COVID-19 pandemic and trends in clinical outcomes and medication use for patients with established atrial fibrillation: A nationwide analysis of claims data.

Study objective: The COVID-19 pandemic disrupted multiple aspects of the health care system, including the diagnosis and control of chronic conditions. This study aimed to quantify pandemic-related changes in the rates of clinical events among patients with atrial fibrillation (AF). Design/setting/participants: In this retrospective cohort study, we identified individuals with established AF at any time before 2019 using de-identified Optum's Clinformatics® Data Mart, and followed them from 3/18/2019 to death, or disenrollment, or the end of the study (09/30/2021). Main outcome: Rates of clinical event, including all-cause hospitalization, ischemic stroke, and bleeding. We constructed interrupted time series to test changes in outcomes after the onset of the COVID-19 pandemic (3/11/2020, date of pandemic declaration). We then identified the first month after the start of the pandemic in which outcomes returned to pre-pandemic levels. Results: A total of 561,758 patients, with a mean age of 77 ± 9.9 years, were included in the study. The monthly incidence rate of all-cause hospitalization decreased from 2.8 % in the period immediately before the pandemic declaration to 1.7 % in the period immediately after, with p-value for level change<0.001. The rate of new ischemic stroke diagnoses decreased from 0.28 % in the period immediately before pandemic declaration to 0.20 % in the period immediately after, and the rate of major bleeding diagnoses from 0.81 % to 0.59 %, both p-values for level change<0.01. The incidence rate of ischemic stroke and bleeding events returned to pre-pandemic levels in October and November 2020, respectively. Conclusions: The COVID-19 pandemic was associated with a decrease in health care visits for ischemic stroke and bleeding in a nationwide cohort of patients with established AF.

COVID-19 pandemic and initiation of treatment for atrial fibrillation: a nationwide analysis of claims data.

BACKGROUND: The COVID-19 pandemic profoundly disrupted the delivery of medical care. It remains unclear whether individuals diagnosed with new onset disease during the pandemic were less likely to initiate treatments after diagnosis. We sought to evaluate changes in the treatment initiation of patients newly diagnosed with atrial fibrillation (AF) after the onset of the COVID-19 pandemic. METHODS: In this retrospective cohort study, we identified individuals with incident AF from 01/01/2016-09/30/2021 using Optum's de-identified Clinformatics® Data Mart Database. The primary outcome was initiation of oral anticoagulation (OAC) within 30 days of AF diagnosis. Secondary outcomes included initiation of OAC within 180 days of diagnosis, initiation of warfarin, direct oral anticoagulants (DOACs), rhythm control medications and electrical cardioversion within 30 days of diagnosis. We constructed interrupted time series analyses to examine changes in the outcomes following the onset of the pandemic. RESULTS: A total of 573,524 patients (age 73.0 ± 10.9 years) were included in the study. There were no significant changes in the initiation of OAC, DOAC, and rhythm control medications associated with the onset of the pandemic. There was a significant decrease in initiation of electrical cardioversion associated with the onset of the pandemic. The rate of electronic cardioversion within 30 days of diagnosis decreased by 4.9% per 1,000 patients after the onset of the pandemic and decreased by about 35% in April 2020, compared to April 2019, from 5.53% to 3.58%. CONCLUSION: The COVID-19 pandemic did not affect the OAC initiation within 30 days of AF diagnosis but was associated with a decline in the provision of procedures for patients newly diagnosed with AF.

Role of independent versus chain pharmacies in providing pharmacy access: a nationwide, individual-level geographic information systems analysis.

