. [36] [37] [38] [39] [40] [41] [42] [43] in addition, during public health disasters, patients with certain chronic diseases (e.g., diabetes and chronic obstructive pulmonary diseases) may not have adequate access to maintenance treatments. 44 proper reporting and the public health and law enforcement chain of command figure 1 illustrates the public health chain of command. internists suspecting an attack or epidemic should immediately inform the local or state health department and contain any possible threat in their clinics, especially if the agent is contagious. providing information to wrong people (especially news media) may cause mass terror and delay the public health system's response. therefore, internists must remain calm, understand how their words can be misunderstood and misconstrued, follow instructions from appropriate health, military and law enforcement officials, and allow properly trained public health officials to deal with the media. local authorities are responsible for the initial response to any public health emergency with appropriate state agencies providing additional support when necessary. depending on the nature and magnitude of the problem, local or state authorities may choose to involve federal agencies. unlike naturally occurring disease outbreaks, bioterrorist attacks are criminal acts and require intervention of law enforcement agencies. 45 when there is a risk of contagious disease transmission across state lines or state efforts are deemed inadequate, the federal government assumes authority. the president makes executive decisions. the cdc administers federal quarantine actions. implementation of order could involve the department of defense or the federal emergency management agency (fema). for travelers seeking to enter the united states, the cdc has the authority to enact quarantine. in areas where the cdc's division of global migration and quarantine personnel are not stationed, the immigration and naturalization service and the united states customs service personnel are trained to identify travelers with potential epidemic. it is essential that health care professionals adequately protect themselves. they are needed to care for both victims of an outbreak/attack and "regular" patients and can inadvertently spread communicable agents rather quickly, especially to vulnerable members of the population. 46, 47 one study examined clinicians' knowledge regarding proper infection control practices during a bioterrorist event and found numerous deficiencies. 48 standard precautions should be exercised for all situations. internists should wash their hands frequently and be careful when handling body tissues and fluids. certain diseases require additional precautions (table 1) . contaminated clothing should be removed promptly and placed in sealed plastic bags. soap and warm water can wash off most noncontagious agents. 49, 50 bleach is needed for chemical decontamination. any health care worker who receives a needle stick from a potentially bacteremic anthrax-infected patient should receive prophylactic antibiotics. although the words quarantine and isolation have been erroneously used interchangeably, quarantine means the separation and confinement of currently healthy people who may have been exposed to a contagious disease, while isolation refers to the separation and confinement of people known or suspected to be infected with the contagious disease. when an infectious disease is confined to a specific locale, the authority to order quarantines usually rests with local or state public health officials. when the event spreads across jurisdictional boundaries within the state, such authority usually is relinquished to the state. there is great variability in quarantine regulations from state to state. 51 clinic patient volume can increase significantly from ill patients and concerned healthy patients (the "worried well"). this "worried well" phenomenon was seen after the 2001 anthrax attacks. 52, 53 internists will have to offer reassurance to the "worried well," relay appropriate disease information, and direct them to the right public health agencies and relevant websites (e.g., fig. 1 and websites listed in "treatment and prophylaxis") for information and mass prophylaxis (if needed). 54 clinics should minimize potentially contagious patients' contact with health care workers and other patients by either temporal segregation (clustering potentially contagious patients later in the day) or spatial segregation (shunting potentially contagious patients towards specific rooms). therefore, clinic schedulers and telephone operators should be aware of the signs and symptoms that suggest a patient is contagious. 55 proper triaging is necessary. minor issues and complaints may have to wait, but urgent problems must be addressed. the clinic will not operate with normal efficiency. health care workers may become ill or be absent. running additional tests, notifying authorities, taking on and off personal protective equipment, rearranging the clinic, and decontaminating rooms will cause operational delays. clinics that routinely run at peak capacity could become overwhelmed, especially if the clinic staff themselves become ill. every clinic should have clearly established contingency plans and build an extra capacity that can handle unexpected surges in patients. 56 specifically clinics will need: 1. additional rooms to place and examine patients. clinics should identify other patient areas (e.g., procedure, radiology, and operating rooms) that can be converted into examination rooms. rooms not normally used for patients (e.g., offices or conference rooms) may be utilized if they meet basic requirements for patients who do not require isolation. mobile clinics and hospitals may be available 57 ; 2. additional health care professionals and staff. clinics should know where and how to reach additional personnel who are cross-trained to handle a wide range of responsibilities in an emergency; 3. diversion plans. when a clinic is overwhelmed, it must know when to close to additional patients and where to send them. anytime medical treatment is administered, legal concerns come into play. public health disasters are no exception. in a mass casualty setting, the ability to mount an adequate response may be hindered by the myriad of rules and regulations that govern the everyday practice of medicine. laws vary from state to state, so internists should be aware of their state's specific regulations. unfortunately, many states have not yet adequately addressed or clarified medico-legal issues and regulations in public health disasters. 45 some of these include: 1. licensing and admitting privileges. internists willing to provide assistance may not be licensed in that state, have appropriate admitting privileges, or have the time or means to complete the necessary paperwork before administering treatment. some states (e.g., colorado) have introduced statutes that ease some regulatory barriers by providing protection to health care workers during a public health disaster, such as allowing physicians to administer care even though they are not licensed in that state; 2. malpractice liability. while states do have "good samaritan" laws that offer some legal protection to physicians who aid strangers in "good faith," the extent of these laws varies from state to state and currently do not cover all potential eventualities. "good samaritan laws" may not apply when treatment is administered against a patient's will. 58 3. maintaining patient confidentiality. bioterrorist attacks and epidemics require physicians to quickly transmit patient and case information to other health care personnel and appropriate authorities. while such communication is paramount, efforts should be made to maintain patient confidentiality and transmit only necessary information. at present, it is unclear how health insurance portability and accountability act (hipaa) regulations would affect the public health and health care system response. in a public health emergency, the hipaa privacy rule does allow disclosure of the following protected health information (phi): for treatment by health care providers; to avert a serious threat to health or safety; to public health authorities for public health purposes; to protect national security; to law enforcement under certain conditions; and for judicial or administrative proceedings. 59, 60 however, during an emergency, misunderstandings of the privacy rule's requirements may hinder the flow of phi. 61 as internists could play a vital role in epidemics, disease outbreaks, or bioterrorist attacks, they must be knowledgeable, equipped, and prepared. in an emergency, potential legal and administrative barriers should be eased. clinics should have appropriate contingency plans. although the risk of large-scale attacks and epidemics seems low, the risk of smaller epidemics and local public health emergencies is much higher. preparing for large events will help prepare for such smaller events. potential financial conflicts of interest: none disclosed. death due to bioterrorism-related inhalational anthrax: report of 2 patients update on emerging infections: news from the centers for disease control and prevention. vibrio illness after hurricane katrina-multiple states but fast enough? responding to the epidemic of severe acute respiratory syndrome a major outbreak of severe acute respiratory syndrome in hong kong the outbreak of west nile virus infection in the new york city area in 1999 the public and the smallpox threat biostorm: a system for automated surveillance of diverse data sources data, network, and application: technical description of the utah rods winter olympic biosurveillance system role of data aggregation in biosurveillance detection strategies with applications from essence index case of fatal inhalational anthrax due to bioterrorism in the united states emergency preparedness and response accuracy of screening for inhalational anthrax after a bioterrorist attack anthrax as a biological weapon, 2002: updated recommendations for management bioterrorism and critical care nato handbook on the medical aspects of nbc defensive operations amedp-6 departments of the army, the navy, and the air force apic bioterrorism task force and cdc hospital infections program bioterrorism working group bioterrorism readiness plan: a template for healthcare facilities a massive outbreak in milwaukee of cryptosporidium infection transmitted through the public water supply an outbreak of hepatitis a associated with green onions crow deaths as a sentinel surveillance system for west nile virus in the northeastern united states dead crow densities and human cases of west nile virus tularemia transmitted by insect bites-wyoming clinical decision making during public health emergencies: ethical considerations symptoms of posttraumatic stress disorder and depression among children in tsunami-affected areas in southern thailand mental health problems among adults in tsunami-affected areas in southern thailand surveillance for world trade center disaster health effects among survivors of collapsed and damaged buildings media exposure in children one hundred miles from a terrorist bombing posttraumatic stress two years after the oklahoma city bombing in youths geographically distant from the explosion referral gridlock: primary care physicians and mental health services posttraumatic stress disorder in rural primary care: improving care for mental health following bioterrorism the impact of terrorism on brain, and behavior: what we know and what we need to know. neuropsychopharmacology incorporating community mental health into local bioterrorism response planning: experiences from the dekalb county board of health incorporating mental health into bioterrorism response planning behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique sudden cardiac death triggered by an earthquake population-based analysis of the effect of the northridge earthquake on cardiac the impact of a catastrophic earthquake on morbidity rates for various illnesses triggering of acute coronary syndromes after a chemical plant explosion earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications, part i earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications: part iii-mental health and psychosocial effects earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications-part ii tsunami induced hyperglycemia and diabetes mortality-two studies from south india preparing for a bioterrorist attack: legal and administrative strategies nosocomial transmission of influenza research gaps in protecting healthcare workers from sars and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach clinicians' knowledge, attitudes, and concerns regarding bioterrorism after a brief educational program efficacy of selected hand hygiene agents used to remove bacillus atrophaeus (a surrogate of bacillus anthracis) from contaminated hands guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force. society for healthcare epidemiology of america/association for professionals in infection control/infectious diseases society of america controlling the resurgent tuberculosis epidemic. a 50-state survey of tb statutes and proposals for reform the impact of anthrax attacks on the american public the psychological impacts of bioterrorism terrorism from a public health perspective pathogen transmission and clinic scheduling impact of an outbreak of severe acute respiratory syndrome on a hospital in taiwan, roc mobile hospital raises questions about hospital surge capacity legal history of emergency medicine from medieval common law to the aids epidemic bioterrorism meets privacy: an analysis of the model state emergency health powers act and the hipaa privacy rule. ann health law guidance from cdc and the u.s. department of health and human services the hipaa privacy rule and bioterrorism planning, prevention, and response bioterrorism preparedness varied across state and local jurisdictions key: cord-261173-lnjh56ts authors: misra-hebert, anita d.; jehi, lara; ji, xinge; nowacki, amy s.; gordon, steven; terpeluk, paul; chung, mina k.; mehra, reena; dell, katherine m.; pennell, nathan; hamilton, aaron; milinovich, alex; kattan, michael w.; young, james b. title: impact of the covid-19 pandemic on healthcare workers’ risk of infection and outcomes in a large, integrated health system date: 2020-09-01 journal: j gen intern med doi: 10.1007/s11606-020-06171-9 sha: doc_id: 261173 cord_uid: lnjh56ts background: understanding the impact of the covid-19 pandemic on healthcare workers (hcw) is crucial. objective: utilizing a health system covid-19 research registry, we assessed hcw risk for covid-19 infection, hospitalization, and intensive care unit (icu) admission. design: retrospective cohort study with overlap propensity score weighting. participants: individuals tested for sars-cov-2 infection in a large academic healthcare system (n = 72,909) from march 8–june 9, 2020, stratified by hcw and patient-facing status. main measures: sars-cov-2 test result, hospitalization, and icu admission for covid-19 infection. key results: of 72,909 individuals tested, 9.0% (551) of 6145 hcw tested positive for sars-cov-2 compared to 6.5% (4353) of 66,764 non-hcw. the hcw were younger than the non-hcw (median age 39.7 vs. 57.5, p < 0.001) with more females (proportion of males 21.5 vs. 44.9%, p < 0.001), higher reporting of covid-19 exposure (72 vs. 17%, p < 0.001), and fewer comorbidities. however, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for hcw vs. non-hcw having a positive test with weighted odds ratio (or) 1.17, 95% confidence interval (ci) 0.99–1.38. among those testing positive, weighted proportions for hospitalization were 7.4 vs. 15.9 for hcw vs. non-hcw with or of 0.42 (ci 0.26–0.66) and for icu admission: 2.2 vs. 4.5 for hcw vs. non-hcw with or of 0.48 (ci 0.20–1.04). those hcw identified as patient facing compared to not had increased odds of a positive sars-cov-2 test (or 1.60, ci 1.08–2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (or 0.88, ci 0.20–3.66, proportions 10.2 vs. 11.4) and icu admission (or 0.34, ci 0.01–3.97, proportions 1.8 vs. 5.2). conclusions: in a large healthcare system, hcw had similar odds for testing sars-cov-2 positive, but lower odds of hospitalization compared to non-hcw. patient-facing hcw had higher odds of a positive test. these results are key to understanding hcw risk mitigation during the covid-19 pandemic. electronic supplementary material: the online version of this article (10.1007/s11606-020-06171-9) contains supplementary material, which is available to authorized users. understanding the risks associated with the covid-19 pandemic 1 on healthcare workers (hcw), including the risk of acquisition at work vs. other settings, is crucial. prediction of risk can inform how to protect hcw such as recommendations on use of personal protective equipment (ppe) at work or in the community. the presence of specific symptoms in hcw (china, usa) 2, 3 and symptoms predicting sars-cov-2 test positivity in hcw (netherlands) 4 has been reported as well as characteristics associated with hcw deaths (china). 5 based upon data from the 2018 national health interview survey, it was estimated that 26.6% of patient-facing hcw were at increased risk for poor outcomes from covid-19 infection because of their comorbidities or age. 6 reported experiences in china, 7 italy, 8 and solano county, ca, without initial use of ppe, 9 showed higher percentages of hcw testing positive for covid19 . in contrast, a screening study of hcw in england showed no significant difference in positive results between electronic supplementary material the online version of this article (https://doi.org/10.1007/s11606-020-06171-9) contains supplementary material, which is available to authorized users. clinical and nonclinical staff with implementation of isolation and ppe protocols perhaps suggesting predominant community rather than nosocomial transmission patterns. 10 the extent of risk modification with ppe remains unclear. [7] [8] [9] 11 a recent prospective study in the uk and usa suggested a fivefold increased risk for hcw caring for patients with covid-19 compared to hcw not caring for patients with covid-19, even with the use of ppe, 12 while another study of hcw in a large healthcare system showed a decrease in positive tests for sars-cov-2 associated with a universal masking recommendation. 13 this heterogeneous landscape makes it difficult for the hcw community to determine actual risk of acquiring covid-19 in healthcare vs. community settings and the effectiveness of various risk-mitigating strategies. the cleveland clinic health system (cchs) is a large, integrated health system with 55,574 eligible employees in ohio and florida. the cchs initiated multiple covid-19related public health initiatives to mitigate the spread of the disease and its impact on the hcw community. in parallel, we maintained a rigorous, comprehensive, and prospective registry capturing disease risk and progression in all individuals tested for covid-19 in our health system. in this study, we aimed to assess whether hcw are at higher risk for covid-19 infection, covid-19-related hospitalization, and intensive care unit (icu) admission compared to non-hcw using advanced statistical methodology to account for various confounders. covid-19 cleveland clinic enterprise registry. all patients, regardless of age, who were tested for covid-19 at all cchs locations in ohio and florida, were included in this research registry. for this study, all individuals who were tested for covid-19 in the cchs between march 8, 2020, and june 9, 2020, were studied. this registry provides better representation of the overall population than testing restricted to one geographic health system site. registry variables were chosen to reflect available literature on covid-19 disease characterization, progression, and proposed treatments, including medications initially thought to have potential for benefit after drug-repurposing network analysis. 14 capture of detailed research data was facilitated by the creation of standardized clinical templates implemented across the healthcare system as patients were seeking care for covid-19-related concerns. data were extracted via previously validated automated feeds from electronic health records 15 (epic; epic systems corporation) and manually by a study team trained on uniform sources for the study variables. study data were collected and managed using redcap electronic data capture tools hosted at the cleveland clinic. 16, 17 the covid-19 research registry team includes a "reviewer" group and a "quality assurance" group. the reviewers were responsible for manually abstracting and entering a subset of variables that cannot be automatically extracted from the electronic health record (ehr). reviewers were also asked to verify high-priority variables that have been automatically pulled into the database from epic. the cleveland clinic institutional review board approved this study and waived the requirements for written informed consent. identification of hcw. individuals were identified as hcw through the cchs occupational health, and their job description was identified as having direct contact with patients or "patient facing" vs. non-patient facing based upon the listing in the cchs human resources database. public health guidelines for cchs employees and availability of testing for covid-19 changed rapidly between march 6, 2020, and april 24, 2020 (appendix 1), the most relevant being the recommendation for universal masking for cchs employees on april 7, 2020, and requirement on april 24, 2020. regarding state public health orders, a stay-at-home order was issued in ohio on march 22, 2020, with phased reopening in may starting with restaurants and bars on may 14, 2020, 18 and in florida, a public health advisory was issued on march 25, 2020, addressing vulnerable populations, private gatherings, and workforce density 19 with reopening beginning on may 18, 2020. 20 all descriptive statistics were reported as counts (percentages) or median (interquartile ranges [iqrs] ). for comparison of demographic variables and comorbidities among cohorts, wilcoxon signed-rank tests were used for numeric variables, while χ 2 or fisher exact tests were used for categorical variables. to address differences in baseline characteristics of non-hcw and hcw, specifically as related to underlying comorbidities, and the limitations of current literature that failed to account for such differences, we leveraged appropriate statistical methodology to study our research questions. overlap propensity score 21, 22 weighting was performed to address potential confounding in comparing hcw to non-hcw given their baseline differences. the overlap propensity score weighting method was chosen given its benefits of preservation of numbers of individuals in each group and of achieving higher levels of precision in the resulting estimates. this methodology is preferred when the propensity score distributions among the groups are dissimilar and when the propensity scores are clustered near the extremes (i.e., close to zero or one). a propensity score for being a hcw was estimated from a multivariable logistic regression model. for the outcome of being test positive for covid-19, the propensity score logistic regression model included covariates that were found to be associated with a positive covid-19 test outcome in our previous work. 23 for the outcomes of hospital and intensive care unit (icu) admission of covid-19 testpositive patients, the propensity score covariates are those that were found associated with covid-19 hospitalization outcome in our previous work including age, race, ethnicity, gender, smoking history, body mass index, median income, population per housing unit, presenting symptoms (including fever, fatigue, shortness of breath, diarrhea, vomiting), comorbidities (including asthma, hypertension, diabetes, immunosuppressive disease), medications (including immunosuppressive treatment, nonsteroidal anti-inflammatory drugs [nsaids]), and laboratory values (including pre-testing platelets, aspartate aminotransferase, blood urea nitrogen, chloride, and potassium). the overlap propensity score weighting method was then applied where each patient's statistical weight is the probability of that patient being assigned to the opposite group. 21 overlap propensity score weighted logistic regression models were used to investigate associations between hcw status and the probability of testing positive for sars-cov-2, hospital admission for covid-19, and icu admission for covid-19 illness. the results are thus reported as weighted proportions, odds ratios, and 95% confidence intervals. all statistical analyses were performed using r 3.5 and sas version 9.4 (sas institute). p values were 2-sided, with a significance threshold of 0.05. we then used locally weighted regression smoother (loess) to summarize the trend of covid-19 test positivity through the study period for hcw and non-hcw as related to the public health measures instituted at the state level and those specific to the cchs. overall tested cohort characteristics. of the 72,909 individuals tested for covid-19 in the cchs research registry, there were 6145 hcw and 66,764 non-hcw with over 90% of hcw and 75% of non-hcw tested from ohio. there were 9% of hcw who tested positive for covid-19 compared to 6.5% of non-hcw, p < 0.001 (table 1 ). the hcw tested were younger than the non-hcw (median age 39.7 vs. 57.5, p < 0.001) with more females (proportion of males 21.5 vs. 44.9%, p < 0.001), higher proportion of asian and lower proportion of black persons (3.4 vs. 1.0% and 16.2 vs. 18.3%, respectively, p < 0.001), higher proportion identifying as non-hispanic (90.8 vs. 87.6%, p < 0.001), higher median income, and higher proportion of nonsmokers. the neighborhood characteristic of population density as measured per square kilometer was similar for tested hcw vs. non-hcw while the population per housing unit was slightly higher. the hcw were more likely to report an exposure to covid-19 (72.0% vs. 17.0%, p < 0.001) and also to report having a family member with covid-19 (28.3 vs. 14.2%, p 0.005). regarding presenting symptoms, a slightly higher proportion of hcw reported cough (32.0 vs. 29.6%, p 0.001), a lower proportion reported fever (15.0 vs. 19.5%, p < 0.001) or shortness of breath (14.6 vs. 25.7%, p < 0.001), while a higher proportion reported diarrhea (11.9 vs. 9.5%, p < 0.001) and a lower proportion reported vomiting (7.4 vs. 9.7%, p < 0.001). of note, the tested hcw were, in general, healthier than the non-hcw group. the hcw had a lower proportion of several comorbidities including chronic obstructive pulmonary disease(copd)/emphysema, diabetes, hypertension, coronary artery disease, heart failure, cancer, history of transplant, or immunosuppressive disease and were more likely to have received the influenza vaccine (85.9 vs. 45.4%, p < 0.001). the hcw tested had a lower proportion of previous prescriptions for immunosuppressive treatment, nsaids, steroids, carvedilol, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or melatonin. covid-19 cohort characteristics and outcomes. there were 551 hcw and 4353 non-hcw who tested positive for covid-19 (appendix table 1 ). of those who tested positive for covid-19, a lower proportion of hcw were hospitalized compared to non-hcw (38 or 6.9% hcw vs. 1205 or 27.7% non-hcw) or were admitted to the intensive care unit (10 or 1.8% hcw vs. 470 or 10.8% non-hcw). in the group who tested positive for covid-19, there was a greater proportion of hcw of asian and white race compared to non-hcw (2.9 vs. 0.8% and 61.0 vs 56.4%, respectively); a similar proportion of hcw with a positive covid-19 test had presenting symptoms of cough, fatigue, diarrhea, loss of appetite, and vomiting; and a lower proportion had fever or shortness of breath. lower proportions of hcw testing positive had cop-d/emphysema, diabetes, coronary artery disease, heart failure, cancer, or immunosuppressive disease and were previously prescribed carvedilol, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or melatonin compared to non-hcw. the neighborhood population characteristics of population density or population per housing unit did not differ for those hcw who tested positive and median income was slightly higher compared to non-hcw. overlap propensity weighting. using the variables in the prediction model for covid-19 test positivity, 23 overlap propensity score weighting (table 2 ) resulted in propensity score weighted proportions of 7.7 vs. 8.9 for non-hcw vs. hcw having a positive test and produced an overlap propensity score weighted odds ratio of 1.17 with a 95% confidence interval (ci) of 0.99-1.38 for a hcw having a positive test compared to a non-hcw (fig. 1a) . then using the variables (fig. 1a) . we then compared characteristics of hcw identified as having positions that required direct contact with patients ("patient facing") and those that did not. there were 5159 hcw with patient-facing positions and 986 hcw in nonpatient-facing roles (appendix table 3 ). the hcw with patient-facing roles were younger (median age 38 vs. 47 years, p < 0.001), with more females (proportion males 20.6 vs. 26.2%, p < 0.001), lower proportion of black race and higher asian race, and with greater proportion reporting exposure to covid-19 (73.7 vs. 62.9%, p < 0.001). the patient-facing hcw had lower proportions presenting with fatigue or shortness of breath and higher proportion with loss of appetite. there were no significant differences in laboratory values upon presentation. the patient-facing hcw had lower proportions of some previously prescribed medications including nsaids, steroids, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and melatonin. the patient-facing hcw group had lower proportions of comorbidities including copd/emphysema, diabetes, hypertension, coronary artery disease, cancer, connective tissue disease, and immunosuppressive disease. applying the overlap propensity score weighting (appendix tables 4 and 5 ; fig. 1b the summary of the trend of sars-cov-2 positive test results in the study period is shown in figure 2 . the overall proportion of positive covid-19 test results decreased during the study period and the trend for hcw and followed that of non-hcw. our analysis of hcw compared to non-hcw who were tested for sars-cov-2 in one health system with 2 geographic locations (ohio, florida), and which controlled for significant differences in baseline characteristics between the hcw and non-hcw groups, showed that the odds of having a positive covid-19 test were not significantly different for hcw compared to non-hcw, and hcw had lower odds of subsequent hospitalization, and without statistically significant differences in icu admission compared to non-hcw once they tested positive. the hcw classified as having patient-facing positions had higher and significant odds of a positive covid-19 test with insignificant differences detected compared to non-patient-facing hcw in outcomes of hospitalization or icu admission. we found a similar proportion of hcw with a positive covid-19 test had presenting symptoms of cough, fatigue, diarrhea, loss of appetite, and vomiting while a lower proportion had fever or shortness of breath. we note that we were not able to capture the symptoms of loss of taste and/or smell and that these symptoms may be common especially with mild cases of covid-19. 