Characterization of COVID-19 Vaccine Hesitancy Among Essential Workforce Members of a Large Safety Net Urban Medical Center.

OBJECTIVES: Vaccine hesitancy among essential workers remains a significant public health challenge. We examined psychological constructs of perceived susceptibility, threat, and self-efficacy and their associations with COVID-19 vaccine hesitancy among a racially and ethnically diverse essential workforce population. METHODS: We performed a cross-sectional survey of essential workers from September-December 2020 at a large Los Angeles safety-net medical center as part of a program offering free COVID-19 serology testing. Program participants completed a standardized survey at the time of phlebotomy. Hierarchical logistic regression was utilized to determine factors independently associated with vaccine hesitancy. RESULTS: Among 1327 persons who had serology testing, 1235 (93%) completed the survey. Of these, 958 (78%) were healthcare workers. Based on expressed intent, 22% were vaccine-hesitant 78% were vaccine acceptors. In our multivariate model, vaccine hesitancy was associated with female gender [aOR = 2.09; 95% CI (1.44-3.05)], African American race [aOR = 4.32; (2.16-8.62)], LatinX ethnicity [aOR = 2.47; 95% CI (1.51-4.05)] and history of not/sometimes receiving influenza vaccination [aOR = 4.39; 95% CI (2.98-6.48)]. Compared to nurses, vaccine hesitancy was lower among physicians [aOR = 0.09; 95% CI (0.04-0.23)], non-nursing/non-physician healthcare workers [aOR = 0.55; 95% CI (0.33-0.92)], and non-healthcare care workers [aOR = 0.53; 95% CI (0.36-0.78)]. CONCLUSIONS: Among a racially/ethnically diverse group of safety net medical center essential workers, COVID-19 vaccine hesitancy was associated with racial/ethnic minority groups, employment type, and prior influenza vaccination hesitancy. Interestingly, we found no association with the Health Belief Model construct measures of perceived susceptibility, threat, and self-efficacy. Psychological constructs not assessed may be drivers of vaccine hesitancy in our population.

Decisions to Choose COVID-19 Vaccination by Health Care Workers in a Southern California Safety Net Medical Center Vary by Sociodemographic Factors.

BACKGROUND: Limited information exists regarding COVID-19 vaccine hesitancy among healthcare workers (HCWs). Our previous survey analyzed the reasons for HCWs' decisions to accept vaccination, suggesting that a "one-size fits all" approach may not suffice to increase vaccine uptake. METHODS: Based on the vaccination acceptance group (acceptor, hesitant, refuser), we examined differences by sociodemographic factors (race/ethnicity, household income, education) from Likert Scale responses to fourteen influences affecting a decision to be vaccinated using the Kruskal-Wallis test and multinomial logistic regression with mutual adjustment for these sociodemographic factors, age, and sex. RESULTS: Non-Hispanic White vaccine acceptors ranked lower confidence in preventing, withstanding, or treating COVID-19, while Non-Hispanic Blacks more highly regarded the motivation of a religious leader, colleague, or family member. Social media was ranked more influential among Non-Hispanic Asians. Acceptors with lower incomes ranked a job requirement influential; conversely, higher income vaccine hesitant HCWs highly rated this reason. More highly educated acceptors ranked being motivated by colleagues, family, and other HCWs higher. Adjustment weakened some but not all the differences between groups. CONCLUSIONS: Sociodemographic factors affect HCWs' decisions to be vaccinated against COVID-19. Our findings may help develop more focused and tailored strategies to improve vaccination acceptance.

Persistence of the invasive bird-parasitic fly Philornis downsi over the host interbreeding period in the Galapagos Islands.