Pharmacy accessibility is critical for equity in medication access and is jeopardized by pharmacy closures, which disproportionately affect independent pharmacies. We conducted a geographic information systems analysis to quantify how many individuals across the US do not have optimal pharmacy access or solely rely on independent pharmacies for access. We generated service areas of pharmacies using OpenStreetMap data. For each individual in a 30% random sample of the 2020 RTI US Household Synthetic Population™ (n=90,778,132), we defined optimal pharmacy access as having a driving distance to the closest pharmacy ≤2 miles in urban counties, ≤5 miles in suburban counties, and ≤10 miles in rural counties. Individuals were then categorized according to their access to chain and independent pharmacies. Five percent of the sample or ~15.1 million individuals nationwide relied on independent pharmacies for optimal access. Individuals relying on independent pharmacies for optimal access were more likely to live in rural areas, be 65 years or older, and belong to low-income households. Another 19.5% of individuals in the sample did not have optimal pharmacy access, which corresponds to 59.0 million individuals nationwide. Our findings demonstrate that independent pharmacies play a critical role in ensuring equity in pharmacy access.

Association Between Redlining and Spatial Access to Pharmacies.

This cross-sectional study evaluates whether there is an association between historic redlining and living within 1 or 2 miles of a pharmacy.

Association between distance to community health care facilities and COVID-19-related mortality across U.S. counties in the COVID-19-vaccine era.

OBJECTIVE: COVID-19 has caused tremendous damage to U.S. public health, but COVID vaccines can effectively reduce the risk of COVID-19 infections and related mortality. Our study aimed to quantify the association between proximity to a community healthcare facility and COVID-19 related mortality after COVID vaccines became publicly available and explore how this association varied across racial and ethnic groups. RESULTS: Residents living farther from a facility had higher COVID-19-related mortality across U.S. counties. This increased mortality incidence associated with longer distances was particularly pronounced in counties with higher proportions of Black and Hispanic populations.

Racial disparities in access to health care infrastructure across US counties: A geographic information systems analysis.

Infrastructure system in the U.S. have been shown to be linked to social and health inequities. We calculated driving distance to the closest health care facility for a representative sample of the U.S. population using ArcGIS Network Analyst and a national transportation dataset, and identified areas where Black residents have a longer driving distance to the closest facility than White residents. Our data demonstrated that racial disparities in access to health care facilities presented large geographic variation. Counties with significant racial disparities were concentrated in the Southeast and did not correspond to counties with a greater proportion of the overall population >5 miles to the closest facility, which were concentrated in the Midwest. This geographic variation demonstrates the need to adopt a spatially explicit data driven approach in the design of equitable health care facility establishment that address the specific limitations of the local infrastructure.

Access to community pharmacies: A nationwide geographic information systems cross-sectional analysis.

BACKGROUND: Pharmacy accessibility is key for the emerging role of community pharmacists as providers of patient-centered, medication management services in addition to traditional dispensing roles. OBJECTIVE: To quantify population access to community pharmacies across the United States. METHODS: We obtained addresses for pharmacy locations in the United States from the National Council for Prescription Drug Programs and geocoded each. For a 1% sample of a U.S. synthetic population, we calculated the driving distance to the closest pharmacy using ArcGIS. We estimated the proportion of population living within 1, 2, 5, and 10 miles of a community pharmacy. We quantified the role of chain vs regional franchises or independently owned pharmacies in providing access across degrees of urbanicity. RESULTS: We identified 61,715 pharmacies, including 37,954 (61.5%) chains, 23,521 (38.1%) regional franchises or independently owned pharmacies, and 240 (0.4%) government pharmacies. In large metropolitan areas, 62.8% of the pharmacies were chains; however, in rural areas, 76.5% of pharmacies were franchises or independent pharmacies. Across the overall U.S. population, 48.1% lived within 1 mile of any pharmacy, 73.1% within 2 miles, 88.9% within 5 miles, and 96.5% within 10 miles. Across the United States, 8.3% of counties had at least 50% of residents with a distance greater than 10 miles. These low-access counties were concentrated in Alaska, South Dakota, North Dakota, and Montana. CONCLUSIONS: Community pharmacies may serve as accessible locations for patient-centered, medication management services that enhance the health and wellness of communities. Although chain pharmacies represent the majority of pharmacy locations across the country, access to community pharmacies in rural areas predominantly relies on regional franchises and independently owned pharmacies.