24, 25 the overall proportion of covid-19 positive tests in hcw was low and decreased during the study period corresponding with implementation of risk-mitigation measures in our health system such as the recommendations for universal masking and physical distancing but also followed the trend for non-hcw. several of the previous studies of hcw risk for infection during the covid-19 pandemic were limited by their sample sizes, 7-9 lack of generalizability for healthcare systems that have adequate access to ppe, 7-9 methodology relying on self-report, 12 limited ability to adjust for known risk factors of disease susceptibility and progression, [7] [8] [9] [10] 12 and lacking data to investigate the relative effects of dual exposure of hcw to covid-19 in the community versus the workplace. [7] [8] [9] [10] 12 the fact that hcw identified as patient facing had a significantly higher odds for sars-cov-2 test positivity suggests an increased risk of covid-19 infection with work exposure. however, it is important to note in our study that over 70% of the hcw group reported an exposure to covid-19 with 28% reporting exposure to a family member with covid-19. in our study, we were not able to confirm if the patientfacing hcw were working in patient-facing areas during the 14-day period before the test was ordered when exposure could have occurred, or whether the exposure occurred with or without ppe-both in the workplace or in the community, or the relative contribution of initially prioritizing testing availability to hcw with reported exposures. while the risk to hcw attributed to community spread may not be captured in our available data, the reported exposure risk including the higher proportion of hcw vs. non-hcw reporting exposure to a family member with covid-19 suggests a degree of community acquisition of infection. a potential contributing factor to community acquisition is that hcw, particularly patient-facing hcw, are less able to follow stay-athome guidelines or work remotely from home. indeed, while ppe use is associated with decreased risk of infection from coronavirus, 26 a recent report estimated less than 5% risk to hcw inadvertently exposed to patients not known to be sars-cov-2-positive at the time of initial exposure with exposure likely occurring without appropriate ppe 27 suggesting that the work exposure risk may actually be low. however, universal pandemic precautions have been recommended for optimal risk mitigation for hcw. 28 in our analysis of one healthcare system which implemented significant risk-mitigation strategies to prevent the spread of covid-19 infection, and which controlled for significant baseline differences in hcw compared to non-hcw, the odds for sars-cov-2 infection were similar for hcw and non-hcw and hcw had lower odds for covid-19-related hospitalization. the patient-facing hcw had higher odds of sars-cov-2 infection. centers for disease control and prevention clinical characteristics of 80 hospitalized frontline medical workers infected with covid-19 in wuhan, china figure 2 proportion of sars-cov-2 positive results during the study period. cchs = cleveland clinic health system characteristics of health care personnel with covid-19 -united states strong associations and moderate predictive value of early symptoms for sars-cov-2 test positivity among healthcare workers, the netherlands characteristics of deaths amongst health workers in china during the outbreak of covid-19 infection health insurance status and risk factors for poor outcomes with covid-19 among u.s. health care workers: a cross-sectional study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention covid-19: the daunting experience of health workers in transmission of covid-19 to health care personnel during exposures to a hospitalized patient first experience of covid-19 screening of health-care workers in england masks for prevention of respiratory virus infections, including sars-cov-2, in health care and community settings risk of covid-19 among frontline healthcare workers and the general community: a prospective cohort study association between universal masking in a health care system and sars-cov-2 positivity among health care workers network-based drug repurposing for novel coronavirus 2019-ncov/ sars-cov-2 | cell discovery. accessed extracting and utilizing electronic health data from epic for research research electronic data capture (redcap)-a metadata-driven methodology and workflow process for providing translational research informatics support department of health covid-19 outbreak the state of florida issues covid-19 updates | florida department of health addressing extreme propensity scores via the overlap weights understanding observational treatment comparisons in the setting of coronavirus disease 2019 (covid-19) individualizing risk prediction for positive covid-19 testing: results from 11,672 patients loss of taste and smell as distinguishing symptoms of covid-19 evolution of altered sense of smell or taste in patients with mildly symptomatic covid-19 epidemiology of and risk factors for coronavirus infection in health care workers covid-19 infections among hcws exposed to a patient with a delayed diagnosis of covid-19 universal pandemic precautions-an idea ripe for the times conflict of interest: the authors declare that they do not have a conflict of interest.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-272679-dobaci5p authors: yan, brandon w.; hsia, renee y.; yeung, victoria; sloan, frank a. title: changes in mental health following the 2016 presidential election date: 2020-10-31 journal: j gen intern med doi: 10.1007/s11606-020-06328-6 sha: doc_id: 272679 cord_uid: dobaci5p background: the 2016 presidential election and the controversial policy agenda of its victor have raised concerns about how the election may have impacted mental health. objective: assess how mental health changed from before to after the november 2016 election and how trends differed in states that voted for donald trump versus hillary clinton. design: preversus post-election study using monthly cross-sectional survey data. participants: a total of 499,201 adults surveyed in the behavioral risk factor surveillance system from may 2016 to may 2017. exposure: residence in a state that voted for trump versus state that voted for clinton and the candidate’s margin of victory in the state. main measures: self-reported days of poor mental health in the last 30 days and depression rate. key results: compared to october 2016, the mean days of poor mental health in the last 30 days per adult rose from 3.35 to 3.85 in december 2016 in clinton states (0.50 days difference, p = 0.005) but remained statistically unchanged in trump states, moving from 3.94 to 3.78 days (− 0.17 difference, p = 0.308). the rises in poor mental health days in clinton states were driven by older adults, women, and white individuals. the depression rate in clinton states began rising in january 2017. a 10–percentage point higher margin of victory for clinton in a state predicted 0.41 more days of poor mental health per adult in december 2016 on average (p = 0.001). conclusions: in states that voted for clinton, there were 54.6 million more days of poor mental health among adults in december 2016, the month following the election, compared to october 2016. clinicians should consider that elections could cause at least transitory increases in poor mental health and tailor patient care accordingly, especially with the 2020 election upon us. supplementary information: the online version contains supplementary material available at 10.1007/s11606-020-06328-6. president donald trump's 2016 election victory and controversial campaign agenda raised concerns about the election's impact on health. 1 a pre-2016 election survey found that 52% of americans considered the election to be a "significant source of stress," while 49% reported the election outcome to be a significant source of stress in january 2017. 2 the few published studies assessing the impact of the election on mental health used online search data and small surveys and found evidence of increased stress and anxiety following the election. [3] [4] [5] however, whether this reported stress translates into population-level changes in perceived mental health and diagnosed mental health conditions is largely unknown. with the 2020 election upon us, understanding the last presidential election's impact on mental health could help health care providers anticipate and better address electionrelated health effects this november and beyond. in this study, we used a large national health survey to analyze changes in mental health and depression in states that voted for secretary hillary clinton versus states that voted for trump. we further investigated whether changes in mental health were associated with a candidate's margin of victory in a state, which we used as a proxy for voter choice. we used the 2016 and 2017 editions of the behavioral risk factor surveillance system (brfss), a joint state and federal annual household survey of more than 400,000 adults, to study changes in mental health indicators in clinton-versus trumpvoting states in the 6 months following november 2016 compared to 6 months prior. the brfss telephone survey is conducted throughout the year using random-digit telephone dialing. our study design is a monthly cross-sectional study of respondents living in the 50 states and the district of columbia who responded to the poor mental health survey question from may 2016 to may 2017. for population sizes used in the supplementary information the online version contains supplementary material available at https://doi.org/10.1007/s11606-020-06328-6. calculation of total days of mental health change in the population, we used the u.s. census bureau's 2016 state characteristics population estimates for us adults ages 18 and older. there were 2 key explanatory variables. the first was a binary variable set to 1 if the survey respondent lived in a state in which trump received a plurality of votes in november 2016 and 0 if he did not. we refer to these states as trump or clinton states for brevity. we had 3 outcomes of interest. the primary outcome was days of "poor mental health" in the last 30 days (range 0-30 days), which was surveyed as "now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?" responses of do not know, not sure, or refused comprised 1.6% of responses and were excluded from analysis. the secondary outcome was the rate of 14 or more poor mental health days in the last 30 days (range yes/no), which is important for its relation to one of the diagnostic and statistical manual of mental disorders, 5th edition's criteria for major depressive disorder (mdd) that requires at least 2 weeks of symptoms. fourteen days of such symptoms alone is insufficient for the diagnosis of mdd but could point towards its possibility. the third outcome was the depression rate, which was surveyed as "has a doctor, nurse, or other health professional ever told you that you had any of the following? tell me "yes", "no", or you are "not sure": (ever told) you that you have a depressive disorder, including depression, major depression, dysthymia, or minor depression?" responses of not sure, do not know, or refused comprised less than 0.5% of responses and were excluded from analysis of this outcome. other explanatory variables used as regression covariates were respondent age (18-24, 25-34, 35-44, 45-54, 55-64, 65+), sex (male, female), race and ethnicity (non-hispanic white, non-hispanic black, hispanic, and other or unknown r a c e ) , a n n u a l h o u s e h o l d i n c o m e ( < $ 1 5 , 0 0 0 ; $15,000-$24,999; $25,000 to $34,999; $35,000 to $49,999; > $50,000), educational attainment (high school graduate or less, attended college or technical school, graduated from college or technical school), state of residence (50 us states and the district of columbia), and pre-election trends (binary variables for each of the 6 months preceding november 2016). stratifying by trump states and clinton states, we analyzed values for the outcome variables in each month for the 6 months following the election compared to values in october 2016. we used ordinary least squares linear regression to fit our model and applied brfss survey weights to obtain nationally representative estimates while adjusting for respondent's age group, sex, race/ethnicity, income, educational attainment, state, and 6 months of pre-november trends. equation 1 describes our study design: where i denotes age group; j, race/ethnicity; k, sex; l, income; m, education; and s, state. the regression modeled mental health outcomes by month (t) relative to the election event (y = 0, t 0 , november 2016). as the coefficient of interest, β y describes the difference in the dependent variable between each month and the month immediately preceding the event (october 2016, y = − 1), the omitted reference group. the β y differences between the pre-election months and october 2016 (y = − 6 to − 1) control for trends in the pre-period. β ijklm is a vector for age, race/ethnicity, sex, income, and education groups. ω captures state fixed effects. the regression analysis was survey weighted and used robust standard errors. the analysis was performed for clinton states and then repeated for trump states. we would expect the coefficients for event times y = − 5, − 4, − 3, and − 2 to not be statistically different from the reference month (y = − 1) if the mental health measure was relatively stable in the months prior to the election. if they are statistically different from y = − 1, then there is evidence of an existing pre-event trend. in the months following the election (event times y ≥ 0), a statistically significant result would indicate a detectable change in the dependent variable from october 2016 that is independent the previously noted covariates, including any pre-event trend. in addition, subgroup analyses were performed for age group, sex, and race to provide data on which groups were particularly affected. survey weights and the same linear model specification were used for each subgroup of respondents. to analyze the association between a candidate's margin of victory in a state and the change in poor mental health between october 2016 and december 2016, we collapsed the personlevel brfss data into a state-level file. we chose these 2 months, the month immediately preceding and the month immediately following the election, to mitigate the influence of other events. because there is variable lag time for when changes in depression might follow from the election, we performed this analysis on the poor mental health variable. the state-level file contained the mean weighted changes in poor mental health from october 2016 to december 2016, as well as the weighted characteristics of the survey respondents (ijklm) in october 2016 and december 2016 by proportion in each state (e.g., weighted proportion of female respondents in october/december 2016 in a particular state). we then used linear regression to estimate the relationship between margin of victory and change in poor mental health, both with and without other covariates (i.e., the survey respondents' characteristics described above). a total of 499,201 respondents from may 2016 to may 2017 were included for analysis. compared to october 2016, the mean number of poor mental health days per adult in the last 30 days increased from 3.35 to 3.85 in december 2016 in clinton states (0.50 days difference, standard error (se) 0.18, p = 0.005) but remained statistically unchanged in trump states, falling from 3.94 to 3.78 days (− 0.17 days difference, se 0.16, p = 0.308). results from adjusted analysis were very similar (fig. 1) . the additional 0.50 days per adult translated into 54.6 million more days of poor mental health in december 2016 alone for the 109.2 million adults living in clinton states. notably, december 2016 was the only month during the 12-month study period when the point estimate of mean poor mental health days was lower in trump states than in clinton states. the increase in average poor mental health days in clinton states and absence of change in trump states largely persisted in the 6 months post-election even after adjustment for the study covariates (fig. 1) . trends in the rate of 14 or more poor mental health days closely followed that of the continuous poor mental health days measure. the proportion of respondents reporting at least 14 days of poor mental health in the last 30 days rose 2percentage points (se 0.7, p = 0.003) in december 2016 compared to october 2016 and remained steady thereafter in clinton states, while no such rise was observed in trump states (fig. 1) . in subgroup analysis, the rise in poor mental health days in clinton states in december 2016 reflected increases in such days by adults aged 65 and older, women, and white individuals (table 1) . on average, white adults in clinton states had 0.74 additional days of poor mental health in the last 30 days in december 2016 than in october 2016 (se 0.19, p < 0.001). of the 3 groups with increases, white individuals had the most sustained increase in the 6 months following the election. notably, no changes in poor mental health days were detected among younger age groups, men, or racial and ethnic minority groups in december 2016 in either clinton or trump states. in trump states, men reported fewer days of poor mental health in december and january than october, although only in january was the difference statistically significant (0.50 fewer days, se 0.24, p = 0.036) ( table 1) . subgroup findings for the 14-day poor mental health version of this variable were similar with two main exceptions. older adults in clinton states did not have a significant increase in 14 or more poor mental health days in december 2016 (2.1-percentage point increase, se 1.1, p = 0.072) as they did in the continuous measure (supplemental table 1 ), but it should be noted that older adults had the lowest baseline number of poor mental health days of any age group ( table 1 ). in addition, the fall in mean poor mental health days for men in trump states in january 2017 did not extend to the 14 or more days measure. in contrast, depression rates compared to october 2016 first rose statistically in clinton states in january 2017 (2.1percentage point increase, se 0.8, p = 0.008), 1 month following the rise in days of reported poor mental health (fig. 2 ). this overall rise was driven by more reports of depression in younger adults (ages 18-34) and older adults ( table 2) . depression rates also began rising compared to october 2016 in trump states in february 2017 (1.8-percentage point increase, se 0.8, p = 0.028). in both groups of states, the rise in depression rates continued into the second quarter of 2017 (fig. 2) . trump's margin of victory in a state was predictive of the degree of mental health change from october 2016 to december 2016. in adjusted regression analysis, a 10-percentage point higher margin of victory for trump predicted 0.41 fewer days of poor mental health (se 0.11, p = 0.001) (fig. 3) . the converse is also true that a 10-percentage point higher margin of victory for clinton predicted 0.41 more days of poor mental health. following the 2016 election, poor mental health days increased in states that voted for clinton but remained relatively stable in trump states. in addition, the margin of clinton's victory in a state predicted the extent of mental health worsening. together, the findings suggest that the outcome of the 2016 election had a negative impact on mental health for voters of the losing candidate overall. although other factors are likely contributory, the sustained mental health worsening in clinton states in the 6 months following the election suggests that the potential effects of trump's victory were not transitory, a hypothesis supported by a closely lagging rise in self-reported diagnoses of depression. in subgroup analysis, it was older adults, women, and white individuals who bore the brunt of mental health worsening in clinton states. the overall finding in clinton states is not surprising, as a survey from the american psychological association (apa) following the election indicated that more democrats faced stress from the election outcome than republicans. 2 however, that survey found higher rates of election-related stress in racial and ethnic minority groups than in white individuals, which contrasts with our study. some key differences are that the apa survey assessed stress whereas the brfss assessed days of poor mental health, and the apa surveyed fewer people (n = 1019). both surveys were available in english and spanish. a possible explanation is that elevated stress may not necessarily translate to a day of perceived poor mental health. further research is needed to better understand the impact of the election on mental health in minority populations. the question of whether the mental health worsening was of clinical significance is also important. it is notable that not only did poor mental health days increase in clinton states following the election but the proportion of those with 14 or more days also increased, suggesting that a proportion of individuals detectable at the population level may newly meet diagnostic criteria for major depressive disorder. indeed, the rate of self-reported diagnoses of depression rose in january 2017, 1 month after the first detectable rise in poor mental days. interestingly, older adults in clinton states experienced a rise in mean poor mental health days and depression but not rate of 14 or more poor mental health days. we offer a few hypotheses. first, older adults have the lowest baseline number of poor mental health days (mean 2.04 days in clinton states) compared to other age groups, thus making increases less likely to cross the 14-day threshold. second, older adults have higher rates of physician visits, which might facilitate the reporting of depressive symptoms to providers who then communicate a diagnosis. 6 third, the survey question allows for a provider-made diagnosis of "depression, major depression, dysthymia, or minor depression," so the rise in depression rate among older adults could reflect rises in dysthymia or minor depression instead of major depression, which requires at least 2 weeks of symptoms. in states that voted for trump, there was no statistically significant drop in poor mental health following the election, although there was a brief non-significant reduction in december and january that suggests that some groups may have benefited. in our subgroup analysis, only men in trump states had a significant improvement in poor mental health days and ionly n january 2017. overall, there is insufficient evidence to suggest that trump's election victory had a beneficial impact on mental health for trump voters overall. the rise in depression in trump states beginning 3 months after the election suggests that there were likely other coinciding factors, especially as time elapsed further from election day, contributing to depression. in particular, the usa faced a concurrent epidemic of rising opioid deaths during this period that killed over 47,000 in 2017 and especially affected many states that voted for trump including west virginia, ohio, and pennsylvania. 7, 8 furthermore, the usa has been experiencing a decade-long rise in depression nationally. 7, 9, 10 in addition, the newly installed trump administration enacted a myriad of executive orders in early 2017, the scope of which is beyond that of this study but important to consider in assessing mental health in the months following his inauguration. this study has several limitations. this is a cross-sectional study based on a national survey taken monthly, not a longitudinal cohort study. therefore, we could not monitor the mental health of respondents over time and, similarly to comparing election polls, depended on the study sample being representative of the population, an assumption made more likely with the use of brfss survey weights in our analysis. as a non-randomized study, this analysis cannot definitively establish a causal relationship from the election results to changes in mental health but instead offers evidence in support or against plausible causal pathways. because the respondents' candidate preference and party affiliation are unknown, linear regression adjusted for age group, sex, race/ethnicity, income, educational attainment, state, and 6 months of pre-november trends se standard error. *p < 0.05, **p < 0.01, ***p < 0.001 we rely on the candidate's margin of victory or loss in a state as a proxy to assess which candidate's voters experienced changes in mental health. the brfss survey data are selfreported, which are not as reliable as clinical records. in particular, the depression measure relies on a respondent's memory of a health care professional diagnosing them and willingness to report. the depression question is also not an indicator of one's depression at time of interview but whether such a diagnosis has been given at any time in one's history. therefore, we make the assumption that changes in this linear regression adjusted for age group, sex, race/ethnicity, income, educational attainment, state, and 6 months of pre-november trends se standard error. *p < 0.05, **p < 0.01, ***p < 0.001 measure over time (i.e., before and after the 2016 election) are largely attributable to newly diagnosed cases. finally, there may be differences in access to care for adults living in states that voted for clinton compared with states that voted for trump, which may not be accounted for in this study. overall, with nearly 55 million more days of poor mental health among the 109.2 million adults living in clinton states in december than october 2016 alone, primary care providers, mental health professionals, and the public should not overlook the potential effects from the 2020 election. the usual approaches to depression screening and mental health care may be insufficient, especially with falling primary care visits in the covid-19 era. 11 the situation is worsened by increased social isolation, substance use, and mental health distress as well as missed or delayed diagnoses during the pandemic. 