Many parasites of seasonally available hosts must persist through times of the year when hosts are unavailable. In tropical environments, host availability is often linked to rainfall, and adaptations of parasites to dry periods remain understudied. The bird-parasitic fly Philornis downsi has invaded the Galapagos Islands and is causing high mortality of Darwin's finches and other bird species, and the mechanisms by which it was able to invade the islands are of great interest to conservationists. In the dry lowlands, this fly persists over a seven-month cool season when availability of hosts is very limited. We tested the hypothesis that adult flies could survive from one bird-breeding season until the next by using a pterin-based age-grading method to estimate the age of P. downsi captured during and between bird-breeding seasons. This study showed that significantly older flies were present towards the end of the cool season, with ~ 5% of captured females exhibiting estimated ages greater than seven months. However, younger flies also occurred during the cool season suggesting that some fly reproduction occurs when host availability is low. We discuss the possible ecological mechanisms that could allow for such a mixed strategy.

Correlates of COVID-19 Vaccine Acceptance, Hesitancy and Refusal among Employees of a Safety Net California County Health System with an Early and Aggressive Vaccination Program: Results from a Cross-Sectional Survey.

Since health professionals provide frontline care to COVID-19 patients, information on vaccine acceptance among healthcare workers is needed. We developed and implemented an anonymous internet-based cross-sectional survey with direct solicitation among employees of a safety net health system. Items queried demographic and health-related characteristics, experience with and knowledge of COVID-19, and determinants of decisions to vaccinate. COVID-19 vaccine acceptance groups (acceptors, hesitant, refusers) were defined; an adapted version of the WHO vaccine hesitancy scale was included. The survey demonstrated good reliability (Cronbach's alpha = 0.92 for vaccine hesitancy scale; 0.93 for determinants). General linear and logistic regression methods examined factors which were univariately associated with vaccine hesitancy and vaccine acceptance, respectively. Multivariable models were constructed with stepwise model-building procedures. Race/ethnicity, marital status, job classification, immunocompromised status, flu vaccination and childhood vaccination opinions independently predicted hesitancy scale scores. Gender, education, job classification and BMI independently predicted acceptance, hesitancy, and refusal groups. Among hesitant employees, uncertainty was reflected in reports of motivating factors influencing their indecision. Despite a strong employee-support environment and job protection, respondents reported physical and mental health effects. The appreciation of varied reasons for refusing vaccination should lead to culturally sensitive interventions to increase vaccination rates amongst healthcare workers.

Using decision trees to determine participation in bundled payments in sepsis cases.

RATIONALE: The purpose of this research is to determine and develop a valid analytical method that can be easily implemented by providers to evaluate whether they should join the bundled payments for care improvement (BPCI) advanced bundled payment program, and analyze the projected impacts of BPCI advanced payment on their margins. METHODS: We have developed a decision tree model that incorporates the types of sepsis encountered and the resultant typical complications and associated costs. RESULTS: The initial cost of a sepsis episode was $30,386. Since Medicare requires that there is a 3% cost reduction under BPCI, we applied the model with a 3% cost reduction across the board. Since the model considers probabilities of the complications and readmission, there was actually a 3.36% reduction in costs when the 3% reduction was added to the model. We applied 2-way sensitivity analysis to the intensive care unit (ICU) long and short costs. We used the unbundled cost at the high end, and a 10% reduction at the low end. Per patient episode cost varied between $28,117 and $29,658. This is a 5.2% difference between low and high end. Next, we looked at varying the hospital bed (non-ICU) costs. Here the resultant cost varied between $28,708 and $29,099. This is only a 1.34% difference between low and high ends. Finally, we applied a sensitivity analysis varying the attending physician and the intensivist reimbursement fees. The result was a cost that varied between $29,191 and $29,366 which is a difference of only 0.595%. CONCLUSION: This is the precise environment where decision tree analysis modeling is essential. This analysis can guide the hospital in just how to allocate resources in light of the new BPCI advanced payment model.

Care management reduced infant mortality for Medicaid managed care enrollees in Ohio.