Disparities in distribution of COVID-19 vaccines across US counties: A geographic information system-based cross-sectional study.

BACKGROUND: The US Centers for Disease Control and Prevention has repeatedly called for Coronavirus Disease 2019 (COVID-19) vaccine equity. The objective our study was to measure equity in the early distribution of COVID-19 vaccines to healthcare facilities across the US. Specifically, we tested whether the likelihood of a healthcare facility administering COVID-19 vaccines in May 2021 differed by county-level racial composition and degree of urbanicity. METHODS AND FINDINGS: The outcome was whether an eligible vaccination facility actually administered COVID-19 vaccines as of May 2021, and was defined by spatially matching locations of eligible and actual COVID-19 vaccine administration locations. The outcome was regressed against county-level measures for racial/ethnic composition, urbanicity, income, social vulnerability index, COVID-19 mortality, 2020 election results, and availability of nontraditional vaccination locations using generalized estimating equations. Across the US, 61.4% of eligible healthcare facilities and 76.0% of eligible pharmacies provided COVID-19 vaccinations as of May 2021. Facilities in counties with >42.2% non-Hispanic Black population (i.e., > 95th county percentile of Black race composition) were less likely to serve as COVID-19 vaccine administration locations compared to facilities in counties with <12.5% non-Hispanic Black population (i.e., lower than US average), with OR 0.83; 95% CI, 0.70 to 0.98, p = 0.030. Location of a facility in a rural county (OR 0.82; 95% CI, 0.75 to 0.90, p < 0.001, versus metropolitan county) or in a county in the top quintile of COVID-19 mortality (OR 0.83; 95% CI, 0.75 to 0.93, p = 0.001, versus bottom 4 quintiles) was associated with decreased odds of serving as a COVID-19 vaccine administration location. There was a significant interaction of urbanicity and racial/ethnic composition: In metropolitan counties, facilities in counties with >42.2% non-Hispanic Black population (i.e., >95th county percentile of Black race composition) had 32% (95% CI 14% to 47%, p = 0.001) lower odds of serving as COVID administration facility compared to facilities in counties with below US average Black population. This association between Black composition and odds of a facility serving as vaccine administration facility was not observed in rural or suburban counties. In rural counties, facilities in counties with above US average Hispanic population had 26% (95% CI 11% to 38%, p = 0.002) lower odds of serving as vaccine administration facility compared to facilities in counties with below US average Hispanic population. This association between Hispanic ethnicity and odds of a facility serving as vaccine administration facility was not observed in metropolitan or suburban counties. Our analyses did not include nontraditional vaccination sites and are based on data as of May 2021, thus they represent the early distribution of COVID-19 vaccines. Our results based on this cross-sectional analysis may not be generalizable to later phases of the COVID-19 vaccine distribution process. CONCLUSIONS: Healthcare facilities in counties with higher Black composition, in rural areas, and in hardest-hit communities were less likely to serve as COVID-19 vaccine administration locations in May 2021. The lower uptake of COVID-19 vaccinations among minority populations and rural areas has been attributed to vaccine hesitancy; however, decreased access to vaccination sites may be an additional overlooked barrier.

Income disparities in driving distance to health care infrastructure in the United States: a geographic information systems analysis.

OBJECTIVE: Inequities in access to health care contribute to persisting disparities in health care outcomes. We constructed a geographic information systems analysis to test the association between income and access to the existing health care infrastructure in a nationally representative sample of US residents. Using income and household size data, we calculated the odds ratio of having a distance > 10 miles in nonmetropolitan counties or > 1 mile in metropolitan counties to the closest facility for low-income residents (i.e., < 200% Federal Poverty Level), compared to non-low-income residents. RESULTS: We identified that in 954 counties (207 metropolitan counties and 747 nonmetropolitan counties) representing over 14% of the US population, low-income residents have poorer access to health care facilities. Our analyses demonstrate the high prevalence of structural disparities in health care access across the entire US, which contribute to the perpetuation of disparities in health care outcomes.