11-13 a review of mental health interventions during pandemics concluded that involving patients in their care over a sustained period of time, digital and social media outreach, and resilience-building sessions are potentially promising interventions in a pandemic setting. 14 in addition to regular primary care screening for depression and subsequent treatment and follow-up as recommended by u.s. preventives services task force 2016 guidelines, providers could specifically inquire about election-related stress and distress when clinically appropriate. 15 our study suggests that older adults and voters of the losing candidate may be most at risk for mental health deterioration. our study reveals a concerning rise in poor mental health and depression in states that voted for the losing presidential candidate shortly following the 2016 election that was not observed in states that voted for the winning candidate. health care providers could potentially help patients in the 2020 election by monitoring for clinically relevant signs of mental health deterioration and offering appropriate support and intervention. in the long term, more research into the impact of elections on mental health is needed to facilitate a more datadriven and holistic approach to care for patients experiencing election-related stress. health effects of dramatic societal events -ramifications of the recent presidential election. malina d american psychological association president trump stress disorder: partisanship, ethnicity, and expressive reporting of mental n risk factors associated with election-related stress and anxiety before and after the 2016 us presidential election. psyarxiv elections have consequences for student mental health: an accidental daily diary study: psychol rep national institute on drug abuse the opioid epidemic blunted the mortality benefit of medicaid expansion trends in depression among adults in the united states, nhanes 2005-2016 drug overdose death rates the impact of the covid-19 pandemic on outpatient visits: practices are adapting to the new normal. the commonwealth fund mental health, substance use, and suicidal ideation during the covid-19 pandemic -united states note: district of columbia was an outlier value at -86 percentage point margin of victory and therefore excluded from this analysis diagnosis of physical and mental health conditions in primary care during the covid-19 pandemic: a retrospective cohort study mental health interventions and supports during covid-19 and other medical pandemics: a rapid systematic review of the evidence screening for depression in adults: us preventive services task force recommendation statement key: cord-339508-nf6ov39g authors: weil, ana a.; newman, kira l.; ong, thuan d.; davidson, giana h.; logue, jennifer; brandstetter, elisabeth; magedson, ariana; mcdonald, dylan; mcculloch, denise j.; neme, santiago; lewis, james; duchin, jeff s.; zhong, weizhi; starita, lea m.; bedford, trevor; roxby, alison c.; chu, helen y. title: cross-sectional prevalence of sars-cov-2 among skilled nursing facility employees and residents across facilities in seattle date: 2020-09-01 journal: j gen intern med doi: 10.1007/s11606-020-06165-7 sha: doc_id: 339508 cord_uid: nf6ov39g background: skilled nursing facilities (snfs) are high-risk settings for sars-cov-2 transmission. infection rates among employees are infrequently described. objective: to describe sars-cov-2 rates among snf employees and residents during a non-outbreak time period, we measured cross-sectional sars-cov-2 prevalence across multiple sites in the seattle area. design: sars-cov-2 testing was performed for snf employees and residents using quantitative real-time reverse transcription polymerase chain reaction. a subset of employees completed a sociodemographic and symptom questionnaire. participants: between march 29 and may 13, 2020, we tested 1583 employees and 1208 residents at 16 snfs for sars-cov-2. main measure: sars-cov-2 testing results and symptom report among employees and residents. key results: eleven of the 16 snfs had one or more resident or employee test positive. overall, 46 (2.9%) employees had positive or inconclusive testing for sars-cov-2, and among those who completed surveys, most were asymptomatic and involved in direct patient care. the majority of employees tested were female (934, 73%), and most employees were asian (392, 30%), black (360, 28%), or white (360, 28%). among the 1208 residents tested, 110 (9.1%) had positive or inconclusive results. there was no association between the presence of positive residents and positive employees within a snf (p = 0.62, mcnemar’s test). conclusions: in the largest study of snfs to date, sars-cov-2 infections were detected among both employees and residents. employees testing positive were often asymptomatic and involved in direct patient care. surveillance testing is needed for snf employees and residents during the pandemic response. electronic supplementary material: the online version of this article (10.1007/s11606-020-06165-7) contains supplementary material, which is available to authorized users. skilled nursing facilities (snfs) are high-risk settings for rapid spread of sars-cov-2 infection because they are congregate settings that frequently house a vulnerable patient population with multiple co-morbidities. 1, 2 many outbreaks in long-term care facilities have been described, often with high mortality rates in residents. 3 symptom screening alone for has been shown to be inadequate for preventing outbreaks in congregate settings, likely because of asymptomatic and presymptomatic spread. 4 for this reason, the centers for medicaid and medicare services released guidance recommending baseline screening for sars-cov-2 in congregate settings and periodic screening of employees and residents. 5 given the essential role of snf employees and their potential role in introducing sars-cov-2 into a high-risk setting, the prevalence of sars-cov-2 in snf personnel is key to understanding outbreaks and disease transmission within snfs. the snf care environment and snf employees have specific characteristics that increase the risk of sars-cov-2 outbreaks in snfs. the covid-19 pandemic has accentuated realities of the snf care environment in which resources and personnel are often inadequate to meet the demands of an infectious disease outbreak, and snfs have also reported employee and supply shortages since the covid-19 pandemic began. 6 snf employees also frequently work at multiple sites, experience higher turnover, receive lower pay compared with acute care settings, have less access to sars-cov-2 testing, and have been less prioritized to receive personal protective equipment (ppe) allocations. [7] [8] [9] [10] [11] a recent account in our state describes snf employees demonstrating heterogeneous ppe use and training, in addition to inadequate ppe supply and delayed recognition of cases. 12 due to fear of infection and/or lack of ppe, absenteeism in the snf environment has also been reported. 13, 14 prior to the covid-19 era, high levels of absenteeism in nursing facilities have been associated with poor outcomes. 15 in washington state, a government call to action on march 10, 2020, led to snfs barring visitors and engaging in employee symptom-based screening. 16 despite these precautions, cases of sars-cov-2 continue to be observed in snfs. to address this, testing for sars-cov-2 among snf employees regardless of symptoms is needed in order to develop strategies for decreasing transmission in snfs and the larger community. in this study, we describe the results of cross-sectional resident and employee sars-cov-2 testing, and infection control and personnel policies associated with 16 seattle area snfs. through two testing strategies, a total of 16 snfs offered testing to either residents, employees, or both. the first testing strategy was directed by public health of seattle & king county (phskc) and focused on snf resident testing with employee testing offered at select sites. the second testing strategy was facilitated by the seattle flu study (sfs) and directed at testing only employees. phskc testing was conducted by providers from university of washington, between march 29, 2020, and may 8, 2020, at 13 snfs and one assisted living facility, of which six offered both resident and employee testing and eight had only resident testing. employee testing by sfs was designed to coincide with resident testing done by phskc when possible. sfs testing was conducted between april 14, 2020, and may 13, 2020, at 13 snfs. at three snfs, both the phskc and seattle flu study teams tested snf employees. phskc identified snfs in need of sars-cov-2 testing, including sites with known covid-19 cases, facilities with no known cases, or where covid-19 testing of residents had not occurred. for testing through phskc, teams of healthcare workers collected nasopharyngeal (np) swabs from all residents in a snf during a single visit. for testing through seattle flu study, facilities identified by phskc were contacted by the study team for employee testing. facilities agreeing to participate messaged all employees before the visit to inform them of the upcoming testing event and distributed a copy of the informed consent form for previewing. employees were eligible to participate if they worked at the facility and were over 18 years old. all testing was voluntary and not required by the employer, and employees were advised that results would not be reported directly to employers. employees who reported prior testing for sars-cov-2 through other mechanisms were eligible for enrollment. study staff consented individuals in english or in the participant's language of preference using an interpreter. after informed consent was obtained, individuals completed an electronic tablet-based questionnaire (project redcap in redcap, nashville, tn) and self-collected a mid-nasal swab under observation by trained study staff. for testing through phskc, np swabs from snf residents were placed in universal viral transport media (becton dickinson, franklin, nj) and transported to the university of washington virology laboratory for testing via a one-step real-time reverse transcription polymerase chain reaction (rt-pcr) assay following the sars-cov-2 cdc assay protocol, as previously described. 17 no samples tested through phskc were resulted as indeterminant. for testing through seattle flu study, self-collected midnasal nylon-flocked swabs were placed in universal viral transport media (becton dickinson, franklin, nj) and transported to the brotman baty institute for precision medicine and the northwest genomics center for testing using a laboratory-developed test for sars-cov-2, as previously described. 18 briefly, sars-cov-2 detection was performed using real-time rt-pcr with a probe set targeting orf1b and s with fam fluor (life technologies 4332079 assays # apgzjkf and apxgvc4apx) multiplexed with an rnase p probe set with vic or hex fluor (life technologies a30064 or integrated data technologies custom made) each in duplicate on a quantstudio 6 instrument (applied biosystems). three or four replicates for rnase p and sars-cov-2 were required to have a detection cycle threshold less than 40 for a sample to be considered positive for this laboratory-developed test, or both replicates must be positive in the research assay. samples resulting with two replicates of positive sars-cov-2 detection were defined as inconclusive. because tests determined to be inconclusive had sars-cov-2 detected in multiple replicates, these results were grouped with positive results for reporting purposes. for individuals tested through phskc, data available included name, date of birth, date of testing, and whether the individual was a resident or an employee. for employees tested through the seattle flu study, data included participant date of birth, date of testing, race and ethnicity, location and nature of work, new symptoms experienced during the last 7 days, and history of sars-cov-2 testing (appendix 1 in the supplementary material). information on snf policies regarding absenteeism, infection control, and employee health were collected from snf management by email 2 weeks following employee testing using a standardized data collection form (appendix 2 in the supplementary material). time between resident and employee testing was calculated as the days elapsed between first testing dates for each group at a snf. for sites with multiple testing dates for employees, residents, or both, tests from all dates for a given group were combined to calculate the prevalence at each site. all data analysis was conducted in the r statistical language (r foundation for statistical computing, vienna, austria). frequencies were tabulated for social and demographic data. to test the association between residents and employees who tested positive for sars-cov-2, a two-tailed mcnemar's test was used. p values < 0.05 were considered statistically significant. for employees, positive or inconclusive sars-cov-2 test results were reported directly to participants by phone within 48 h and to the washington state department of health. resident results were reported to the ordering physician at the snf. the seattle flu study was approved by the university of washington institutional review board. other testing of residents and employees was conducted as a public health surveillance activity under the direction of phskc. overall, 1583 employees at 16 snfs were tested, with 287 (18%) tested through phskc and 1296 (82%) through sfs. a total of 46 (2.9%) employees had positive or inconclusive testing for sars-cov-2 ( fig. 1; supplemental table 1 ). demographic information from employees tested through sfs is shown in table 1 . this information is not available for employees tested through phskc. the majority of employees tested were female (934, 72%) and identified their race as asian (392, 30%), black (360, 28%), or white (360, 28%), and worked in direct patient care (795, 62%). only 8.1% (105) of employees reported working at more than one snf. new symptoms were reported in 8.7% (106) during the week prior to testing. most employees (930, 73%) had not previously been tested for sars-cov-2. of employees who reported prior testing, 13% (46) had a previous positive or inconclusive test result. of the 46 total employees who tested positive for sars-cov-2, 33 were tested through the phskc and 13 through sfs, and only the latter 13 had accompanying survey data. the majority of those tested through sfs reported performing direct patient care (table 1) . employees who tested positive were more likely to have had a prior positive test compared with employees that tested negative (6 (46%) versus 40 (3%), respectively). employees who tested positive were less likely to be asymptomatic (9 (69%) versus 1170 (92%), respectively). among the six individuals with sars-cov-2 detected who had not previously been tested, only one (14%) reported symptoms. based on the employee counts provided by snfs, an average of 70% (range 34-108%) of employees on-site on the day of testing participated (supplemental table 2 ). despite facility policies that any employees with new respiratory symptoms should not come to work, several employees reported respiratory symptoms (2 with cough, 1 with sore throat) and tested positive in our study, and several employees reporting gastrointestinal symptoms also tested positive. residents of 14 snfs were tested through the phskc. of 1208 residents, 110 (9.1%) tested positive for sars-cov-2 ( fig. 1; supplemental table 1 ). resident testing was conducted within an average of 1.6 days (range 0-7 days) of employee testing. five snfs (36%) had sars-cov-2-positive residents, and among snfs with at least one resident who tested positive, the mean positivity rate for sars-cov-2 was 33% (range, 3.0-70%). of the 14 snfs with resident and employee testing (fig. 1) , four (29%) had both positive residents and positive employees, three (22%) had positive employees but no positive residents, and one (7.1%) had positive residents but no positive employees. there was no significant association between presence of positive residents and positive employees (p = 0.62). thirteen of the 16 snfs responded to the survey (supplemental table 2 ), although only six sites completed all survey questions. all sites reported that they had a policy in place that employees with any new respiratory symptoms should not come to work, and all sites reported having paid sick leave policies. these policies varied with regard to eligibility and how leave was made available. for example, one snf reported a paid sick leave policy that allowed employees to accrue negative sick leave if necessary, while others did not allow this option. most snfs reported following the centers for disease control guidelines for return to work after a respiratory illness. 19 seven of the 16 snfs reported their ppe policy and all required universal masking. the type of mask used was not specified. we report the results of a large cross-sectional study evaluating sars-cov-2 prevalence in skilled nursing facilities (snfs) in the seattle area during the spring 2020 peak of the covid-19 pandemic. to our knowledge, this is the first study to report occupational sars-cov-2 for snf workers outside of an outbreak investigation and the largest study to date evaluating prevalence of sars-cov-2 in snf workers. we detected sars-cov-2 in both residents and employees at multiple sites. the majority of employee testing positive for sars-cov-2 were asymptomatic and involved in direct patient care. in this study, all surveillance was performed starting at least 2.5 weeks after the implementation of a strict no visitor policy at snfs throughout the region. given that many infected snf employees were asymptomatic, transmission events have the potential to go undetected without broad-based testing of all employees. this is critical, because asymptomatic and presymptomatic infections have led to significant transmission events in other high-density congregate living facilities with highrisk residents. 1, 4 similar to other congregate environments like cruise ships, correctional institutions, and long-term care facilities, [20] [21] [22] snfs are an environment where introduction of one case may lead to rapid transmission. we did not assess for routes of disease transmission during the study period, and transmission of sars-cov-2 to snf residents could have occurred from contact between residents, infected employees, or other outside contacts, such as exposure to dialysis centers outside of the snf. minority communities are over-represented in low-wage healthcare clinics and include populations known to be disproportionately impacted by covid-19. 9, [23] [24] [25] we found that snf employees in our study were disproportionately more non-white and non-hispanic individuals, including a higher proportion of asian and black participants, than are represented in the population of the seattle area. 26 while all facilities reported some form of paid sick leave program, many had limits on eligibility for part-time and contracted employees. lacking paid sick leave is a financial disincentive to report symptoms or positive tests. these factors highlight the vulnerability of snf employees as an often overlooked group in the transmission of sars-cov-2. this study was conducted during an ongoing pandemic in seattle. in the conduct of this study, we encountered obstacles including shortages of ppe, viral transport media, and nasal swabs. participation was voluntary across sites, and an average of 70% on-site employees participated. the administration at each snf presented the opportunity for testing with different levels of enthusiasm and support, and this may have impacted employee participation. furthermore, when approached with the offer of employee testing, the administrative leadership of some of the snfs in the seattle area declined to participate. common concerns about mass employee testing from snf administration were that testing would result in increased fear, employee absenteeism, and/or consequent staffing shortages. strengths of this study include broad testing of both residents and employees in a group of snfs at the spring 2020 peak of the covid-19 pandemic in a major metropolitan area. we collected sociodemographic and symptom data on the majority of the employees, and information on infection control policies across sites. limitations of this study included that sites were included only if administrative leadership agreed to participate, and the sites that did not participate may have differed in infection rates and ppe practices compared with those that agreed. testing at sites did not include all employees; only employees volunteering for testing participated. collection of sars-cov-2 samples used different collection methods between residents and employees, and the timing of testing for resident and employees was not simultaneous. however, both methods of collection have proven to be concordant (citation of a manuscript under review will be inserted here) and the mean difference between employee and resident testing was small (mean of 1.6 days). symptom data was self-reported and may be limited by a social desirability bias and/or by recall bias. to mitigate bias, employees filled out the questionnaire using an electronic tablet while at a six foot distance from other participants, which afforded some privacy. additionally, we do not have longitudinal data on participants and do not know how many asymptomatic individuals were presymptomatic. as sars-cov-2 infections continue to cause disproportionate numbers of deaths in facilities for older adults throughout the country, strategies to prevent mortality in this fragile population are critical. we found that infections in both employees and residents persisted even with no visitor policies, and facilities had heterogenous paid leave policies. based on our findings, implementation of periodic point prevalence testing of both residents and employees, coupled with rigorous infection control precautions and universal paid sick leave for employees, may provide an improved strategy to reduce mortality in this highly vulnerable population. future research should focus on trials of strategies, such as routine employee testing, to understand their effectiveness in sars-cov-2 high-risk occupational settings. percentages may not sum to 100% due to missing responses other respiratory symptoms include dyspnea, rhinorrhea, anosmia, and ageusia gastrointestinal symptoms are defined as diarrhea, nausea, or vomiting other systemic symptoms include chills, fatigue, myalgia, or sweats *non-patient care positions include administration, facilities, food service, and transportation †covid-19-like illness is defined as fever and cough or shortness of breath asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility considerations for preventing spread of covid-19 in assisted living facilities. department of health and human services epidemiology of covid-19 in a long-term care facility in king county, washington presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility safety and oversight group at centers for medicare and medicaid services data from: covid-19 nursing home data. 2020;2.1. data.cms.gov staffing characteristics, turnover rates, and quality of resident care in nursing facilities keeping patients safe: institute of medicine looks at transforming nurses' work environment. the quality letter for healthcare leaders this time must be different: disparities during the covid-19 pandemic unplanned transfer to emergency departments for frail elderly residents of aged care facilities: a review of patient and organizational factors institute of medicine (us) committee on the adequacy of nursing staff in hospitals and nursing homes. nursing staff in hospitals and nursing homes: is it adequate covid-19 in a long-term care facility short staffing an issue at nc nursing homes marked by covid-19 outbreaks. north carolina health news caregiving at a nursing home is a hard job. coronavirus could make it even harder. miami herald influence of nurse aide absenteeism on nursing home quality long-term care facility director. state of washington: department of health covid-19 in critically ill patients in the seattle region -case series centers for disease control. return to work criteria. national center for immunization and respiratory diseases (ncird), division of viral diseases public health responses to covid-19 outbreaks on cruise ships -worldwide covid-19 in correctional and detention facilities -united states outbreak investigation of covid-19 among residents and staff of an independent and assisted living community for older adults in labor force statistics from the current population survey covid-19 and racial/ ethnic disparities sex and gender disparities in the covid-19 pandemic us/pst045219 last accessed acknowledgments: we acknowledge the assistance of public health -seattle & king county coronavirus testing team, which included volunteers from uw medicine, and the many committed research assistants who made this study possible. we acknowledge the support of the brotman baty institute advanced technology lab and the northwest genomics center. we thank the participating snfs and their employees and residents for their cooperation and collaboration in the recruitment process. the seattle flu study portion of testing was funded by gates ventures. the university of washington provided material support including ppe and swabs to phskc for this surveillance activity. conflict of interest: dr. helen chu performs consulting services for merck and pfizer and has grant funding from ellume, cepheid, and sanofi-pasteur. dr. james lewis consults for pwn health. other authors have no conflicts of interest.disclaimer: the funder was not involved in the design of the study and does not have any ownership over the management and conduct of the study, the data, or the rights to publish.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/. key: cord-306352-agppehpz authors: christensen, daniel mølager; strange, jarl emanuel; gislason, gunnar; torp-pedersen, christian; gerds, thomas; fosbøl, emil; phelps, matthew title: charlson comorbidity index score and risk of severe outcome and death in danish covid-19 patients date: 2020-06-24 journal: j gen intern med doi: 10.1007/s11606-020-05991-z sha: doc_id: 306352 cord_uid: agppehpz nan studies assessing the impact of total comorbidity burden on outcomes of covid-19 in age-and sex-controlled analyses are lacking. previous studies identified the following single comorbidities as risk factors for poor covid-19 outcomes: coronary heart disease, congestive heart failure, cardiac arrhythmia, chronic obstructive pulmonary disease, cancer, and diabetes. 1 in this nationwide study of danish covid-19 patients, we investigated if charlson comorbidity index score (ccis) was associated with the risk of severe outcome and death. in denmark, all permanent residents are provided a unique personal identification number enabling cross-linkage of complete nationwide healthcare registries. we included all patients diagnosed with covid-19 until may 3, 2020, using information from the danish civil registration system (holding demographic data) and the danish national patient registry (holding data on all hospital contacts classified according to icd-10 codes). data on comorbidities 10 years prior to the date of covid-19 were identified to calculate the exposure of interest: ccis of 0, 1-2, 3-4, and > 4. 2 outcomes of interest were (1) a composite of death, diagnosis of severe acute respiratory syndrome (icd-10: db972a), intensive care unit (icu) admission, and (2) death. logistic regression models adjusted for sex and age as a continuous variable were employed to associate ccis 1-2, ccis 3-4, and ccis > 4 with odds of outcomes. the models were used to estimate the absolute risk of both outcomes according to ccis groups across ages 40-85 for both sexes. a total of 4480 patients were diagnosed with covid-19, of which 2911 (65.0%), 1112 (24.8%), 288 (6.4%), and 169 (3.8%) had a ccis of 0, 1-2, 3-4, and > 4, respectively ( table 1 ). the median age of the total population was 55 years, with the oldest patients in the ccis 3-4 group (78 years). overall, 17.8% had severe outcome and 9.3% died. in the ccis 0 group, 265 (9.1%) had severe outcome and 77 (2.6%) died. the estimated absolute risks of severe covid-19 and death were increased for ccis 1-2, 3-4, and > 4 compared with those for ccis 0 across ages and sexes (fig. 1) . a charlson comorbidity index score above 0 was associated with an increased risk of severe covid-19 and death when controlled for age and sex. this expands upon previous findings of individual comorbidities as independent risk factors for poor covid-19 outcomes. 