OBJECTIVES: In 2012, the Ohio Department of Medicaid introduced requirements for enhanced care management to be delivered by Medicaid managed care organizations (MCOs). This study evaluated the impact of care management on reducing infant mortality in the largest Medicaid MCO in Ohio. STUDY DESIGN: Observational study using infant and maternal individual-level enrollment and claims data (2009-2015), which used a quasi-experimental research design built on a sibling-comparison approach that controls for within-family confounders. METHODS: Using individual-level data from the largest MCO in Ohio, we estimated linear probability models to examine the effect of infant engagement in care management on infant mortality. We used a within-family fixed-effects research design to determine if care management reduced infant mortality and estimated models separately for healthy infants and nonhealthy infants. RESULTS: Infant engagement in care management was associated with a reduction of 7.4 percentage points (95% CI, -10.7 to -4.1; P <.001) in infant mortality among the most vulnerable infants, those identified as not well at birth. This effect was larger in recent years and likely driven by new statewide enhanced care management requirements. Infant mortality was unchanged for healthy infants engaged in care management (coefficient = 0.03; 95% CI, -0.01 to 0.08). CONCLUSIONS: This study provides evidence that care management can be effective in reducing infant mortality among Medicaid MCO enrollees, a population at high risk of mortality. Few infants were engaged in care management, suggesting to policy makers that there is room for many additional infants to benefit from this intervention.

Medical Practice Consolidation and Physician Shared Patient Network Size, Strength, and Stability.

BACKGROUND: Properties of social networks and shared patient networks of physicians are associated with important outcomes, including costs, quality, information exchange, and organizational effectiveness. OBJECTIVES: To determine whether practice consolidation affects size, strength, and stability of US practice-based physician shared patient networks. RESEARCH DESIGN: We used a dynamic difference-in-differences (event study) design to determine how 2 types of vertical consolidation (hospital and health system practice acquisition) and 2 types of horizontal consolidation (medical group membership and practice-practice mergers) affect individual shared patient network characteristics, controlling for physician fixed effects and geographic market (metropolitan statistical area). SUBJECTS: Practice-based US physicians whose practices consolidated 2009-2014 are identified via health system, hospital, and medical group affiliation information and appearance/disappearance of listed practice affiliations in the SK&A Physician Database. MEASURES: Outcomes measured were network size (number of individual physicians with whom a physician shares patients within 30 d), strength (average number of shared patients within those relationships), and stability (percent of shared patient relationships that persist in the current and prior year), all generated from Medicare Shared Patient Patterns (30-d) data. RESULTS: Shared patient network stability increases significantly after acquisition of practices by horizontal practice-practice mergers [ßt=1=0.041 (P<0.001), ßt=2=0.047 (P<0.001), ßt=3=0.041 (P<0.001), ßt=4=0.031 (P<0.05), where t is the number of years after the consolidation event]. These effects were robust to sensitivity analyses. Shared patient network size and strength are not observably associated with practice consolidation events. CONCLUSIONS: Practice consolidation can increase the stability of physician networks, which may have positive implications for organizational effectiveness.

Modeling Dr. Dynasaur 2.0 Coverage and Finance Proposals: Effects of the Expansion of Vermont's Dr. Dynasaur Program to All Individuals Through Age 25.

The authors assessed an expansion of Vermont's Dr. Dynasaur program that would cover all residents age 25 and younger. The current Dr. Dynasaur program combines Vermont's Medicaid program and Child Health Insurance Program for children ages 0 through 18 to provide a seamless insurance program for those with family incomes below 317 percent of the federal poverty level. The authors used RAND's COMPARE-VT microsimulation model with Vermont-specific demographic, economic, and actuarial data to estimate the effects on health insurance coverage, costs, and premiums. They also identified the new revenues required to fund the program expansion and explored three alternative financing strategies to raise those funds: (1) an increase in the Vermont income tax, (2) a Vermont payroll tax, and (3) a Vermont business enterprise tax. The authors found that enrollment would increase by more than 260 percent under the 100-percent enrollment scenario and by nearly 200 percent under the 70-percent enrollment scenario by 2019. Not surprisingly, the children and young adults who move off employer-sponsored insurance (ESI) and into Dr. Dynasaur 2.0 have considerably lower expected health care costs than those who remain on ESI, increasing the per-person premiums by nearly $1,000 for those remaining enrolled in ESI. Annual health care expenditures per person for children and young adults in 2019 are estimated at $4,325 with Medicare prices. The combination of increased reimbursement rates, large increases in enrollment, and relatively low Dr. Dynasaur premiums (no more than $720 per year) will require significant new tax revenues to meet program obligations.

Interactions between the Avian Parasite, Philornis downsi (Diptera: Muscidae) and the Galapagos Flycatcher, Myiarchus magnirostris Gould (Passeriformes: Tyrannidae).

An incidental observation of the fly Philornis downsi parasitizing a Galapagos Flycatcher (Myiarchus magnirostris) nest has revealed new insights into the searching behavior and biology of this invasive fly parasite and its interactions with endemic landbirds in the Galapagos Islands. Observations suggest that P. downsi relies on olfactory cues, or olfactory cues combined with the activity of adult birds, to locate nests and that flies continue to visit nests when chicks are >3 d old. At least 200 eggs were laid by P. downsi in different parts of the nest and >40 early-instar larvae were found inside the head of one chick, with additional larvae found in the base of the nest. Parasitism was the likely cause of mortality of both chicks found in or near the nest. This description of P. downsi parasitizing chicks of M. magnirostris highlights the vulnerability of this endemic bird species to this invasive fly.

Cost outcomes of supplemental nurse staffing in a large medical center.

Use of agency-employed supplemental nurses on nursing personnel costs was examined in 19 adult patient care units in a large academic medical center. Results indicated that the modest use of supplemental nurses was cost-efficient with regard to overall nursing personnel costs, but heavy reliance on supplemental nurses to meet staffing needs was not cost-efficient. In addition, there was no statistical difference in hourly personnel cost between the use of supplemental nurses and overtime worked by permanent nurses.

Assessing variation in utilization for acute myocardial infarction in New York State.

BACKGROUND: Wide variations exist in healthcare expenditures, though most prior studies have assessed aggregate utilization. We sought to examine healthcare utilization variation in New York State by assessing hospitals in peer groups of similar capabilities. METHODS: Using charge data in New York State from the 2008 Statewide Planning and Research Cooperative System (SPARCS) and cost-to-charge ratios at the cost-center level drawn from Institutional Cost Reports, we calculated total, routine, and ancillary costs for patients discharged with an acute myocardial infarction (AMI) diagnosis in 2008. We assessed the correlation of these cost data to Hospital Referral Region (HRR) Medicare reimbursement data from the 2007 Dartmouth Atlas of Health Care. After describing hospital level cost variability, we examined characteristics associated with higher costs within peer groups of similar cardiac care capabilities. RESULTS: We found greater costs in hospitals providing the highest level of cardiovascular services, with cardiac surgery capable hospitals and non-invasive hospitals having total costs of $21,166 and $9268 per AMI discharge, and ancillary costs of $12,006 and $4167 per AMI discharge, respectively. Substantial variability in utilization existed in all levels of hospitals and across individual departmental cost centers. The two factors most frequently associated with higher total and ancillary costs across peer groups were patient case mix index and major or minor teaching status. CONCLUSIONS: Significant variation in cost per AMI discharge exists even within peer groups of hospitals with similar cardiac care capabilities. IMPLICATIONS: These findings support measurement and analysis at the hospital level to further understand the reasons for variation in utilization.

Supplemental nurses are just as educated, slightly less experienced, and more diverse compared to permanent nurses.

In the past three decades, the shortage of nurses willing to work in hospitals has been a persistent challenge in the United States. Hiring supplemental registered nurses-nurses on short-term contracts obtained through an external staffing agency-has been common to fill gaps in nurse staffing. But there has been insufficient evidence about supplemental nurse workforce trends to inform workforce policy. To address this concern, we compared qualifications and characteristics of supplemental nurses with those of permanent nurses during 1984-2008. The two groups shared similar education levels in terms of possessing a baccalaureate or higher degree. Supplemental nurses were somewhat less experienced than permanent nurses, averaging fifteen years of experience in 2008 compared to eighteen years for permanent nurses. The supplemental nurse workforce was more diverse racially and ethnically and more likely to be male than the permanent nurse workforce. These data show that employing supplemental nurses could help meet the challenges of an aging nursing workforce, the projected future shortage of nurses, and an increasingly diverse US population.