1 our findings may inform epidemic modeling, public health, and clinical decisions regarding the management of the covid-19 pandemic. a limitation of this study was that not all patients had reached a study outcome or recovered by the end of the study period. additionally, it was not possible to associate the individual comorbidities constituting the ccis with the outcomes due to lack of power. the danish healthcare system is free with universal access and its icu capacity was not exceeded during the study period, 3 which must be considered when interpreting our findings. more studies are needed to assess the impact of comorbidity combinations on covid-19 outcomes and to determine if other validated comorbidity scores can predict poor outcomes of covid-19. daniel mølager christensen and jarl emanuel strange contributed equally to this work. figure 1 estimated risks of severe outcome and death according to sex, age, and charlson comorbidity index score (ccis). comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis coding algorithms for defining comorbidities in icd-9-cm and icd-10 administrative data covid-19 in denmark epidemiological surveillance report (danish) key: cord-350321-jy4i403g authors: ku, benson s.; druss, benjamin g. title: associations between primary care provider shortage areas and county-level covid-19 infection and mortality rates in the usa date: 2020-08-21 journal: j gen intern med doi: 10.1007/s11606-020-06130-4 sha: doc_id: 350321 cord_uid: jy4i403g nan as covid-19 disproportionately impacts certain regions across the usa, there have been speculations on various factors that may contribute to this disparity. 1 primary care health professional shortage areas (hpsas) are regions with a lack of primary care providers based on need for care. these areas have been associated with greater poverty, larger proportions of racial minorities, 2 low-wage essential workers, and congregate settings, including homeless shelters and prisons, all of whom could be at increased risk of contracting the virus. 1 shortage areas may also have limited availability of testing and treatment, which may contribute to higher covid-19 mortality. 1 however, it is not known whether shortage areas are associated with higher covid-19 infection or mortality rates. this study investigates the hypothesis that primary care hpsas are associated with higher rates of covid-19 infection and mortality. county-level covid-19 daily new cases and deaths from march 22, 2020, to may 16, 2020, in the usa were extracted from https://coronavirus.1point3acres.com/en and covid-19 data repository by the johns hopkins university center for systems science and engineering population-based datasets on may 18, 2020. cases and deaths were aggregated by county into weeks and only counties with reported covid-19 cases and deaths during all 8 weeks were included so that all counties were proportionately represented. 10,328 countyweeks were linked to county-level characteristics including 2019 population estimates from the us census bureau. 3 socioeconomic variables including poverty, unemployment, low educational attainment, population ages 65 and older, male gender, and non-hispanic white race/ethnicity were derived from the 2017 american community survey 5-year estimates. 3 the 2013 rural-urban continuum codes used to classify rurality and whole county primary care hpsas were separately derived from the 2018 area health resource file. 4 primary care hpsas were based on ratios of primary care specialties (general or family practice, general internal medicine, pediatrics, and obstetrics and gynecology) to residents depending on needs for primary care services in specific geographic areas. 4 because most counties still do not have covid-19 testing available, counties without any reported infections may lack cases due to a lack of local testing capacity. 5 therefore, we focused on infection rates for the 10,328 county-weeks with reported covid-19 infections as a proxy for infection burden. generalized linear mixed models with negative binomial distribution were used to test the associations of primary care hpsas and covid-19 rates, controlling for time, rurality, population, and six county-level socioeconomic variables. during this study period, 1,381,197 individuals were diagnosed with covid-19 in the usa, and 85,097 died from this condition. there were 170 (13.2%) whole county primary care hpsas and 1121 (86.8%) areas that were not whole county primary care hpsas. covid-19 infection and death rates were higher in whole county primary care hpsas compared with non-whole county primary care hpsas (overall median: 30.9 vs 18.0 per 10,000 residents and 1.1 vs 0.7 per 10,000 residents, respectively). in models adjusting for county-level factors and sociodemographic characteristics shown in table 1 our findings suggest that primary care provider shortage areas with reported covid-19 cases face a higher burden of covid-19 infections and death even after adjusting for socioeconomic and other county-level factors. while it is not possible to assess causal pathways using these cross-sectional, publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. model b mutually adjusted for all population characteristics and covid-19 confirmed case rates 3 model c individually assessed the association between each characteristic and covid-19 mortality rates 4 model d mutually adjusted for all population characteristics and confirmed covid-19 mortality rates hpsas, health professional shortage areas; irr, incidence rate ratio; rucc, rural-urban continuum codes; low educational attainment (%), the percentage with less than high school educational attainment among the population ages 25 and older; unemployment (%), percentage of unemployment among civilian labor force population 16 years and over; poverty (%), percentage of families and people whose income in the past 12 months is below the poverty level this time must be different: disparities during the covid-19 pandemic the geographic alignment of primary care health professional shortage areas with markers for social determinants of health health resources and services. area health resources files location, location key: cord-326399-ey8g4pom authors: phadke, neelam a.; del carmen, marcela g.; goldstein, susan a.; vagle, jacqueline; hidrue, michael k.; botti, eirian siegal; wasfy, jason h. title: trends in ambulatory electronic consultations during the covid-19 pandemic date: 2020-05-18 journal: j gen intern med doi: 10.1007/s11606-020-05878-z sha: doc_id: 326399 cord_uid: ey8g4pom nan introduction sars-cov2, the virus responsible for the covid-19 pandemic, 1 has forced rapid changes in healthcare delivery. telehealth has previously played a role in delivering ambulatory care in the setting of similar disasters. 2 electronic consultations (e-consults), in particular, may be an effective method of sustaining specialty consultative care while preserving social distancing and reducing demands for personal protective equipment. hypothesizing that e-consult requests would increase during the pandemic, we sought to define covid-19associated changes in e-consult requests. methods e-consults are asynchronous clinician-to-clinician exchanges that rely on information in the patient's electronic health record (ehr). requesting clinicians ask specific clinical questions; specialist physicians review the patient's ehr and document detailed recommendations as an ehr note ( fig. 1 ). our institution, which first implemented e-consults as pilot programs in cardiology and dermatology, 3 has completed over 35,000 e-consults in 50 subspecialty areas and extensively studied their use. 4 our primary outcome was e-consult proportion, defined as e-consult volume over total consult volume (e-consult volume plus traditional ambulatory consult volume). we used an interrupted time series (ist) model to assess the effect of the pandemic on e-consult proportion. we assessed daily volumes from february 1, 2020, through april 1, 2020; the defined date of "intervention" was march 11, 2020, when massachusetts declared a covid-19-related state of emergency. we included weekend/holiday as a covariate to account for differences in consult requests between business days and weekends. we excluded specialty areas with less than 20 e-consult requests, specialty areas that did not offer both an active e-consult and ambulatory consult option, and psychiatry as it included some requests for behavioral health resources without a need for specialist guidance. this work, performed for administrative purposes, was exempt from review by the partners healthcare institutional review board (irb) per the irb's policies. statistical analysis was performed using sas, version 9.4 (sas institute, inc., cary, nc). before march 11, 2020 (n = 40 days), a median of 565 ambulatory consults and 48 e-consults were requested daily. after march 11, 2020 (n = 21 days), a median of 144 ambulatory consults and 40 e-consults were requested daily. while both types of consult requests declined after march 11, the ambulatory consults declined more than the e-consults resulting in an increase in absolute e-consult proportion from 8.5 to 19.6%. after adjusting for weekend and secular trend, we found e-consult proportion increased by 5% (95% ci 2-7%) daily from pre-emergency declaration levels (fig. 2) . we describe a significant increase in e-consult utilization relative to traditional ambulatory referrals following the covid-19-related state of emergency declaration in massachusetts. our results suggest that e-consults can provide a mechanism for sustaining outpatient consultative care during this pandemic. study limitations include the fact that these results obtained from a single boston-based academic medical center may not be generalizable, particularly to institutions without a strong econsult program in place. additionally, this study design cannot assess the relative effectiveness of e-consults versus other types of virtual and in-person care delivery mechanisms. these results suggest an increase in e-consult utilization associated with the covid-19 pandemic in the usa. e-consults may be a promising method of ambulatory consultative care delivery as they can potentially replace some specialty consultations in a manner that provides clinical guidance while reducing the risk of in-person visits to both patients and physicians. this question is electronically transmitted to a specialist physician who reviews the question and clinical information in the ehr and provides clinical guidance including recommendations for further diagnostic testing or therapeutic management via a note entered in the patient's ehr. the referring clinician reviews the specialist's recommendations and orders necessary testing or therapies. obtained prior to this date; points to the right represent data obtained after this date. tick marks refer to the number of days in either direction. a linear model was fitted to the pre-and post-intervention data to better demonstrate the changing trend in e-consult proportion over time. world health organization. who characterizes covid-19 as a pandemic the role of telehealth in the medical response to disasters initial results of a cardiac e-consult pilot program electronic consultations in allergy/immunology the authors acknowledge elizabeth fonseca, funding information e-consults are funded internally by the massachusetts general physicians organization. no additional funding was obtained for this work.compliance with ethical standards: conflict of interest: n.a.p. reports spousal employment by chiesi farmaceutici. j.h.w. reports consulting fees from pfizer and biotronik, career development awards from the american heart association (current), the national institutes of health (past), and harvard catalyst (past); honoraria from new england cepac for which he serves as vice chair; and travel compensation from the american college of cardiology, academic medical centers, and academic conferences. he has additionally participated as a member on a public-private partnership convened by the u.s. department of health and human services on cardiac bundled payments. none of these relationships for either of these authors influenced the work presented here. the other authors disclose no conflicts of interest. key: cord-271599-1yu1yl12 authors: bailey, stacy cooper; serper, marina; opsasnick, lauren; persell, stephen d.; o’conor, rachel; curtis, laura m.; benavente, julia yoshino; wismer, guisselle; batio, stephanie; eifler, morgan; zheng, pauline; russell, andrea; arvanitis, marina; ladner, daniela p.; kwasny, mary j.; rowe, theresa; linder, jeffrey a.; wolf, michael s. title: changes in covid-19 knowledge, beliefs, behaviors, and preparedness among high-risk adults from the onset to the acceleration phase of the us outbreak date: 2020-09-01 journal: j gen intern med doi: 10.1007/s11606-020-05980-2 sha: doc_id: 271599 cord_uid: 1yu1yl12 background: the us outbreak of coronavirus disease 2019 (covid-19) accelerated rapidly over a short time to become a public health crisis. objective: to assess how high-risk adults’ covid-19 knowledge, beliefs, behaviors, and sense of preparedness changed from the onset of the us outbreak (march 13–20, 2020) to the acceleration phase (march 27–april 7, 2020). design: longitudinal, two-wave telephone survey. participants: 588 predominately older adults with ≥ 1 chronic condition recruited from 4 active, federally funded studies in chicago. main measures: self-reported knowledge of covid-19 symptoms and prevention, related beliefs, behaviors, and sense of preparedness. key results: from the onset to the acceleration phase, participants increasingly perceived covid-19 to be a serious public health threat, reported more changes to their daily routine and plans, and reported greater preparedness. the proportion of respondents who believed they were “not at all likely” to get the virus decreased slightly (24.9 to 22.4%; p = 0.04), but there was no significant change in the proportion of those who were unable to accurately identify ways to prevent infection (29.2 to 25.7%; p 0.14). in multivariable analyses, black adults and those with lower health literacy were more likely to report less perceived susceptibility to covid-19 (black adults: relative risk (rr) 1.62, 95% confidence interval (ci) 1.07–2.44, p = 0.02; marginal health literacy: rr 1.96, 95% ci 1.26–3.07, p < 0.01). individuals with low health literacy remained more likely to feel unprepared for the outbreak (rr 1.80, 95% ci 1.11–2.92, p = 0.02) and to express confidence in the federal government response (rr 2.11, 95% ci 1.49–3.00, p < 0.001) conclusions: adults at higher risk for covid-19 continue to lack critical knowledge about prevention. while participants reported greater changes to daily routines and plans, disparities continued to exist in perceived susceptibility to covid-19 and in preparedness. public health messaging to date may not be effectively reaching vulnerable communities. the global outbreak of severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the virus that causes coronavirus disease 2019 (covid19) , has rapidly evolved into a worldwide public health crisis. in the uncertainty of this pandemic, effective public health messaging is needed to inform the us population of risks posed by covid-19 and to motivate individuals, communities, and those in power to take action to minimize infection and prevent further spread of the virus. 1 this need is particularly salient as recent data have revealed striking racial and ethnic disparities with covid-19 infection and mortality. 2, 3 in chicago, where black residents represent less than a third of the total population, they account for half of those who have tested positive for covid-19 and two-thirds of those who have died. 3 the success of the us response to this pandemic will depend largely upon the actions taken to protect and support the most vulnerable as well as how effectively public health information is conveyed to all americans, particularly those at greatest risk of severe infection and death. 1, 4, 5 evidence has shown that how individuals obtain, interpret, and react to public health messages is influenced by socioeconomic, cultural, and health-related factors. [6] [7] [8] to examine these influences within the context of the emerging coronavirus pandemic, our team previously conducted a telephone survey from march 13 to 20, 2020 among high-risk, predominately older adults living with one or more chronic conditions. 9 we investigated participants' level of awareness and knowledge of covid-19, their impressions of the seriousness of the pandemic, their perceived susceptibility to the virus, whether the outbreak was affecting their daily routine and plans, and how prepared they felt for the pandemic. at the onset of the us outbreak, we found that almost a third of respondents lacked critical knowledge of covid-19 symptoms and methods of prevention. there were also marked disparities: individuals who were black, living in poverty, and/or with low health literacy were significantly less likely to believe they would become infected with covid-19; they also reported feeling less prepared for an outbreak. from march 20 to april 7, 2020, more than 350,000 americans tested positive for the coronavirus and over 10,000 died. 10 by april 7, 42 states had issued orders to close non-essential businesses and schools, restrict individual movement, and limit gatherings. 11 an estimated 316 million americans, 95% of the us population, were living under "shelter in place" or similar orders to reduce transmission of the virus. 11 given this monumental shift in americans' daily lives, the purpose of this investigation was to longitudinally examine how adults' covid-19 knowledge, beliefs, behaviors, and sense of preparedness changed over time, from the onset to the acceleration phase of the us outbreak. we also explored psychosocial and sociodemographic factors influencing adults' beliefs surrounding covid-19 as well as individuals' adoption of preventive behaviors. the chicago covid-19 comorbidities (c3) survey is a longitudinal, telephone-based study conducted among predominately older adults in chicago, il. 9 we administered wave 1 of the survey at the onset of the us outbreak (march 13-20, 2020) and wave 2 during the acceleration phase of the pandemic (march 27-april 7, 2020). the northwestern institutional review board (irb) approved the study procedures. c3 participants were active enrollees in one of four ongoing, federally funded studies led by our team. parent studies have been described in depth previously. 9, [12] [13] [14] in brief, these studies included a longitudinal cohort study examining the cognitive function and aging among older adults and three randomized trials evaluating technology-based strategies to improve patient adherence to complex drug regimens. 9, 12-14 participants were recruited into parent studies after receiving care from one of 5 academic or 2 community health centers in chicago, il. the eligibility criteria for each study varied and have been described in detail. 9 overall, the target populations for these studies were older, english-speaking patients and those diagnosed with ≥ 1 chronic condition; one trial also recruited spanish-speaking adults. 12 only participants who provided consent to be contacted for future research opportunities and who completed a parent study interview from 2018 to 2020 were eligible to participate in wave 1. a description of wave 1 methods has been published. 9 all participants who completed wave 1 were eligible to participate in wave 2. data collection was standardized across waves. research staff contacted participants via telephone and invited them to complete a survey about covid-19. responses were recorded using redcap. surveys took < 20 min to complete and participants were offered a $10 gift certificate per wave. participants completed standardized assessments of personal attributes as part of their participation in the nih parent studies. this included items assessing sociodemographic (e.g., age, sex, race/ethnicity, income) and health characteristics (self-reported chronic conditions, overall health) as well as health literacy (the newest vital sign) and health activation (consumer health activation index). 15, 16 all assessments were administered, and results analyzed, according to published guidelines. 15, 16 covid-19 awareness, perceived seriousness, and perceived susceptibility. awareness of covid-19 was measured by asking participants whether they had heard of the coronavirus and, if so, if they knew someone who had or thought they had the virus. perceived seriousness of covid-19 was assessed by asking participants to rate, on a scale of 1 to 10 (1 being no threat at all and 10 being very serious), how serious a public health threat they believed the coronavirus is or might become. for perceived susceptibility, respondents were asked to rate the likelihood that they would get sick from the coronavirus (definitely will, probably will, it's possible, or not at all). assessed through two open-ended questions which asked participants to name 3 symptoms of the coronavirus and 3 actions they could take to prevent infection. clinician raters independently coded verbatim responses as correct or incorrect. participants were also asked to estimate the percentage of people who would die from the coronavirus once infected and the percentage of those who would have mild symptoms. covid-19 reported behaviors, perceived preparedness, and confidence in government. participants were asked how much the coronavirus had changed their daily routine (a lot, some, a little, or not at all) and whether they had changed plans due to the virus. they also rated their confidence in the federal government's ability to prevent further covid-19 outbreak (very confident, somewhat confident, not very confident, or not confident at all) and perceived preparedness for a widespread outbreak (very prepared, somewhat prepared, a little prepared, or not prepared at all). descriptive statistics (means with standard deviations and percentage frequencies) were calculated for all patient characteristics and survey responses. paired t tests, ranked tests, and mcnemar's tests were conducted to determine whether patient responses at waves 1 and 2 differed significantly. associations between patient characteristics and responses to covid-19 knowledge, beliefs, reported behaviors, and perceived preparedness items were evaluated in bivariate analyses using chi-square tests. multivariable regression models were used to examine differences in outcomes; a poisson distribution was used rather than odds ratios for the relative risk estimates. all models included health literacy, age, sex, race, poverty, number of days between waves 1 and 2 and parent study; this mirrored the models conducted for wave 1. 9 in order to assess change between waves 1 and 2, generalized linear mixed models with a repeated effect were used to model interactions between wave and relevant covariates for each outcome. least square means were then calculated for all covariates at wave 1 and 2, and post hoc paired tests were conducted within each level of the covariate. all p values from the paired tests were bonferroni adjusted. analyses were performed using sas, version 9.4 (cary, nc). of the 630 participants in wave 1, 11 declined to participate in wave 2, 29 could not be reached or asked to be contacted later, 2 had incomplete or missing data, and 588 completed the survey, for an overall cooperation rate of 93.3%. the 42 adults who did not complete wave 2 were more likely to be black, to live below the poverty line, and to have low health literacy than those who participated. table 1 summarizes participant characteristics for wave 2. overall, patients were socioeconomically diverse, at an average of 62.4 years old, and 60.9% had ≥ 3 chronic conditions. all participants had heard of the coronavirus and 27% said they knew of someone who had or thought they had the virus. participants rated the coronavirus as a more serious public health threat in wave 2 than wave 1 (mean (sd) 8.9 (1.7) vs. 9.4 (1.3); p < .001; table 2 ). almost a quarter (22.4%) of participants at wave 2 believed they were "not at all" likely to get sick from the coronavirus ( table 2 ). in bivariate analyses, individuals who were female, black, living below the poverty level, unemployed, and with low or marginal health literacy were more likely to believe that they were "not at all" likely to become infected (table 3) . after multivariable adjustment, individuals who were black or had marginal health literacy skills were significantly more likely to state that it was "not likely" they would become sick (table 4 ). this was similar to wave 1, which found that adults who were black, living below the poverty line, and with low health literacy believed it was "not likely" they would become sick. 9 while overall perceptions of susceptibility increased over time (table 2 ), in multivariate analyses investigating change from wave 1 to wave 2, no significant interaction between survey wave and any participant characteristic was found. this suggests there was no change in how certain groups, particularly by race, income, or health literacy, at wave 2, participants estimated significantly higher fatality rates from covid-19 than in wave 1 (mean (sd) 14.0 (19.3) vs. 15.5 (20.6), p = 0.02; table 2 ). most participants (81.6%) were able to correctly identify 3 symptoms and 74.3% could name 3 methods of preventing infection. knowledge of symptoms increased significantly from wave 1 to 2 while knowledge of prevention did not (table 2 ). in bivariate analyses, men, individuals with low or marginal health literacy, englishspeaking adults, and those with multiple chronic conditions had less knowledge of coronavirus symptoms ( table 3) . as in wave 1, hispanic and lep adults had significantly greater knowledge of methods to prevent coronavirus (table 4 ). 9 after multivariable adjustment, no participant characteristics were significantly associated with knowledge of coronavirus symptoms or prevention. this was consistent with wave 1 findings. 9 when examining change from wave 1 to wave 2, individuals who were older, female, black, or with low health literacy skills were more likely questions re-worded at wave 2 to account for acceleration in the outbreak. at wave 1, questions were "how confident are you that the federal government can prevent a nationwide outbreak of the coronavirus?" and "how prepared do you think you are if there were to be a widespread coronavirus outbreak?" covid-19 coronavirus disease 2019 *values are percentages unless otherwise stated †46 participants did not respond at wave 2; 34 did not respond at wave 1 ‡30 participants did not respond at wave 2; 28 did not respond at wave 1 to increase their knowledge of coronavirus symptoms; those who lived below the poverty level as well as those above the poverty line also experienced increases in symptom knowledge (table 5) . at wave 2, 73.0% of participants reported that coronavirus had changed their daily routine "a lot" and 86.0% stated that they had changed plans due to coronavirus. there was a significant increase in both of these behaviors from waves 1 to 2 ( table 2) . participants who were older, unemployed, and with low health literacy were less likely to report changing their daily routine "a lot" at wave 2 while men, individuals with low health literacy, and adults with three or more chronic conditions were less likely to report changing plans (table 3) . after multivariable adjustment, there were no participant characteristics that were associated with changes in daily routine or plans at wave 2. this was consistent with wave 1. 9 in repeated effect interaction models assessing changes between waves 1 and 2, increased changes in behavior were noted across a number of participant characteristics. specifically, participants under the age of 70, both men and women, individuals of both black and white race, those living below and above the poverty line, and those with low, marginal and adequate health literacy experienced either more changes to daily routines or plans or both (table 5) . confidence in the federal government's ability to prevent further outbreak did not change significantly between waves and 8.9% of participants at wave 2 reported that they were "very confident" in the government's response. in multivariate analyses, individuals with low or marginal health literacy were more likely to express that they were "somewhat" or "very" confident in the government (low: relative risk 2.11, 95% ci 1.49-3.00; p < 0.001; marginal: relative risk 1.46, 95% ci 1.04-2.07; p = 0.03); a similar relationship with low health literacy was found in wave 1. 9 more than a quarter (27.3%) of participants at wave 2 believed they were "very prepared" for the coronavirus outbreak and most (52.1%) thought they were "somewhat prepared" while 20.6% stated they were "a little" or "not prepared at all." there were significant differences in the level of perceived preparedness between waves 1 and 2, with more participants at wave 2 feeling prepared (table 2 ). however, similar to wave 1, individuals who were hispanic, those with limited english proficiency, individuals living below poverty level, the unemployed, those with low or marginal health literacy, and participants with low or moderate health activation were more likely to state that they were "not at all prepared" in bivariate analyses (table 3) . in multivariable analyses, only individuals with low health literacy were more likely to be "a little" or "not prepared at all" (table 4 ). in wave 1, black participants and individuals with low health literacy were more likely to report feeling low preparedness. in regard to change, adults living below the poverty line and those who were black, male, and ages 60-69 were less likely to report being "a little" or "not at all" prepared during the acceleration phase of the us outbreak in comparison to the onset. findings from this longitudinal study reveal key changes in adults' knowledge, beliefs, behaviors, and preparedness from the onset of the us outbreak to the acceleration phase. our results indicate that adults increasingly perceive covid-19 as a very serious public health threat and made more changes to their daily routine and plans as the pandemic progressed. importantly, most individuals' perceptions of their own preparedness for the outbreak also increased. these changes are particularly notable among black adults and those living below the poverty level, who at the onset of the pandemic were disproportionately more likely to feel unprepared. participants' ability to identify covid-19 symptoms improved over time. despite these positive developments, serious public health concerns remain. participants with low health literacy continue to be more likely to report feeling unprepared for the outbreak and 1 in 4 of these high-risk adults was unable to accurately identify methods of preventing covid-19, a proportion that was unchanged since the onset of the pandemic. additionally, almost a quarter of participants-who are predominately older, with multiple underlying health conditions-reported believing that it was "not at all likely" that they would become sick from the coronavirus. black adults and those with lower health literacy continued to be more likely to have lower perceived susceptibility. the c3 study has provided a unique opportunity to understand how high-risk adults' knowledge, beliefs, behaviors, and preparedness changed over the initial stages of a pandemic. wave 1 was conducted at the onset of the us outbreak, when the number of cases of covid-19 in illinois ranged from 46 to 585 and no "stay at home" order had been issued. 17 in contrast, during wave 2, there were between 3026 and 13,549 cases in illinois and all state residents had been ordered to stay home. 17 unsurprisingly, there was a marked shift in participants' daily routines between waves 1 and 2 and increased recognition of the public health threat posed by covid-19. yet, our findings also reveal clear differences in how adults perceive their own individual risk for covid-19, their sense of preparedness for the outbreak, and their knowledge of what can be done to prevent infection. these findings suggest that public health messages on risk factors for coronavirus, its potential spread, and methods of preventing covid-19 are not reaching all americans, particularly the most vulnerable. misinformation on effective methods of prevention are widespread and may be contributing to poorer understanding of how to effectively reduce transmission of the virus. 18, 19 individuals with low health literacy, who are likely to struggle to obtain, process, and understand public health messages related to covid-19, are more likely to feel unprepared for the pandemic and to perceive themselves as less susceptible to covid-19, which may place them at greater risk. 7, 20 this study has limitations. participants were predominately older, most had three or more chronic conditions, and all lived in metro chicago, il. as such, findings may not be generalizable to younger or healthier adults or to individuals in other geographic locations. findings indicate that adults' knowledge, beliefs, behaviors, and preparedness changed over time with the pandemic; as such, results from this wave may not be reflective of current norms by the time of publication. however, our team is mobilizing to conduct additional waves of this study at future dates. finally, this study relied upon self-report measures. it is possible that social desirability bias may have led participants to over-report changes to their behaviors. however, given the restrictions currently in place in illinois, it is likely changes in daily routines and plans occurred for most participants. our first longitudinal assessment of the c3 study revealed that participants increasingly perceived covid-19 to be a serious public health threat, reported more changes to their daily routine and plans, and had a greater sense of preparedness from the onset to the acceleration phase of the outbreak. yet, knowledge deficits remain and many high-risk participants still perceived themselves as being "not at all likely" to become sick even after cases had greatly increased in the region. accurate, easy-to-understand, and consistent public health messaging that can reach all americans, including the most at risk and vulnerable, is needed to reduce the threat posed by the covid-19 outbreak and to ensure that everyone is prepared and aware of the actions that can be taken to protect themselves, their families, and their communities from this rapidly evolving public health crisis. data availability: the datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. corresponding author: stacy cooper bailey, phd mph; division of general internal medicine & geriatrics, feinberg school of medicine at northwestern university, 750 n. lake shore drive, 10th floor, chicago, il 60611, usa (e-mail: stacy-bailey@northwestern.edu). funding information this work was supported by grants r01ag030611, r01ag046352, r01dk110172, and r01nr01544 from the national institutes of health (nih). dr. linder is supported by a contract from the agency for healthcare research and quality (hhsp233201500020i) and by grants from the national institute on aging (r33ag057383, r33ag057395, p30ag059988), the agency for healthcare research and quality (r01hs026506), and the peterson center on healthcare. the northwestern institutional review board (irb) approved the study procedures. effective health risk communication about pandemic influenza for vulnerable populations hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 -covid-net, 14 states latest data: covid-19. city of chicago effective communication during an influenza pandemic: the value of using a crisis and emergency risk communication framework protecting vulnerable populations from pandemic influenza in the united states: a strategic imperative public response to community mitigation measures for pandemic influenza health literacy: a prescription to end confusion demographic and attitudinal determinants of protective behaviours during a pandemic: a review awareness, attitudes, and actions related to covid-19 among adults with chronic conditions at the onset of the u.s. outbreak: a cross-sectional survey see which states and cities have told residents to stay at home rationale and design of the regimen education and messaging in diabetes (remind) trial development and rationale for a multifactorial, randomized controlled trial to test strategies to promote adherence to complex drug regimens among older adults literacy, cognitive function, and health: results of the litcog study quick assessment of literacy in primary care: the newest vital sign development and validation of the consumer health activation index springfield: illinois department of public health. accessed at: www.dph.illinois.gov/covid19 on 11 why misinformation and distrust are making covid-19 more dangerous for black america. national public radio (npr) united kingdon: reuters institute for the study of journalism. accessed at reutersinstitute.politics.ox.ac.uk/types-sources-and-claims-covid-19-misinformation on 11 public health literacy in america: an ethical imperative conflict of interest: dr. bailey reports grants from the nih, merck, pfizer, the gordon and betty moore foundation, and eli lilly and personal fees from the gordon and betty moore foundation, sanofi, pfizer, and luto outside the submitted work. dr. serper reports personal fees from biovie outside the submitted work. ms. batio reports grants from the nih during the conduct of the study. dr. ladner reports grants from the national institute of diabetes and digestive and kidney diseases during the conduct of the study. dr. persell reports grants from omron healthcare and pfizer outside the submitted work. dr. wolf reports grants from the nih during the conduct of the study; grants from merck, the gordon and betty moore foundation, the nih, and eli lilly outside the submitted work; and personal fees from sanofi, pfizer, and luto outside the submitted work. authors not named here have disclosed no conflicts of interest. key: cord-336577-uvnbgsds authors: salazar, james w.; sharpe, bradley; raffel, katie title: sunset rounds: a framework for post-death care in the hospital date: 2020-10-01 journal: j gen intern med doi: 10.1007/s11606-020-06249-4 sha: doc_id: 336577 cord_uid: uvnbgsds nan notifying the donor network and medical examiner were relatively straightforward. others felt more nuanced and skillbased such as debriefing with loved ones and discussing autopsy. a loud sob alerted me that his friend had entered the ward. i shared with her a few words of condolence and reflection. she was in disbelief. i hoped we could quickly manage the logistics so she could grieve in peace. gingerly, i introduced autopsy. however, before i could get to my untrained summary of possible benefits, she declined. she had more pressing concerns including what would happen to the body. my answer felt unhelpful. in a hopeful and guilty fabrication of staff members i would only later learn definitively existed, i explained that others would come to help and that, for now, she should grieve as necessary and be with the patient. i went to follow up with her a couple hours later, only to find an empty room. although we achieved so much in my patient's final days, the emptiness of that room and my final memory of his friend in distress would stay with me. i knew there had to be a better approach to post-death care for survivors and providers alike. as a resident, heroic accomplishments in end-of-life care have felt tarnished by an ambiguous set of post-death care responsibilities often performed in isolation and without formal training. the discomfort and awkwardness surrounding postdeath processes illustrated in the patient vignette are not unique to the plight of a resident though, but rather emblematic of an aspect of patient care that is broadly neglected by the healthcare system. to move post-death care beyond an afterthought, several changes should be implemented. first, clear institutional guidance on roles, responsibilities, and resources is needed. limited literature exists to guide best practices in post-death care. of the most thorough, the american academy of pediatrics published a review for pediatric death in the emergency department. 1 they provide guidance on several essential aspects of post-death care including organ donation, autopsy, family bereavement, and care for the care provider. to support this need, we propose "sunset rounds" as a concise framework to address post-death issues (table 1) . second, structured communication should be employed by a multidisciplinary team. sunset rounds can function as an interprofessional timeout, wherein a group consisting of primary physicians and nurses, relevant consultants (e.g., palliative care), spiritual personnel, and decedent affairs team members could gather to address post-death care. many hospitals have a decedent affairs team to assist family members with navigating post-death logistics. however, in our experience, the primary medical team typically has limited interface and awareness of this important, yet often understaffed, resource, a missed opportunity for a more effective, coordinated approach. third, trainees should have formal training and feedback on post-death care. autopsy is an example of the many educational opportunities in post-death care. my hospital requires us to inquire about autopsy. however, without formal training on the details and value of autopsy, it is unsurprising that many discussions unfold like mine did and that autopsy rates are "vanishing." 4 it is only through my own research on out-of-hospital sudden cardiac death 5 that i became familiar with autopsy. i learned that presumed cause of death is often wrong in cases of diagnostic uncertainty; almost half of sudden cardiac deaths by the world health organization (who) clinical criteria were found to have non-arrhythmic cause on autopsy (e.g., occult overdose, pulmonary embolism, intracranial hemorrhage). 5 i also learned that incisions are made to facilitate open casket viewing and that autopsies typically do not delay funeral proceedings. autopsy is a surgical procedure; as with procedures on the living, trainees should receive formal training on how to appropriately inform consent. amidst the coronavirus disease 2019 (covid-19) pandemic, the fog of death looms particularly large. unique challenges-limited workforce, racial disparities, lack of patient and family contact, and specialized guidance on safe post-death arrangements in patients with covid-19 from the who 3 -have compounded the difficulties of post-death transitions. overcoming these difficulties in post-death care will require a significant, sustained investment in education and resources coordinated across multiple disciplines. fortunately, as with other neglected areas of the healthcare system brought to light by covid-19, we are beginning to see long needed recognition of and innovation in post-death care; these range from novel approaches to death disclosure training 6 and condolence communication 7 to renewed attention to the proper completion of the death certificate. 8 now, more than ever, it as soon as possible after death, gather as a multidisciplinary care team for an interprofessional timeout to develop a plan and assign a responsible party for each of the following aspects of post-death care: notification of survivors -determine the most appropriate patient contact and the team-member best suited to disclose -use "spikes" 2 principles and the words "died" or "death" -offer assistance in sharing the news with other friends or family -consider saying a few closing words honoring the patient care team should include primary physicians and nurses, relevant consultants (e.g., palliative care), spiritual personnel, and decedent affairs team members death in the context of covid-19: for specific guidance on the safe management of a dead body in the context of covid-19 and how it may inform the above framework, please refer to the world health organization interim guidance 3 *state reporting guidelines can be found at: https://www.cdc.gov/phlp/publications/topic/coroner.html †local networks can be found at: https://www.organdonor.gov/awareness/organizations/local-opo.html is important that we work collectively to care for each other, support our survivors, and honor the sunsets of our patients. death of a child in the emergency department spikes-a six-step protocol for delivering bad news: application to the patient with cancer infection prevention and control for the safe management of a dead body in the context of covid-19: interim guidance the vanishing nonforensic autopsy refining the world health a call to include death disclosure training alongside cardiopulmonary resuscitation training: after the code bereavement care in the wake of covid-19: offering condolences and referrals the importance of proper death certification during the covid-19 pandemic key: cord-286679-g67ewzlp authors: ordaz-johnson, omar h.; croff, raina l.; robinson, latroy d.; shea, steven a.; bowles, nicole p. title: more than a statistic: a qualitative study of covid-19 treatment and prevention optimization for black americans date: 2020-10-06 journal: j gen intern med doi: 10.1007/s11606-020-06259-2 sha: doc_id: 286679 cord_uid: g67ewzlp nan coronavirus disease 2019 (covid-19) magnifies the disproportionate burden of cardiovascular disease, diabetes, and other chronic diseases black americans face due to structural racism, psychosocial stress, and socioeconomic status. 1, 2 to monitor the progression of covid-19 which has increased incidence in black communities, us regional programs began implementing surveillance and strategies to increase testing and reduce spread among vulnerable populations in april 2020. 1, 3 yet, black populations are generally less likely to participate in research, largely due to cultural barriers to recruitment and low representation in educational and healthcare institutions. 4 community-based methods and partnerships with underrepresented populations can increase trust and study participation; accordingly, we sought to understand potential barriers specific to covid-19 treatment and prevention in black americans using focus groups. 4 self-identified black american residents aged 30-60 years with regular access to primary care (parent study requirement) were recruited nationally using craigslist and researchmatch advertisements. focus groups were conducted remotely via webex from april to may 2020. study design and interview analysis followed the consolidated criteria for reporting qualitative studies (coreq) (see table 1 for interview guide) 5 . online focus groups were each an hour long with a maximum of five participants and 2-3 facilitators. interviews were recorded with video and audio, transcribed verbatim, and de-identified. using grounded theory, patterns within the data were analyzed and identified through inductive thematic analysis; recruitment continued until thematic saturation was reached; an inter-coder reliability analysis was performed using percent agreement between raters. 6 participants provided verbal informed consent per ohsu irb exemption guidelines. eight focus groups engaged 29 participants (22 women) aged 40 ± 8 years (mean ± sd). regarding optimized treatments for and prevention of covid-19 among black americans, three major themes emerged: patient autonomy, holism, and structural racism. secondary codes were not used in analysis as inter-coder reliability was found to be in ≥ 95% agreement. the data that support the findings of this study are available on request from the corresponding author npb. table 2 lists themes and representative quotes. patient autonomy. over 73% of participants emphasized accountability for one's own health, described by some as a method for mitigating pervasive historical and personal disadvantages regarding health access due to their black heritage and identities. participants placed the onus largely on individuals to reduce risk factors for disease and slow covid-19 infection. holism. eighty-three percent of participants viewed medications for diseases disproportionally affecting black americans as a last option, often because of unwanted side effects, and preferred holistic approaches including supplements and lifestyle changes. structural racism. considering covid-19 infection and death rates among black americans, many participants questioned how their race, and not pre-existing conditions, could heighten their risk. participants held two predominate beliefs about covid-19's disproportionate effect on black americans despite underlying conditions: (1) implicit bias within health care, and (2) apathy among individuals, possibly influenced by misinformed administration of policies regarding social distancing and subsequent reopening in predominantly black neighborhoods. participants also believed that infrastructure and finances limiting one's ability to stay home or socially distance contributed to disproportionate infection rates. participants generally preferred health initiatives that recruit according to structural or socioeconomic variables contributing to disparity, instead of initiatives that recruit by racial demographics. emergent themes in our focus groups suggest that community involvement at the outset is critical for proper needs assessments, as well as in subsequent design and implementation of any new approaches aimed at assessing or reducing unfair burden of morbidity and mortality due to conditions disproportionately affecting black americans. for example, covid-19 transmission surveillance programs that oversample black communities may face barriers to optimizing outreach if (1) race, isolated from lifestyle or acknowledgement of personal health accountability, is a criterion in sampling or study design; or (2) established community rapport is lacking or overlooked in program design, perhaps prevented through the involvement of community liaisons. black americans would likely benefit more from initiatives that emphasize patient autonomy and provide tools for addressing socioeconomic or pathologic risk factors relevant to health outcomes. potential study limitations include generalizability to populations lacking health coverage. overall, findings highlight the importance of understanding community concerns about the orchestration of optimized treatments for covid-19 among black americans, and underscore the health benefits of building community trust through early research involvement. covid-19 and african americans us disparities in health: descriptions, causes, and mechanisms identifier nct04342884, covid-19 community research partnership effective recruitment and retention of minority research participants consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups applying constant comparative method with multiple investigators and inter-coder reliability conflict of interest: the authors declare that they do not have a conflict of interest. key: cord-349099-s33nd9hz authors: gaffney, adam w.; himmelstein, david; bor, david; mccormick, danny; woolhandler, steffie title: home sick with coronavirus symptoms: a national study, april–may 2020 date: 2020-09-10 journal: j gen intern med doi: 10.1007/s11606-020-06159-5 sha: doc_id: 349099 cord_uid: s33nd9hz nan reports from hospitals and locales 1 have highlighted racial/ethnic disparities in covid-19 outcomes. however, few national studies in the usa have examined disparities among persons with symptoms suggestive of covid-19. we analyzed a unique, nationally representative survey to assess demographic characteristics and social vulnerabilities among those with symptoms attributed to the coronavirus. we analyzed data on adults age 18-64 in weeks 1 (april 23-may 5) and 4 (may 21-26) of the census bureau's household pulse survey (hps), which collects data on pandemic-related health and financial problems. 2 individuals reporting not working the preceding week were asked why; one of 12 response options was "… because i am/ was sick with coronavirus symptoms." (previous research demonstrated that 83.0% of americans correctly identify fever, cough, and dyspnea as the three leading covid-19 symptoms). 3 we compared the demographic characteristics, health insurance status, food insecurity, and prevalence of covid-19 in their state of residence 4 (divided into quartiles), of those selecting this response to two other groups: (1) those working and (2) persons out-ofwork because of a non-coronavirus-related illness/ disability. we performed univariate logistic regressions to evaluate the association of each factor with being out-sick due to coronavirus symptoms relative to each comparator group. we generated nationally representative estimates (and standard errors) using hps' sample weights (and replicate weights) and stata/ se 16.1. our sample included 89,490 adults working the past week, 457 out-sick with coronavirus symptoms, and 3503 out-ofwork because of a non-coronavirus illness/disability. during may 21-26, 1.3 million workers nationally were out-sick because of coronavirus symptoms. table 1 presents characteristics of that group and the comparator groups. relative to both other groups, those out-sick with coronavirus symptoms were younger and more likely to be people of color: 24.2% were black (vs. 11.5% of those working and 18.2% of those not-working due to a non-coronavirus illness/disability), 11.7% were asian (vs. 5.6% and 2.0%), and 26.5% were hispanic (vs. 17.2% and 12.7%). those out-sick with coronavirus symptoms were lesseducated and had lower incomes than those working; their education levels and incomes were more similar to those not working due to a non-coronavirus illness/disability. they had larger household size: 42.4% lived in a household with 5+ members, vs. less than a quarter in each comparison group. 29.2% of those out-sick with coronavirus symptoms were uninsured, vs. 8% in each comparison group; 36.2% were food insecure, vs. 7.5% among those working and 20.8% among those out-sick for non-coronavirus symptoms/disability. finally, we observed an association between states' prevalence of coronavirus and being out-sick with coronavirus symptoms: 45.1% of americans out-sick with coronavirus symptoms resided in a state in the top quartile of coronavirus prevalence, while only 15.2% lived in a bottom-quartile state. in contrast, individuals in the two comparison groups were divided roughly equally among the four state quartiles. minority race/ethnicity, low income, and residence in a state with high covid prevalence were associated with work absence because of coronavirus symptoms in april-may 2020. this national-level evidence of the disparate impact of covid-19 bolsters reports based on diagnoses from regions and hospital systems, 1 as well as our previous findings of an increase in illness-related work absence in april that disproportionately affected minorities. 