Quality outcomes of hospital supplemental nurse staffing.

Use of supplemental RNs (SRNs) is common practice among US hospitals to fill gaps in nurse staffing. The objective of this study was to examine the relationship between use of SRNs and patient outcomes. Multilevel modeling was performed to analyze hospital administrative data from 19 hospital units in a large tertiary medical center for the years 2003 to 2006. Patient outcomes included in-hospital mortality, medication errors, falls, pressure ulcers, and patient satisfaction with nurses. Use of SRNs ranged from 0% to 30.4% of total RN hours per unit quarter. Among 188 of the 304 unit quarters in which SRNs were used, the average SRN use was 9.8% in non-ICUs and 6.4% in ICUs. All observed effects of SRN use on patient outcomes were nonsignificant. Use of SRNs was substantial and varied widely by unit. No evidence was found that links SRN use to either adverse or positive patient outcomes.

Advances, challenges and a developing synthesis of ecological community assembly theory.

Ecological approaches to community assembly have emphasized the interplay between neutral processes, niche-based environmental filtering and niche-based species sorting in an interactive milieu. Recently, progress has been made in terms of aligning our vocabulary with conceptual advances, assessing how trait-based community functional parameters differ from neutral expectation and assessing how traits vary along environmental gradients. Experiments have confirmed the influence of these processes on assembly and have addressed the role of dispersal in shaping local assemblages. Community phylogenetics has forged common ground between ecologists and biogeographers, but it is not a proxy for trait-based approaches. Community assembly theory is in need of a comparative synthesis that addresses how the relative importance of niche and neutral processes varies among taxa, along environmental gradients, and across scales. Towards that goal, we suggest a set of traits that probably confer increasing community neutrality and regionality and review the influences of stress, disturbance and scale on the importance of niche assembly. We advocate increasing the complexity of experiments in order to assess the relative importance of multiple processes. As an example, we provide evidence that dispersal, niche processes and trait interdependencies have about equal influence on trait-based assembly in an experimental grassland.

Psychological attributes of preoperative total joint replacement patients: implications for optimal physical outcome.

In this study, 107 primary total joint replacement (TJR) patients were assessed preoperatively using the SF-36 (Mental Component Score [MCS] and Physical Component Score [PCS]), Beck Depression Inventory (BDI), Spielberger Trait Anxiety Inventory, Interpersonal Support Evaluation List, and the Coping Strategies Questionnaire. Patients with preoperative MCS < 50 had significantly higher trait anxiety (P <.001), higher BDI scores (P <.001), and lower appraisal (P <.018) and belonging (P <.006) support when compared with patients with preoperative MCS > or = 50. Low MCS patients used more catastrophizing coping techniques (P <.001) and reported poorer pain control (P <.04). A multivariate prediction model found that adding preoperative MCS to baseline demographic and physical function (PCS) measures significantly improved the prediction of 6-month change in PCS. Further research should evaluate the role of multimodality emotional support in assuring optimal physical return after TJR.

Children's Preventive Care Use Under Two Mature Medicaid Managed Care Plans in California.

We investigated the extent to which children continuously enrolled in two mature county-organized Medicaid managed care plans for 6, 12, and 24 months received recommended well-child visits and immunizations. We also investigated whether any improvements in compliance were evident during the period 1989-92. Compliance was low for well-child visits and immunizations at the recommended ages regardless of eligibility group. Although slight improvements in immunizations were made over time, little progress was made in compliance with well-child visits. Continued vigilance is required to achieve the government's goal of 90 percent immunization compliance among 2-year-olds.