5 we also identified social vulnerabilities-uninsurance and food insecurity-among many out-sick with coronavirus symptoms, which likely intensifies their risk of health and financial harms. our study has strengths and limitations. the census bureau recruited respondents via email and text messages to generate almost-real-time data; 6 the trade-off was poorer response rates, 2 which, despite weighting designed to account for nonresponse, may compromise generalizability. additionally, the survey did not involve performance of diagnostic testing; some of those with "coronavirus symptoms" no doubt had other illnesses. however, the correlation between the statelevel covid-19 infection rate and the proportion out-sick with coronavirus symptoms is reassuring, as is the consistency of findings across the two comparison groups. the high rate of uninsurance among those with "coronavirus symptoms" that we observed could, of course, obstruct medical evaluation and other care even among those with other illnesses. during the covid-19 pandemic, poor and minority americans have been doubly disadvantaged: they are more often infected, but have fewer household resources and inferior health protection. protecting the health and welfare of these patients must be a policy priority. *univariate logistic regressions. the dependent variable is employment status (out-sick with coronavirus symptoms versus working, or out-sick with coronavirus symptoms versus not working due to noncoronavirus illness/disability) and the independent variable is the indicated characteristic (e.g., age category, sex) †white, black, asian, and other are non-hispanic whites, non-hispanic blacks, non-hispanic asians, and non-hispanic others. hispanic individuals may be of any race ‡10,759 individuals had missing data on income (11.5% of n = 93,450 sample) §insurance status is defined similar to the approach used by the american community survey. we considered individuals insured if they report private insurance (through an employer), private insurance (individually obtained), tricare, medicare, medicaid, or veterans health administration coverage; those who report not having each of these insurance types (including those who only report indian health service or "other" insurance) are considered uninsured. others (n = 8677 in our sample) were treated as missing (9.2% of n = 93,450 sample) || we top-coded the categorical household size variable at 7 ¶this is based on a four-category variable that we re-categorized as a binary variable: not insecure (either enough food or enough but not the types wanted) vs. insecure (sometimes not enough food or often not enough food). n = 1203 with missing data on current food security (1.3% of n = 93,450 sample) **data on state-level per 100,000 population coronavirus infections was downloaded from the cdc on june 12, 2020 4 ; data is current as of june 9, 2020. the total survey population was divided into quartiles based on the coronavirus infection rate in their state (using sample weights) disparities in outcomes among covid-19 patients in a large health care system in california source of the data and accuracy of the estimates for the 2020 household pulse survey disparities in coronavirus 2019 reported incidence, knowledge, and behavior among us adults united states covid-19 cases and deaths by state. cdc covid data tracker illness-related work absence in mid-april was highest on record measuring household experiences during the coronavirus (covid-19) pandemic key: cord-352726-ep0xfen2 authors: ali, mohammed k.; shah, deep j.; del rio, carlos title: preparing primary care for covid-20 date: 2020-06-09 journal: j gen intern med doi: 10.1007/s11606-020-05945-5 sha: doc_id: 352726 cord_uid: ep0xfen2 nan t he covid-19 crisis prompted government and healthcare leaders to marshal resources from every corner of the nation to cope with surge demand. the focus has been on increasing floor and intensive care bed capacity, ventilator caches, and stores of lifesaving personal protective equipment (ppe). similarly, public health measures such as broad testing and social distancing are being implemented with vigor. beyond these on-the-ground battles, however, there is a larger war that policymakers and health system leaders need to consider: sars-cov-2 and respiratory pathogens are not one-time occurrences. the pandemic, along with its health and economic devastation, may recur in the second half of 2020, or possibly sooner as southern hemisphere countries face winter from may onwards. populations remain vulnerable as we are unlikely to see vaccines, reliable therapies, and universal testing anytime soon. early, well-planned, and well-resourced pandemic preparedness for the next wave(s) is much needed and we need a transformation in america for how we prepare. we argue that our health and economy may be best served by strengthening the role of primary care in tackling the next wave(s), thereby reducing the burden on public health, emergency, and inpatient services. we discuss what will be required to equip primary care practices to lead early management and disease notification in the short time frame before the next wave. primary care, when paired with robust public health infrastructure, is the linchpin of any modern healthcare system's ability to track and manage disease pandemics, 1 but has largely been sidelined in the current pandemic. primary care physicians (pcps) in the usa are uniquely positioned to shoulder greater responsibility during the next phase of covid-19. pcps are trusted resources for and claim strong, longitudinal relationships with patients. pcps can leverage multiple established avenues to reach patients as well as close contacts especially given the evolving focus on isolation and contact tracing. an additional channel of communication has been added with the rapid implementation of telemedicine and remote care monitoring during the current crisis. moreover, primary care clinics-including single and networked primary care offices, federally qualified health centers, and frequently visited retail clinics-are well distributed across the country. finally, primary care offices are capable of managing patients flow across home, clinic, hospital, and post-acute care; recent lifting of data sharing restrictions by the u.s. department of health and human services will enhance this coordination. there is no equivalent comparison with the covid-19 pandemic, given its lethal combination of transmissibility, unpredictable course, and case fatality. however, there are valuable lessons from previous outbreaks (e.g., h1n1) and the role that pcps play in seasonal influenza management. the majority of influenza-like illnesses (ili) are assessed and managed in primary care. observational data have shown that early testing and treatment for seasonal flu and h1n1 are associated with less pneumonias, repeat visits, hospitalizations, and mortality. 2, 3 as testing and perhaps a therapy with some benefit become more broadly available, these can be administered in primary care. and even if not, pcps can administer more supportive care in their offices as ppe becomes more available. whenever sars-cov-2 vaccines ultimately enter clinical practice, pcps can assume an even greater role through prevention. robust primary care infrastructure for ili facilitates access and surge capacity; enables timely diagnosis and treatment; and could reduce health disparities in the incidence of pneumonias, hospitalizations, and related morbidity and mortality. 4, 5 the clock is already ticking. the tight timeline is further complicated by limited reliable data. it is imperative, though, that policymakers begin to outline the basic requirements if primary care is to play a greater role in saving lives and reducing the burden on healthcare systems. specifically, the primary care community needs the following (table 1) : (1) definitions and standards for evaluating and managing cases; (2) outbreak protocols giving primary care offices a central role in early detection, local safety, and surveillance; (3) clinical decision-making tools including rapid tests and prediction rules; and (4) supportive policies. to obtain and operationalize definitions, protocols, and clinical tools, we propose efficient accumulation of data with an emphasis on the role of asymptomatic carriers and prognostic factors for early symptomatic cases-those most likely to present to the outpatient setting. leadership and support from federal agencies can promote generous health system data sharing and rapid translation of findings to workable standards. quickly leveraging electronic medical records and online search data will expedite identification of risk factors for infection and transmission; time course of illness; and risk factors for hospitalization, intensive care admission, mortality, and/or healthy discharge. for efficient use of data as it is released, we propose a task force bringing together a coalition of professional societies representing pcps in internal and family medicine, pediatrics, gynecology, and infectious disease and public health experts. this group should review the data by mid-summer and develop iterative consensus care algorithms at both state and federal levels by early fall. lastly, policymakers will need to facilitate pathways to manage the next wave. when deployed properly, pcps can assume leadership roles in disease surveillance in partnership with local health departments and hospitals. 6 local reporting systems should be able to handle high volume; "stress testing" the systems through drills between now and then will be invaluable. at the national level, higher primary care participation in the cdc's outpatient influenza-like illness surveillance network (ilinet) will help identify regional hotspots where focused testing, contact tracing, and isolation in the next covid outbreak can support rapid containment. 7 widespread testing and syndromic surveillance could prevent the economy from shutting down again. federal and state guidance for pcps to invest in preparedness measures alone will be insufficient. opt-out instead of opt-in policies will lead to wider adoption. however, at a minimum, pcps will need guarantees of support in the form of ppe and funding indexed on panel size. these could be executed through memoranda of understanding. payments will need to focus on business continuity through payroll and fixed cost support-similar to the small business administration's paycheck protection program loans. in addition, participating primary care clinics may benefit from training for primary office care personnel and/or workforce support to meet surge demand. travel nurses, typically utilized in hospitals, may prove valuable coaches for medical assistants less familiar with strict infection control protocols. to be sure, this cannot be callous deployment of front-line physicians and much relies on the availability of ppe and effective anti-viral therapies. that said, investing in primary care pandemic preparedness may enhance and reshape relationships between primary care and government, payer, medical supplier, and hospital stakeholders. these changes may have benefits beyond pandemic response(s), heralding a renaissance in the role of primary care in america's health landscape. pcps serve as quarterbacks in coordinating their patients' care and have a unique vantage point and patient trust, which has been underused in the covid-19 detection, prevention, and management responses. this pandemic might be the stimulus for rethinking healthcare delivery and leaning into the notion that primary care is the foundation of a strong healthcare system. publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. a world at risk: annual report on global preparedness for health emergencies effectiveness of oseltamivir on disease progression and viral rna shedding in patients with mild pandemic 2009 influenza a h1n1: opportunistic retrospective study of medical charts in china prompt oseltamivir therapy reduces medical care and mortality for patients with influenza infection: an asian population cohort study hcup statistical brief #253 influenza-related hospitalizations and poverty levels -united states detection of excess influenza severity: associating respiratory hospitalization and mortality data with reports of influenza-like illness by primary care physicians a national covid-19 surveillance system: achieving containment. 2020 key: cord-307946-1olapsmv authors: xu, zhijie; ye, yuanqu; wang, yang; qian, yi; pan, jianjiang; lu, yiting; fang, lizheng title: primary care practitioners’ barriers to and experience of covid-19 epidemic control in china: a qualitative study date: 2020-08-31 journal: j gen intern med doi: 10.1007/s11606-020-06107-3 sha: doc_id: 307946 cord_uid: 1olapsmv background: the coronavirus disease 2019 (covid-19) emerged in december 2019 and posed numerous challenges to china’s health system. almost 4 million primary care practitioners (pcps) participated in controlling the outbreak. however, pcps’ barriers to and experience of the epidemic control remain unknown and are essential for improving countermeasures. objective: to better understand the barriers pcps faced in covid-19 epidemic control and their psychological and occupational impacts, and explore potential solutions. design: this qualitative study was conducted through semi-structured, in-depth interviews from february 12, to march 10, 2020. participants: a purposive sample of frontline pcps affiliated with either community health centers or township health centers in four provinces of china were recruited. approach: interviews were conducted by telephone, and then recorded, transcribed, and content analyzed. themes surrounding pcps’ barriers to covid-19 epidemic control, their experience, and potential solutions were iteratively identified using the constant comparative method. key results: of the 21 pcps interviewed, 10 (48%) were women and 5 (24%) worked in rural areas. barriers to epidemic control in primary care included inappropriate pcp scheduling and role ambiguity, difficult tasks and inadequate capacities, and inexperienced community workers and insufficient cooperation. some pcps perceived respect and a sense of accomplishment and were preoccupied with the outbreak, while others were frustrated by fatigue and psychological distress. pcps reported potential solutions for improving countermeasures, such as improving management, optimizing workflows, providing additional support, facilitating cooperation, and strengthening the primary care system. conclusions: due to their roles in controlling the covid-19 epidemic, pcps in china faced a series of barriers that affected them physically and mentally. support for pcps should help them to overcome these barriers and work efficiently. the current findings provide insight into the challenges and potential solutions for strengthening the preparedness and response of china’s primary care system in future disease outbreaks. electronic supplementary material: the online version of this article (10.1007/s11606-020-06107-3) contains supplementary material, which is available to authorized users. i n december 2019, a novel coronavirus was detected from a series cases of pneumonia of unknown cause in wuhan, china, which was subsequently named the coronavirus disease (covid-19) by the world health organization (who). [1] [2] [3] as of june 13, 2020, 84,671 cases including 4645 deaths had been confirmed in china, 4 and a global pandemic had emerged. in addition, a total of 215 countries had reported over 7,640,000 confirmed cases and 426,000 deaths, and the numbers continue to grow. [4] [5] [6] primary care practitioners (pcps) are essential in confronting the pandemic. for example, almost 4 million pcps in china participated in covid-19 epidemic control. 7 they worked in collaboration with the community workers and community police in a "joint defense team" led by the neighborhood committee. 8 pcps were responsible for screening suspected cases, visiting residents in quarantine, contact tracing and monitoring, and surveillance at checkpoints, while community workers and community police provide nonmedical support to residents in quarantine. 8 pcps regularly recorded work-related information on forms and uploaded the forms to the neighborhood committee and health administrative departments. similar procedures were undertaken by pcps in singapore. 9 numerous studies have focused on barriers to epidemic control in primary care. a systematic review identified challenges faced by pcps in different countries during previous pandemic response, such as a shortage of personal protective equipment (ppe), limitations of provided information, and insufficient training. 10 a qualitative study showed that pcps experienced difficulties in translating pandemic guidelines into practice. 11 however, the barriers pcps encountered in covid-19 epidemic control and their solutions have not been explored. another research focus has been the impact of epidemic control on pcps and their experiences. a recent survey showed that general practitioners (gps) in shanghai displayed psychological health problems of varying severity during epidemic control, and 88.4% of gps felt stressed. 12 similarly, previous studies demonstrated that the pandemic outbreak changed pcps' work environment and lifestyle, 13 and led to a series of negative emotions, such as depression, anxiety, and fear. 14 they could also experience symptoms of acute stress disorders or post-traumatic stress disorder (e.g., intrusion, avoidance, and hyperarousal) after the outbreak. 15 therefore, pcps' experience in covid-19 epidemic control deserves closer attention to inform improvement efforts. to understand pcps' perceived barriers to and experience of performing their tasks in epidemic control, we recruited frontline pcps in china and conducted in-depth interviews using a qualitative design. we aim to understand pcps' perspectives on their work and explore the strategies for improving countermeasures in primary care. from february 12 to march 10, 2020, we conducted a descriptive qualitative study involving semi-structured, in-depth interviews with purposive samples of pcps. 16 interviews were conducted by telephone because of the nationwide traffic restriction, and they lasted a mean of 34 minutes (range: 30-45 minutes). all participants provided verbal informed consent before the interviews began and were not compensated for their participation. the study was approved by the sir run run shaw hospital ethics committee and adhered to the declaration of helsinki. 17 we used wechat, an instant messaging app, to invite pcps to participate in the interviews, using the principle of maximum variation. 18 three family physicians refused to participate because they were not responsible for tasks in epidemic control. participants were affiliated with local government-owned community health centers in urban areas (zhejiang and guangdong province) or township health centers in rural areas (shaanxi and hunan province). participants knew the investigators prior to the interview, but none had worked with the investigators. the sample size was determined using thematic saturation: two investigators (z.x. and y.y.) analyzed the transcripts and notes for newly emergent themes after the first 10 in-depth interviews, and after every 1 or 2 thereafter. we stopped scheduling interviews when additional interview data created little or no change to the codebook and no new patterns or themes emerged. 19, 20 repeat interviews were not carried out. the interview guide was adapted from relevant qualitative studies involving healthcare workers in infectious disease outbreak, 21, 22 and was refined through pilot interviews with three pcps to improve appropriateness and clarity (eappendix 1). each interview began with a question about the types of tasks participants had performed in epidemic control. probing questions were then used to encourage participants to describe tasks in which they felt their performance was deficient and whether they encountered any barriers to task performance (e.g., how did the barriers or difficulties affect your work?). probing questions also elicited details of pcps' experiences and the occupational and psychological effects of epidemic control (e.g., have you experienced any positive or negative emotion?). at the end of the interviews, investigators encouraged pcps to talk freely about their perspectives regarding strategies that could contribute to improved control measures in primary care. information regarding participants' characteristics was collected before the interviews, which were independently audio recorded and transcribed verbatim by two male general practitioners as interviewers (z.x. and y.y.) who had received training on qualitative interviewing. the interviewers made field notes during the interview when necessary. they independently identified major themes and subthemes via thematic content analysis and developed a preliminary codebook for data analysis based on the first three transcripts. 23 they reviewed transcripts continuously using the constant comparative method to expand existing themes and identify new ideas or themes. 24 the codebook was iteratively refined and finalized via internal consensus until 100% agreement was reached. maxqda (version 2018.1.1) was used in the data analysis and retrieval. transcripts were not returned to participants for comment or correction, but we randomly selected three participants and sent them our main findings via e-mail. they agreed with the themes without modification. we recruited 21 eligible pcps (14 family practitioners, 4 internists, 2 surgeons, and 1 pediatrician) from 21 practices (16 community health centers and 5 township health centers). of the 21 participants, 10 (48%) were women, and 5 (24%) participants undertook administrative tasks in their medical practice. the mean age of participants was 36 years (range: 29-46 years), and the mean duration of practice was 12 years (range: 3-25 years) (eappendix 2). inappropriate pcp scheduling and role ambiguity. participants described numerous barriers to epidemic control (table 1) . some felt overburdened and assigned to unsuitable positions. one family physician explained this feeling using a surprising example: "there were 270 residents [to be quarantined] that day, but the community health center only assigned 5 physicians [to visit them]." others felt confused, as they were asked by the leaders of their community/township health centers to perform low-skilled work and believed they needed an additional supportive workforce. the confusion was described by an internist as follows: "when i came back [from the home visits], i was not free until i disinfected the ambulance. but why not employ a cleaner?" some policies were considered inflexible and pcps felt they limited effective scheduling. for example, the quarantine duration was fixed for everyone leaving the epidemic area, regardless of whether self-quarantine had already been undertaken. one participant commented, "[there is] a one-size-fitsall approach that we need to follow, and it took much more time to address the consequences." these inflexible policies not only increased the unnecessary workload but also may have reduced residents' trust in epidemic control. another reported barrier was excessive inspection and meetings. the government officials and medical experts irregularly visited the community/township health centers and inspected pcps' daily practice of epidemic control, including the material preparation and arrangement, and held meetings to discuss the existing problems and potential solutions with pcps. one participant stated, "it really troubled me that i had to accompany those supervisors, maybe 3 to 5 times a week, and show them what we had done with countless papers and forms and photos." some instructions distributed to pcps by supervisors were perceived as "scratching the surface". in addition, the frequent modification of guidance regarding epidemic control confused pcps. difficult tasks and inadequate capacities. although routine care was largely canceled in many primary care practices, participants frequently noted the deficiencies of the workforce and that they worked for extended hours during epidemic control. pcps were on call 24 hours per day to visit newly quarantined residents. online consultation with residents increased workload during time off. one family physician stated, "i often kept an eye on my mobile phone because the residents often left a message of inquiry in the wechat group waiting for my reply." all participants had limited experience in working during a pandemic and more than half perceived their professional training as inadequate and not tailored to their work of epidemic control in the community. in addition, most institutions lacked ppe (particularly masks and gowns) and pcps generally compromised their safety by reusing ppe. cooperation. pcps in china performed home visits for quarantined residents in cooperation with community workers. 8 a few participants complained that community workers were sometimes inactive in terms of participation in epidemic control: "the home visits should be implemented by a group of family physicians and community workers, but sometimes they arrived late." another barrier pcps encounter was that community workers received inadequate training in epidemic control. as one internist commented, "the temporarily recruited [community workers] had no clinical background; they might fall in a rut and fail to deal with things case by case." participants also described a lack of cooperation between pcps and community workers. one family physician stated, "it might cause a delay if there was any error of communication. sometimes the community workers isolated the resident 1 or 2 days before i received the notice. but [the resident] still needed to stay at home for 14 days." a possible explanation for the miscommunication was that orders were released by different administrative departments with limited previous interaction or experience of cooperation. preoccupation. the heavy tasks and work stress involved in epidemic control resulted in pcps devoting additional energy and effort to their daily practice. one source of pcps' preoccupation with epidemic control was the culture of commitment and sacrifice in the healthcare workforce. one participant expressed his pride in participating in epidemic control: "in my school days, i witnessed the outbreak of sars in 2003 and was impressed by the sacrifice of angels in white…so i feel proud to have the opportunity to control the outbreak on the frontline." sense of respect and accomplishment. all participants expressed a sense of respect for epidemic control, which enhanced their relationship with residents. pcps received increased emotional support and appreciation, and their efforts were recognized by residents in the community. participants also expressed satisfaction with the insurance and compensation provided by the government. some pcps felt a sense of accomplishment when the quarantine expired, and the residents they managed were not infected. others were inspired to have greater solidarity with colleagues, described as follows: "it's impressive to see my colleagues bearing the hardship…our cohesion is greater than before and makes it all worthwhile." fatigue. more than half of the participants claimed they experienced fatigue as a result of participating in epidemic control. some participants complained that the work content was beyond their capacity and the requirements were incongruous with their training. the intensive work and tough tasks were described as the main factors affecting fatigue. insomnia was cited as another cause of fatigue. one participant reported that the overwhelming work stress deteriorated his sleep quality, which led to inadequate rest and intensified his experience of fatigue. many other symptoms, such as "memory decline," "weight loss," and "inappetence," were reported as common concomitant manifestations of fatigue. psychological distress. participating in epidemic control made pcps a vulnerable group susceptible to psychological distress ( table 2 ). some experienced fear of being infected, and this fear was intensified by the inadequate supply of ppe and prolonged frontline work. pcps frequently experienced anxiety because they needed to adapt to a fast-paced, highly efficient working environment. some participants felt anxious about errors of omission and residents' complaints. most pcps experienced frustration with the paperwork required for reporting, which was deemed as time-consuming but scarcely conducive to practice. another reason for their frustration was that their efforts and contributions were not always recognized by supervisors. pcps would become angry when residents refused to comply with the quarantine and were offended by scurrilous remarks. however, all participants denied persistent or severe depressive symptoms (e.g., feeling hopeless or suicidal thoughts). most participants found psychological support from their colleagues for their psychological distress, but all participants described a lack of external support, and the reasons were "no available professional psychological support," "too busy to seek for help," and "won't help things at all." "i was constantly taking on new tasks and adapting to new requirement, dealing with things that might come up. i was very anxious at that time." frustration "the guidance was problematic at the early stage of epidemic control, but we had no voice to make a change…i felt helpless and powerless." anger "some villagers were frightened of virus transmission through us physicians and hurled insults at me…i choke down their acrimony…it's very annoying." improving management and supervision. to solve certain problems, such as improper task allocation and inflexible policies, participants generally suggested that administrative departments should develop measures that were more personcentered and based on specific contexts. one participant stated, "i appreciate those officials who listened to our voices, sympathized with our dilemmas, and were capable of providing practical strategies." moreover, streamlining excessive inspection and meetings was suggested by some participants. one surgeon remarked, "…facing a succession of inspec-tions…then i became unmoved. i didn't care about what they asked anymore." optimizing workflow. many participants expressed a wish to work efficiently. for example, paperwork and reporting were frequently mentioned as a barrier to epidemic control and occupied much of pcps' time. strategies involved rational workforce arrangement and internal coordination. as one participant stated, "[the medical institution] could recruit full-time medical assistants to perform the low-skilled tasks, such as the daily statistical report." in addition, participants proposed the option of streamlining the procedures for reporting using an intelligent approach. one physician admitted, "the task of surveillance [at the checkpoints] is getting easier because now we have an identity database to screen the contact history for the travelers." providing necessary support. most participants emphasized an imperative of increasing the supply of ppe to pcps, although they all understood the shortage. 25 one suggested strategy was to "use ppe in a planned way" to ensure the security of the frontline healthcare workforce. other options included "collecting ppe from the public" and "centralized purchasing." some participants thought they lacked the experience of coping with major infectious diseases and needed more professional training. one participant commented, "the online education program helped me gain much knowledge of covid-19, but we need lessons more tailored for primary care." facilitating cooperation. participants described the need to reinforce cooperation with community workers. participants noted that it was necessary to identify the division of responsibilities for both sides and strengthen the training and supervision of cooperation. an effective approach would be to establish a mechanism of interaction and communication. as one participant stated, "tacit cooperation cannot be expected in one stroke…if the effect of communication was not significant, then we must try again." strengthening the primary care system. participants unanimously agreed that the covid-19 outbreak was a challenge to the chinese primary care system. to strengthen this system, participants' recommendations ranged from "increasing investment in primary care institutions" and "developing information technology" to "improving the capacity of healthcare personnel." participants expected a system that was "more resilient", "offered universal coverage down to the community level," and "provided integrated care for residents." primary care is the first line of defense in controlling an epidemic at a community level, but the susceptibility of pcps to tasks and the serious consequences were not fully recognized. to enhance understanding of the current status of covid-19 epidemic control in primary care, we characterized pcps' perceived barriers and experience. we also examined pcps' perspectives on the solutions that could potentially benefit the primary care system in coping with major infectious diseases. to our knowledge, this was the first qualitative study to explore pcps' work in major infectious disease control in china. the pcps described a series of barriers to epidemic control. aside from the extreme workload, rapidly evolving practice environment, ppe shortage, and inadequate training, which are consistent with international reporting, 26, 27 participants emphasized specific concerns about inappropriate pcp scheduling and role ambiguity, which complicated their routine work, and insufficient cooperation with community workers, which reduced their work efficiency. these findings highlight new problems within and beyond the primary care system during emergency emergencies. therefore, a feedback channel between pcps and leaders should be established to detect problems in epidemic control. implementation of epidemic control had varied occupational and psychological effects on pcps. some pcps responded to the epidemic proactively because of inner motivation or external pressure, whereas others felt fatigued and expressed psychological distress. evidence suggests that frontline healthcare workers are generally vulnerable to the emotional impact of epidemics. [28] [29] [30] in this study, we inductively identified 4 manifestations of psychological distress among participants-fear, anxiety, frustration, and anger ( table 2 )-most of which were reported as mild in degree and short in duration, and seldomly the cause of absenteeism or disease. our findings provide insights into the factors affecting emotions that primary care managers should acknowledge. for example, pcps felt frustrated with the paperwork of reporting surveillance data not only because it was time-consuming or complex but also it was of little practical value. remarkably, most participants found support from their colleagues, but none received external psychological support, suggesting potential gaps in mental health services for pcps during emergencies. 31 although many studies have reported that positive professional relationships, including dialogue and emotional support, were an essential protective factor for preventing physician burnout, 32 our findings support and expand on the existing knowledge regarding the essential role that the peer support plays in pcps' psychological support during a time of pandemic and workforce scarcity. strategies to help pcps overcome challenges and prevent the primary care system from being overwhelmed are urgently needed. first, health authorities and institutional leaders were expected to provide specific support in terms of material, technology, and mental care to make pcps equipped for epidemic control. it is worth noting that leaders must listen to pcps' concerns and encourage them to ask for help, instead of blaming or criticizing them. an array of feedback channels, such as listening sessions and email suggestion box, could be considered to make pcps' voice be part of the decision-making process. 33 second, the burden of unnecessary work could be reduced to maximize the capacity of pcps during this turbulent time. pcps wished to be freed from non-essential tasks and meetings to perform to their full potential and provide integrated care for residents in the community. it is advisable to consider innovative ways proposed by participants in our study to reduce workload and streamline procedures, such as rational workforce arrangement, effective internal coordination, and establishing an intelligent system of communication and surveillance. third, professional training could be provided to community workers to help facilitate their cooperation with pcps. current healthcare systems in many countries are under extreme pressure, and the use of community workers for the covid19 response would fill gaps in routine primary care. 34 there is a potential to improve community workers' capacity to deliver a wider range of care for the residents. for example, community workers receiving a basic training program might help pcps manage older people in terms of drug delivery and collection of medical information, and this idea should be investigated in a future study. fourth, steps should be taken to build a more peoplecentered primary care system. several long-standing limitations to china's primary care system, particularly the shortage of professional human resources, substantially increased the difficulty of epidemic control in the community. 35 pcps in china are paid low wages and minimal benefits, receive inadequate training, and experience high rates of occupational burnout, which impede pcps' delivery of integrated and highquality care. 36 therefore, the primary care system should ensure an adequate total income and strengthen the career development opportunities for pcps. there are several limitations in our study. first, the results may not be generalizable to other regions of china because we only interviewed pcps in four provinces. second, pcps other than clinicians (e.g., nurse practitioners) were not included in our study because their scope of responsibilities was narrower than that for clinicians. third, our study was not designed to compare the differences between urban and rural areas. finally, we were unable to triangulate the results with those from other stakeholders, such as policymakers and community workers, but we will consider this in future studies. pcps in china perceived a series of barriers in confronting the covid-19 epidemic, which had positive and negative effects on their physical and mental health. therefore, effective approaches are urgently needed to help pcps overcome these barriers and work in an orderly and efficient manner. the current findings offer important lessons for policymakers and leaders for improving future control measures. in addition, they highlight the importance of developing the primary care system to strengthen preparedness and response to upcoming health challenges. emerging understandings of 2019-ncov coronavirus infections-more than just the common cold latest data on novel coronavirus who strategic and technical advisory group for infectious hazards. covid-19: towards controlling of a pandemic responding to covid-19-a once-in-a-century pandemic? national health commission of the people's republic of china. nearly 4 million primary care practitioners are participating in prevention and control of the epidemic outbreak contributions and challenges of general practitioners in china fighting against the novel coronavirus crisis covid-19: notes from the frontline, singapore's primary healthcare perspective response of general practitioners to infectious disease public health crises: an integrative systematic review of the literature challenges of the pandemic response in primary care during prevaccination period: a qualitative study survey on the difficulties, needs and psychological status of general practitioners in community-based prevention and control of the covid-19 epidemic primary care physicians in hong kong and canada-how did their practices differ during the sars epidemic? how infectious disease outbreaks affect community-based primary care physicians: comparing the sars and h1n1 epidemics post-sars psychological morbidity and stigma among general practitioners and traditional chinese medicine practitioners in singapore semistructured interviewing in primary care research: a balance of relationship and rigour world medical association declaration of helsinki: ethical principles for medical research involving human subjects research design: qualitative, quantitative, and mixed methods approaches research and evaluation in education and psychology: integrating diversity with quantitative, qualitative, and mixed methods qualitative data analysis: practical strategies sources and symptoms of stress among nurses in the first chinese anti-ebola medical team during the sierra leone aid mission: a qualitative study qualitative study on psychological experience of front-line nurses combating new coronavirus pneumonia three approaches to qualitative content analysis patient-perceived barriers and facilitators to the implementation of a medication review in primary care: a qualitative thematic analysis covid-19: gps call for same personal protective equipment as hospital doctors covid-19: don't forget the impact on us family physicians supporting the health care workforce during the covid-19 global epidemic timely mental health care for the 2019 novel coronavirus outbreak is urgently needed factors associated with mental health outcomes among health care workers exposed to coronavirus disease occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and metaanalysis online mental health services in china during the covid-19 outbreak understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic national uk programme of community health workers for covid-19 response early appraisal of china' s huge and complex health-care reforms the primary healthcare system in china acknowledgments: the authors would like to thank frontline primary care practitioners who participated in this study for their timely feedback and contributions to the epidemic control. the authors declare that they do not have a conflict of interest.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/. key: cord-297935-fk9j7q67 authors: wilson, ellen k.; siegfried, noëlle richa; sorensen, asta v. title: patients’ and caregivers’ experiences with the multi-payer advanced primary care practice demonstration date: 2020-09-11 journal: j gen intern med doi: 10.1007/s11606-020-06177-3 sha: doc_id: 297935 cord_uid: fk9j7q67 background: the patient-centered medical home (pcmh) model aims to improve primary health care using a patient-centered approach. little qualitative research has investigated how the pcmh model affects patient experience with care. objective: to understand medicaid and medicare patient and caregiver experiences with pcmhs participating in the multi-payer advanced primary care practice (mapcp) demonstration. design: qualitative study. participants: medicare, medicaid, and dually eligible patients who were patients in primary care practices participating in the mapcp demonstration and caregivers of such patients (n = 490). approach: from july through november 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the mapcp demonstration. separate groups were held for medicare high-risk, medicare low-risk, medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of medicaid children (or, in vermont, with patients participating in the support and services at home program), in two different geographical areas in each state. focus group discussions were recorded, transcribed, and analyzed using nvivo qualitative data analysis software. results: participants’ experiences with care were generally consistent with the expectations of a pcmh, although some exceptions were noted. medicaid only and dually eligible beneficiaries generally had less-positive experiences than medicare beneficiaries. most participants said their practices had not solicited feedback from them about their experiences with care. few participants knew what the term “medical home” meant or were aware that their practices were working to become pcmhs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records. conclusions: most participants had positive experiences with their care. opportunities exist, however, to improve care for medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in pcmh practice transformation. in recent years, centers for medicare & medicaid services (cms) and other payers have invested significant resources in testing the patient-centered medical home (pcmh) model as a means to improve the organization and delivery of primary health care and reduce health care expenditures. goals of the pcmh model are to improve patient access to care, improve coordination and quality of care, and increase patient participation in health-related decisionmaking and self-management. 1, 2 understanding how the pcmh model affects patient experience with care is essential to assessing the model's overall impact and identifying areas in need of improvement. quantitative studies to date have shown mixed but promising results. [3] [4] [5] [6] [7] qualitative research allows for more in-depth exploration and deeper understanding of patients' experiences of care, but little work has been done in this area. the multi-payer advanced primary care practice (mapcp) demonstration provides an opportunity to explore the effects of pcmh transformation across a broad variety of populations, health care systems, and geographic areas. the mapcp demonstration began in 2011 when the cms joined ongoing pcmh initiatives in eight states (maine, michigan, minnesota, new york, north carolina, pennsylvania, rhode island, and vermont). through cms's involvement, medicare partnered with medicaid and commercial payers to make payments to participating primary care practices to support pcmh transformation activities, including extending office hours, staffing care teams, coordinating care, and enhancing electronic health record (ehr) capabilities. by the end of 2014, 857 advanced primary care practices were participating in the demonstration. this paper describes the perspectives of patients and patient caregivers from practices participating in the mapcp demonstration regarding their experiences with aspects of their care that are expectations for a pcmh (i.e., enhanced access to care, high-quality and coordinated care, support for shared decision-making and patient self-management, and solicitation of patient input) and how their care had changed since their practices' pcmh transformation. the study design was to hold 12 focus groups in each of the eight mapcp demonstration states-one group for each of six categories in two separate geographical regions, including both rural and urban areas. the six categories were medicare high-risk (defined as having a hierarchical condition category score ≥ 1.22), medicare low-risk, medicaid, medicare/ medicaid dually eligible beneficiaries, caregivers of medicaid or medicare beneficiaries, and caregivers of medicaid children (in vermont, groups were conducted with participants of the support and services at home [sash] program, which provided support services and care coordination to medicare beneficiaries living in subsidized housing and the surrounding communities, instead of caregivers of medicaid children). we aimed to recruit 10 people per group, with the goal of having 6-8 participants. we recruited participants by mailing letters to medicare, medicaid, and dually eligible beneficiaries inviting them or their caregivers to participate. to identify medicare and dually eligible beneficiaries, we selected six mapcp demonstration practices in each of two regions of each state and then used the medicare enrollment database to select a random sample of beneficiaries attributed to those practices who met the following criteria: age 18 or older, had been assigned to a mapcp demonstration practice for more than 1 year, and had visited the practice at least twice in the prior 12 months. to identify medicaid beneficiaries and the caregivers of children with medicaid, four practices in each state generated a random sample of medicaid beneficiaries who had received care at those practices over the prior 12 months and mailed the recruitment letter to the sample on the study's behalf. the recruitment letter asked beneficiaries to call to be screened for eligibility. to be eligible to participate, beneficiaries had to be proficient in english and not have participated in a focus group in the prior 12 months; they also had to confirm that they had either medicare or medicaid insurance and that they received their primary care from a practice participating in the mapcp demonstration. to ensure that beneficiaries and caregivers had sufficient experience with the practice to be able to speak knowledgably about it and that they would be able to address questions about coordination with specialists, they also had to have seen a specialist at least once in the prior year and have a chronic condition. because contact information for beneficiaries' caregivers was not available, the recruitment letters to beneficiaries also invited caregivers to call and be screened for eligibility. a caregiver was defined as the main person responsible for the beneficiary's health care who usually or always took the beneficiary to appointments at his or her primary care practice. to capture a broader variety of experiences, we did not recruit both a beneficiary and their caregiver. if we did not receive a sufficient number of incoming calls to recruit 10 participants for any of the medicare and dually eligible groups, we called beneficiaries from among those who received recruitment letters to identify additional participants. we were unable to supplement the medicaid groups in this way because we did not have contact information for the medicaid beneficiaries and caregivers. an experienced focus group moderator facilitated the groups between july and november 2014. all participants read and signed an informed consent form. the moderator followed a discussion guide that explored participants' awareness of the pcmh concept and their experiences with care related to key pcmh constructs. for example, related to access to care, participants were asked about the ease or difficulty of getting an appointment when they needed one; how they could schedule appointments and their satisfaction with those methods; wait times; if they had used a patient portal and if so, their experience with it; and whether the practice had taken any steps to help them reduce use of the emergency room. participants were also asked whether they had experienced any changes in any of these areas in the previous few years. groups lasted 1.5 h on average, and participants were given a $50 visa gift card for their participation. each group was audio-recorded and transcribed. to guide our analysis of the data, we developed a coding scheme based on a priori theoretical constructs as well as on themes that emerged from a review of the focus group transcripts. a team of six coders used nvivo qualitative data analysis software to code the transcripts. to refine the coding scheme and ensure that all of the coders were interpreting the codes in the same way, all six coders initially coded the same two transcripts and discussed any discrepancies. once the team had refined the codebook and reached consensus on how to apply it, they divided the remaining transcripts, coded them, and prepared coding reports. for each state, one team member reviewed the coded reports, analyzed the data to identify patterns and themes, and prepared a report summarizing findings for the state. though some distinctions were found across the eight states, our analysis focuses on the comprehensive findings from all the states, with differences noted by focus group type when applicable. when summarizing the frequency with which specific views were expressed, we use "few" for fewer than 10% of participants; "some" for 10 to 25%; "many" for 25 to 50%; and "most" for more than 50%. we conducted 81 focus groups with 490 individuals, of whom 80 were caregivers and 410 were beneficiaries (table 1) . this is 15 fewer groups than intended: the shortfall is primarily due to the fact that most of the participating practices had very few pediatric patients, so we were able to recruit enough participants for just 1 of the planned 14 focus groups with caregivers of medicaid children (and even that group had only 3 participants). twelve people participated in the two focus groups of participants in the sash program in vermont. most participants described themselves (or, in the case of caregivers, the person they cared for) as being in very good (25%), good (35%), or fair (27%) health, with few on either extreme ( table 2 ). almost two-thirds (64%) were 60 years of age or older, and only 9% were under age 40. sixty percent of participants were female, and a large majority (83%) were non-hispanic white. nearly one-third (31%) of participants had a high school education or less, half (52%) had some college or a college degree, and 17% had more than a college degree. compared with medicare beneficiaries, medicaid and dually eligible beneficiaries were, on average, in worse health, younger, more likely to be female, and had lower levels of education; medicaid beneficiaries also were more likely to be non-hispanic black. results from the focus group discussions are presented in the sections that follow and are summarized in table 3 . most participants reported convenient access to care during office hours, and some thought that it had improved in recent years: wait times were short and they could typically get a same-day appointment when needed (although usually not with their primary care providers [pcps]). after-hours access was more problematic, however: most participants said that their practices' hours were limited to weekdays during the day, forcing participants to visit an urgent care facility or the emergency department when they had an urgent health care need after hours. the biggest recent change in access described by participants was the addition of patient portals. participants who had used the portal were enthusiastic about its ability to help them make appointments, check test results, and communicate with their pcps. as one said, "i like that i'm able to see my test results beforehand, especially if there's something that we've been following for a period for the caregiver focus groups, overall health and age were reported by the caregivers for the beneficiaries for whom they care. sex, race/ethnicity, and education are reported for the caregivers of time" (low-risk medicare, new york). however, most participants had not used the portal, and many were not even aware of it. some were interested in trying it, but others were not because the current process worked for them, they were "technology averse," they were worried about privacy issues, or they did not have a computer or internet service. in the words of one participant, "i like to talk to people when i make appointments, not hit buttons on a computer"(dually eligible, vermont). participants' experiences with coordination of care varied widely. most said that information was readily shared between their pcps, specialists, and hospitals-for example, their pcp knew if they had been in the hospital and was able to access test results from their specialists. many said that their pcp either visited them in the hospital or called to follow up after they were discharged. some participants, however, said that information did not readily transfer between the pcp and the hospital or specialists, particularly if they were in different systems. some said their pcp did not know when they had been in the hospital, or that the pcp did not have access to lab results from the hospital and would order the same tests again. most participants thought that the transfer of information had improved in recent years, particularly with the introduction of ehrs. however, some participants noted that the transfer of information did not necessarily mean that their pcps were coordinating their care for them: they were not sure to what extent their pcps actually digested the information, and some caregivers, in particular, said that they still felt that they were the ones who had to take the lead in coordinating the care for their loved ones: "the information is there, but i always feel like i have to be the advocate for my mom to say, 'well, she had this and the results came back that way, so does that mean we need to do something?'" (caregiver, new york). some participants mentioned that their practices were providing more assistance in scheduling appointments with specialists than they had in the past. some medicaid and dually eligible participants reported, however, that the specialists their pcps referred them to often would not accept their insurance, so they ended up having to find specialists on their own. a few participants mentioned that their pcps seemed more willing to provide referrals to specialists than in the past; some considered this an improvement, but some wished the pcp would provide more care themselves, rather than sending them to specialists. a final change in coordination of care noted by some participants was that during hospital stays, care was increasingly provided by hospitalists, and their pcps, who knew them best, were not involved with their care. they felt that this practice reduced coordination of care. most participants thought that their pcps communicated well with them: listened carefully, explained things thoroughly and in terms they understood, and spent as much time as needed to address all their concerns. on the other hand, some participants (most of whom were in medicaid or dually eligible groups) said that their pcps rushed them, allowed them to discuss only one or two concerns per appointment, did not address their emotional or mental health needs, or made assumptions about their needs. most participants were also pleased with the office staff at their practices, describing them as friendly, helpful, professional, courteous, and efficient, and a few thought that the staff had become more efficient and friendlier in recent years. a few participants had complaints, however, including that staff were rude, were inefficient, did not respect confidentiality, did not transmit messages to their pcps, or made it difficult to reach the pcp. again, most of the participants who had negative experiences were in medicaid or dually eligible groups. as one said, "[the staff] act like they are doing you a favor by taking your medicaid" (medicaid, pennsylvania) . the primary changes that participants noted in patientcentered care related to the introduction of ehrs. participants said that the ehrs helped to ensure that their pcps remembered their medical information, facilitated filling prescriptions, and shortened the wait time for getting test results. many participants had started receiving a printout at the end of their appointments summarizing key information, which most appreciated. some commented that the ehr did not always work well, especially when first implemented, but that it improved over time. one drawback of ehrs mentioned by some participants, however, was that their pcps were now typing on the computer during their time with them, and they felt that this made for less personal communication "sometimes i think they spend more time looking at the computer than looking at you" (low-risk medicare, pennsylvania). a few participants mentioned other changes. some said that their pcps took more time to discuss health issues, took a more holistic approach, followed up more, and were more responsive. others said that the practice seemed to be taking a more proactive approach to care, including administering screeners to assess depression or other health risks, calling patients to remind them about appointments or to tell them when they were due for a test or an appointment, and providing support for non-medical issues, such as transportation or food access. finally, a few participants noticed a new teambased approach to care-for example, that a nurse would ask them questions before they saw their pcps; some appreciated this because it made more efficient use of their time with the pcp, but others were frustrated that they had to repeat the same information. most participants viewed their relationships with their pcps as partnerships and said that their pcp respected their opinions and preferences and involved them in making decisions about their treatment. some, however (primarily medicaid and dually eligible beneficiaries), felt that their pcps disregarded their perspectives by not focusing on the health concerns most important to them, not taking their health concerns seriously, or pushing them to have treatments or tests they did not want: "i just don't think they listen to me sometimes…. something's wrong, and… i really wish it could be checked out, not just telling me to go home and relax" (medicaid, new york). some participants commented that they thought that, in general, patients need to advocate for themselves to make sure that their concerns are addressed. in the words of one participant, "it seems like i have to take the lead in asking [my pcp] questions about my… diabetes. i have to be very assertive… in getting information from her about diet or medication, things of that sort"(low-risk medicare, rhode island). a few participants noted some changes in shared decisionmaking. some commented that their pcps were now starting appointments by asking open-ended questions, such as "what's concerning you?" or "what are your goals?" others noted a general shift in approach: "i think [they now] want you to be an active part of the team and not just sit back and be told what to do" (low-risk medicare, minnesota). most participants said that their pcps talked to them about things they could do to improve their health, but almost none reported having a written care plan and few indicated that they had set specific health-related goals with their pcps. moreover, a few participants said their pcps talked to them about managing their health only if they, the patients, brought it up, and they wished that the pcps spent more time discussing prevention. on the other hand, some participants said that their pcps had given up talking to them about behavior change, because they knew that it would be "in one ear and out the other" (medicaid, michigan). participants reported receiving varying levels of support for managing their health. only a few, all of whom were either medicaid or dually eligible participants, had care managers through their pcps, who helped with needs such as home care, housework, transportation, housing, employment, emotional support, reviewing medications, setting up appointments, and obtaining needed medical equipment. nearly all participants who received these services found them to be very helpful. some participants said that their pcps had referred them to classes on topics such as smoking cessation, diabetes control, or weight loss. while most found the classes helpful, a few said that they were too basic or not relevant for their situation or that they were not able to attend the classes because they could not afford the cost of the class or transportation to get to the class. a few participants said that their pcps had offered other supports, such as referring them to a dietitian or nutritionist to help support healthy eating or setting them up with a blood pressure cuff and logbooks to monitor their blood pressure. some commented, though, that the only support their pcps gave them to aid behavior change was written information such as a pamphlet, which they found inadequate: "nothing's been said to either [me or my wife] about diet, especially me being diabetic. i was just handed a pamphlet" (dually eligible, north carolina). the extent to which participants reported that their practices solicited feedback from them varied. many said that their practice administered patient surveys or had other mechanisms for soliciting patient input; some participants said that this solicitation of feedback was new. almost no participants were familiar with the term "medical home." when the concept was explained to them, most agreed that their practices met the definition of a medical home and most thought a medical home would be a positive thing: "if everybody's involved in your situation, it's kind of like a brainstorm type thing, you know? if they're all working together, it could… be a lot more beneficial to everybody" (medicaid, rhode island). some participants expressed concerns about the medical home concept, however. some thought that pcps did not have time to fulfill the role envisioned under a medical home: "if doctors are so busy, how are they going to have time to look at records of everybody who don't necessarily have a problem?" (high-risk medicare, rhode island). others were concerned that the medical home concept could increase bureaucracy, restrict patients' access to providers, increase costs to patients, or threaten patient privacy. some felt that they personally did not need a medical home, but it could benefit those with more health problems. the pcmh paradigm is complex and primary care practices have many opportunities to integrate its diverse components into their daily activities. our findings suggest that from the patient perspective, most of the practices participating in the mapcp demonstration were delivering care in a way that was largely consistent with pcmh principles. most participants described having accessible, well-coordinated, and highquality care and appropriate engagement in shared decisionmaking. these findings are similar to earlier, smaller qualitative studies of patient perspectives on pcmh care. 8, 9 our findings also highlight several areas that may require enhanced transformation from the patient perspective. relatively few participants used patient portals, indicating that practices' investments in new technologies may have limited effect when patients are not aware of their existence, cannot access them, or do not want to use them. despite practices' efforts to expand access to care, participants still struggled to reach their pcps and receive care when facing emergencies during nights and weekends, suggesting the need for additional effort in this area. participants rarely received written plans or set specific goals with their physicians, which are critical tools for supporting patients' self-management of chronic conditions. participants noted that although care was generally well-coordinated within a health care system, practices still need to improve coordination of care across systems, including the transfer ehr information and allowing for their pcps to be engaged in their care when they were in the hospital. as primary care practices function within the realities of limited financial and staffing resources, adoption of pcmh components may require strategic prioritization. the need for prioritization is likely to escalate in the aftermath of covid-19 pandemic, as many primary care practices may struggle to maintain pcmh functions that they have put in place and introduce new ones. patients' perspectives also revealed persistent disparities and the need to enhance the paradigm of patient-centered care. some participants from medicaid and dually eligible groups reported feeling stigmatized or that their health concerns were not taken seriously, and some experienced challenges with coordination of care because many specialists would not accept their insurance. these findings are consistent with previous research, which has shown that people who are uninsured or who have medicaid insurance often feel that they are treated poorly by their health care providers 10, 11 and that many providers are unwilling to accept patients with medicaid coverage. [12] [13] [14] these challenges suggest the need for enhanced focus on provider training in cultural competencies, reevaluation of effectiveness of cultural competency trainings across existing programs, and incentives to serve medicaid beneficiaries and dually eligible. as reported in other recent qualitative studies describing patient experiences with pcmhs, 9 we also found that most participants did not know what a medical home was and were not aware that their practices were participating in an initiative seeking to enhance patient centeredness of care. in addition, few participants said that their practices had taken any steps to solicit their feedback. while practice improvement is a responsibility of practice staff, meaningful transformation cannot be achieved in the absence of patient engagement and buy-in. more recent iterations of cms valued based care initiatives such as accountable care organizations and the comprehensive primary care plus initiative require more structured patient engagement in organizational operations than those required in mapcp, such as patient representation on organizational boards and advisory councils, 15 which may help to improve practices' responsiveness to patient needs and concerns. while seeking patient input and feedback is an important and necessary step forward, it is the willingness of practices and providers to act on patient input and recommendations that will facilitate change. this study is subject to several limitations. first, the selection criteria for the study (that participants be medicaid, medicare, or dually eligible beneficiaries or caregivers of beneficiaries in eight select states and speak english fluently) led to a sample that was primarily non-hispanic white, over age 60, and english-speaking; results may not be generalizable to other demographic groups. we were also unable to summarize the experiences of children enrolled in medicaid because we were unable to recruit a sufficient number of caregivers of medicaid children. however, because participants were drawn from eight different states, including both urban and rural areas, the study represents a much greater breadth of experiences than previous studies, and the high number of medicaid and dually eligible beneficiaries ensures that perspectives of low-income and disabled populations are reflected. second, because we collected data only from patients of practices that were participating in the mapcp demonstration, we cannot assess the extent to which their experiences may differ from those whose practices were not participating in the mapcp demonstration. third, because the focus groups were conducted at one point in time, approximately 2.5 years after the mapcp demonstration began, we can only indirectly assess the extent to which patient experiences changed after their practices began their pcmh transformation. finally, because each focus group included participants from more than one practice, it was not possible to link the comments from participants in specific focus groups to individual practices. as a result, we were unable to assess which practices had been most successful in achieving pcmh transformation or to what extent patient perceptions of care aligned with practice transformation efforts. additional research is needed to further understand pcmh transformation from the patient perspective. research that links patient experiences to specific practices, including characteristics of the practices (e.g., practice culture, leadership, and physician engagement) and the pcmh transformation strategies the practices have implemented, could help elucidate how practice characteristics or strategies influence patient experiences. transforming the organization and delivery of primary care. u.s. department of health and human services, patient centered medical home resource center defining the medical home: a patient-centered philosophy that drives primary care excellence differences in patient ratings of medical home domains among adults with diabetes: comparisons across primary care sites effects of patient-centered medical home transformation on child patient experience patient-centered medical home transformation with payment reform: patient experience outcomes patient experience over time in patient-centered medical homes patient experience with the patient-centered medical home in michigan's statewide multi-payer demonstration: a cross-sectional study asking the patient about patient-centered medical homes: a qualitative analysis veteran patient perspectives and experiences during implementation of a patient-centered medical home model the role of stigma in access to health care for the poor reports of insurance-based discrimination in health care and its association with access to care effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and medicaid patients nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help no association found between the medicaid primary care fee bump and physician-reported participation in medicaid cpc+ care delivery requirements crosswalk. centers for medicare and medicaid services acknowledgments: the authors wish to acknowledge all those who helped in recruitment, data collection, and data analysis for the focus groups. they include the following: funding the analyses for this manuscript were performed under cms contract number hhsm-500-2010-00021i. the contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the us department of health and human services or any of its agencies. all participants read and signed an informed consent form. the authors declare that they do not have a conflict of interest. key: cord-305110-mujpekyu authors: cloud, david h.; ahalt, cyrus; augustine, dallas; sears, david; williams, brie title: medical isolation and solitary confinement: balancing health and humanity in us jails and prisons during covid-19 date: 2020-07-06 journal: j gen intern med doi: 10.1007/s11606-020-05968-y sha: doc_id: 305110 cord_uid: mujpekyu in the face of the continually worsening covid-19 pandemic, jails and prisons have become the greatest vectors of community transmission and are a point of heightened crisis and fear within the global crisis. critical public health tools to mitigate the spread of covid-19 are medical isolation and quarantine, but use of these tools is complicated in prisons and jails where decades of overuse of punitive solitary confinement is the norm. this has resulted in advocates denouncing the use of any form of isolation and attorneys litigating to end its use. it is essential to clarify the critical differences between punitive solitary confinement and the ethical use of medical isolation and quarantine during a pandemic. by doing so, then all those invested in stopping the spread of covid-19 in prisons can work together to integrate medically sound, humane forms of medical isolation and quarantine that follow community standards of care rather than punitive forms of solitary confinement to manage covid-19. t he nation's poor preparation and slow response to the risks posed by covid-19 have been compounded in jails and prisons, many of which are now reporting high numbers of infections among incarcerated people and staff. evidence so far indicates that correctional facilities, including jails in new york city and chicago and prisons in ohio, have the highest rates of confirmed cases of covid-19 of any setting. 1 as the covid-19 pandemic sweeps through an alarming number of us jails and prisons, guidance from the medical community on the ethical and humane use of medical isolation and quarantine in these settings is urgently needed. while social distancing is critical to slowing the spread of disease, it is exceedingly challenging in the unique settings of prisons and jails. consequently, some correctional systems are employing isolation in ways that are haphazard or inhumane and will, in turn, undermine their public health intentions. recently, some prison reform advocates and litigators working on behalf of incarcerated people have called for a prohibition against the use of isolation to combat covid-19, out of concern that recent strides made toward ending solitary confinement in the usa are being put in jeopardy. 2, 3 this tension, left unresolved, could rapidly result in a health and humanitarian crisis affecting the residents, employees, and surrounding communities of our nation's over 5000 places of detention. from a public health perspective, the concerns of both correctional systems and prison reform advocates are valid. solitary confinement is a punishment, in widespread use in us correctional facilities, despite a wealth of evidence that it contributes to excess morbidity and mortality among currently and formerly incarcerated people. [4] [5] [6] [7] the hallmarks of solitary confinement-social isolation, physical idleness, and sensory deprivation-lead to immense psychological suffering and lasting trauma, and too often result in self-harm, violence, and suicide, even after only relatively short periods of time. 4, 8 following decades of litigation and advocacy, an increasing number of state correctional systems have adopted reforms focused on curbing and eventually eliminating solitary confinement. 9 even states with high rates of incarceration and greater proportions of their prisoner population in solitary confinement, such as louisiana, have made notable progress in this area of punishment. 10 many advocates fear that use of isolation to curb transmission of covid-19 in correctional facilities will complicate the emerging crisis, as incarcerated people become reluctant to report symptoms for fear of being moved to solitary confinement, those who do report symptoms will be forced to endure an experience known to cause psychological and physical harm, and system-wide unrest will be triggered in institutions where fears about being placed in medical isolation could run rampant. yet, quarantine and medical isolation in response to covid-19 are necessary to halt the spread of infection; without them, containment of disease transmission will be exceedingly difficult if not impossible, posing significant health risks to incarcerated people, correctional healthcare providers, security staff, and the families and communities to which workers return at the end of each shift. clearly defining and instituting the ethical and humane application of wellestablished medical isolation and quarantine practices in the community is critical for curbing transmission in these highly hazardous environments and protecting the dignity of incarcerated people. most us jails and prisons continue to operate at or above their designed capacity and are chronically understaffed in both security and healthcare services. overcrowding renders social distancing efforts unlikely to be successful once covid-19 is introduced into a us jail or prison. as a result, any effective and ethical medical isolation and quarantine program in us jails and prisons must be preceded by the immediate release of as many people as possible from jails and prisons to ensure that adequate physical space and medical staff are available for the population that remains. 11 unfortunately, the numbers of releases in most jurisdictions to date have been relatively small and woefully insufficient. given the grave health risks that covid-19 pose to correctional institutions and their surrounding communities, corrections officials and advocates for incarcerated people and their families should find common cause in persuading governors, legislators, and the public that rapid decarceration, including of the sentenced population, is necessary and can be done safely. 12 population reduction efforts should only be deemed adequate once every facility can safely accommodate complete social distancing by newly organized cohorts of incarcerated people; these cohorts should be sized with some consideration of medical care capacity in the facility and surrounding community and based on the family unit in communities under "stay home" orders. facilities must also have the capacity to clean shared spaces (including eating, recreating, and bathing areas) regularly so that these cohorts can serve as a first-line defense against the broader spread of infection already evidenced in some jails and prisons. once populations are reduced to a manageable level, temporary and humane medical isolation and quarantine for those exposed to or infected with covid-19 must be used to stem transmission of the virus and mitigate the worst outcomes associated with a surge in cases. in this context, it is critical to clearly distinguish between solitary confinement, medical isolation, and quarantine so that leaders, practitioners, and advocates are working to support appropriate medical responses to outbreaks in correctional facilities. "medical isolation" and "quarantine" procedures are substantively different from "solitary confinement" (table 1) . however, critical misperceptions persist inside and outside correctional facilities about what these procedures should be and how they affect the people living and working in prisons and jails. the only commonality that solitary confinement should share with quarantine and medical isolation is a physical separation from other people. in fact, those in medical isolation may be housed together with others who also have covid-19. this means that people in quarantine or medical isolation should have enhanced access to resources that can make their separation psychologically bearable-for example, television, tablets, radio, reading materials, and means of communicating with loved ones-since they are enduring isolation for the greater good, not for punishment. they should have easy access to medical and mental health professionals, and daily updates from healthcare staff as to why separation is necessary and how long they can expect it to last. corrections officials should make additional efforts to communicate with and show compassion for people in their custody who are scared and feeling unwell in quarantine or medical isolation. 13 some simple ideas include distributing cell phones, tablets, televisions, gaming consoles, and other equipment that people in medical isolation, quarantine, or sheltering-in place in the community may be using to cope with the anxiety of isolation. healthcare providers working outside corrections could offer telehealth consultations with patients via tablets and other hipaa-compliant digital platforms. if corrections systems lack these resources, public health agencies, non-profit organizations, advocates, faith-based entities, and philanthropies should mobilize to assist in providing them. in many correctional facilities, the only available spaces for implementing quarantine or medical isolation are those typically used for punishing people with solitary confinement. this is because these units have single cells with solid cell doors and are removed from communal living areas. repurposing solitary confinement units for medical purposes, however, runs the risk of corrections officials falling back on policies that subject people to living conditions known to harm their health. it is imperative that if these units are used to contain the covid-19 epidemic, there must be accompanying communication from medical and correctional staff to the wider population and clear examples of how housing in these units will differ from "run of the mill" solitary confinement. similarly, any housing used as part of a medical response must be medically appropriate with, for example, proper ventilation and adequate sanitation. given the high rates of comorbid conditions in correctional settings, corrections and public health officials should ensure that people undergoing quarantine do so in reasonable proximity to urgent care. additionally, solitary confinement is often used for extended or even indeterminate periods of time, with release back to general population housing at the discretion of correctional officers. in stark contrast, quarantine and medical isolation are temporary procedures that should be overseen by medical professionals. cdc guidelines for discontinuing quarantine and medical isolation should govern decisions in jails and prisons, just as they do in the community. 14 community standard length of time for quarantine and medical isolation, on average about 14 days, aligns closely with (and do not exceed) the united nation's standard minimum rules for the treatment of prisoners (the "nelson mandela rules") that define punitive use of solitary confinement for longer than 15 days as "torture" 15 ( table 2) . implementing time-restrictions for quarantine and medical isolation in any setting hinges on having sufficient capacity for testing patients for covid-19. while some facilities have increased testing efforts for residents and staff, others have not. without system-wide testing, disease prevention strategies will fail and result in collateral harms. 16 if healthcare staff lack knowledge of infected residents and staff, then they cannot make informed decisions about quarantine or medical isolation. this lack of testing will increase anxiety and stress among residents and staff in the correctional setting and could lead to widespread and indiscriminate solitary confinement, which would compound unrest and mistrust. therefore, it is critical for corrections, public health, and medical officials to allocate resources necessary for robust covid-19 testing kits for people living and working in jails and prisons. the use of punitive isolation during the covid-19 epidemic-including indeterminate system-wide facility lockdowns where people cannot communicate with their families, exercise outside, participate in programming, or interact with healthcare professionals-will deter people from reporting symptoms, in turn threatening the health of all those who work in jails and prisons. because the correctional workforce returns home at the end of each shift, outbreaks in correctional facilities threaten the health of those in surrounding communities. with the covid-19 crisis in jails and prisons worsening daily, many under-resourced correctional health systems are already overwhelmed by this crisis. this is not business as usual in prison reform. elected officials, correctional leaders, advocates, litigators, family members, and others concerned about people behind bars must work together for immediate population reduction in our jails and prisons and to secure the needed medical supplies, testing kits, staffing support, and other vital resources for those who remain incarcerated and the staff supervising and caring for them. collective action among uncomfortable allies is a challenging but necessary strategy for minimizing the harms of this pandemic. but to meet the demands of this rapidly unfolding crisis, now is the time to put health first in correctional policy and practice, release all people who can be safely released to the community, and ensure that medical isolation and quarantine procedures follow community stan-dards of care and are not, in reality, solitary confinement by another name. latest map and case count wisconsin associate of criminal defense lawyers v. evers. 2020 the psychological effects of solitary confinement: a systematic critique public health and solitary confinement in the united states association of restrictive housing during incarceration with mortality after release solitary confinement, post-release health, and the urgent need for further research psychological distress in solitary confinement: symptoms, severity, and prevalence in the united states reforming solitary-confinement policy-heeding a presidential call to action the safe alternatives to segregation initiative: findings and recommendations for the louisiana department of public safety and corrections, and progress toward implementation flattening the curve for incarcerated populations-covid-19 in jails and prisons covid-19 in correctional settings: immediate population reduction recommendations world health organization. preparedness, prevention and control of covid-19 in prisons and other places of detention (2020), interim guidance 15 disposition of nonhospitalized patients with covid-19 united nations standard minimum rules for the treatment of prisoners (the nelson mandela rules) correctional facilities in the shadow of covid-19: challenges and proposed solutions conflict of interest: the authors declare that they do not have a conflict of interest.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the 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