Emergency department claims among Medicare beneficiaries with HIV, STDs, viral hepatitis or tuberculosis before and during the COVID-19 pandemic.

BACKGROUND: Changes in emergency department (ED) usage among US Medicare beneficiaries (MB) with fee-for-service claims for HIV, viral hepatitis, sexually transmitted diseases (STDs) or tuberculosis (TB) (HHST) services have not been assessed since the COVID-19 pandemic. METHODS: During 2006-20, we assessed the annual number of MB with each HHST per 1000 persons with ED claims for all conditions, and changes in demographic and geographic distribution of ED claimants for each HHST condition. RESULTS: Of all persons who attended an ED for any condition, 10.5 million (27.5%) were MB with ≥1 ED claim in 2006; that number (percentage) increased to 11.0 million (26.7%) in 2019 and decreased to 9.2 million (22.7%) in 2020; < 5 MB per 1000 ED population had HHST ED claims in 2020. The percentage increase in ED claims was higher for MB with STDs than for those with other HHST conditions, including a 10% decrease for MB with TB in 2020. CONCLUSIONS: Trends in ED usage for HHST conditions were associated with changes in demographic and geographic distribution among MB during 2006-20. Updated ED reimbursement policies and primary care practices among MB might improve prevention, diagnosis and treatment of HHST conditions in the future.

Provisional COVID-19 Age-Adjusted Death Rates, by Race and Ethnicity - United States, 2020-2021.

Disparities in COVID-19 death rates by race and ethnicity have been reported in the United States (1,2). In response to these disparities, preventive, medical care, and social service assistance programs were implemented to lessen disparities in COVID-19 outcomes, including grants to support state, tribal, local, and territorial health department responses (3). The potential impact of such efforts on annual changes in racial and ethnic disparities in mortality rates that identify COVID-19 as the underlying cause of death has not been previously reported. This analysis used U.S. provisional mortality data from death certificates collected by CDC's National Vital Statistics System (NVSS) to estimate changes in COVID-19-related age-adjusted death rates (AADRs) by race and ethnicity during 2020-2021. Compared with non-Hispanic multiracial persons (the group with the lowest death rate), significant decreases in AADR ratios occurred during 2020-2021 among non-Hispanic American Indian or Alaska Native (AI/AN) persons (34.0%), non-Hispanic Asian (Asian) persons (37.6%), non-Hispanic Black or African American (Black) persons (40.2%), Hispanic persons (37.1%), and non-Hispanic White (White) persons (14%); a non-statistically significant 7.2% increase in AADR ratio occurred among non-Hispanic Native Hawaiian or other Pacific Islander (NH/OPI) persons. Despite reductions in AADR disparities from 2020 to 2021, large disparities in AADR by race and ethnicity remained in 2021. Providing effective preventive interventions, including vaccination and clinical care, to all communities in proportion to their need for these interventions is necessary to reduce racial and ethnic disparities in COVID-19 deaths.

Racial and ethnic differences in COVID-19 hospitalizations by metropolitan status among Medicare beneficiaries, 1 January-31 December 2020.

BACKGROUND: Risk for COVID-19 hospitalizations increases with increasing age and presence of underlying medical conditions. However, the burden has not been well-assessed in metropolitan and nonmetropolitan areas by race/ethnicity among Medicare population with chronic conditions. METHODS: We used the 2020 Medicare data to estimate COVID-19 hospitalization rates by race/ethnicity among Medicare beneficiaries for COVID-19 by metropolitan status and to assess the association of hospitalizations from COVID-19 with each of selected 29 chronic conditions for patients by metropolitan status and by race/ethnicity. RESULTS: The COVID-19 hospitalization rate was higher among beneficiaries residing in nonmetropolitan counties than those residing in metropolitan counties in 2020. Approximately 1 in 2 AI/AN, 1 in 3 NHB, Hispanic and A/PI, and 1 in 4 NHW beneficiaries with COVID-19 residing in nonmetropolitan counties were hospitalized. Beneficiaries with COVID-19 and chronic conditions were more likely to be hospitalized compared with those without chronic conditions. CONCLUSIONS: Hospitalization rates among beneficiaries with COVID-19 and chronic conditions were not distributed equally by race/ethnicity and by metropolitan status. Researchers, policymakers and practitioners can use these findings to explore more effective ways of reducing racial/ethnic and geographic disparities among minorities disproportionately affected by COVID-19 and are at highest risk of hospitalization.

Telehealth Availability and Usage Among Medicare Beneficiaries During the COVID-19 Pandemic, October and November 2020.

CONTEXT: During the COVID-19 pandemic, demand for telehealth services increased to reduce disease exposure for patients and providers and to meet preexisting demand for physician services in health resource shortage areas. OBJECTIVE: To estimate self-reported telehealth availability, equipment for accessing telehealth, and telehealth usage among Medicare beneficiaries during the COVID-19 pandemic. DESIGN: We used data from the 2020 Medicare Current Beneficiary Survey (MCBS) COVID-19 Fall Supplement Public Use File to estimate the weighted percentages of beneficiaries who had (a) access to telehealth before or during COVID-19; (b) equipment for accessing telehealth; and (c) telehealth visits during COVID-19. We used logistic regression to examine sociodemographic factors associated with telehealth usage. PARTICIPANTS: Beneficiaries who participated in the MCBS COVID-19 Fall Supplements. RESULTS: During October and November 2020, telehealth appointments offered by providers were available to 63.8% (95% confidence interval [CI], 61.8-65.9) of Medicare beneficiaries who had accessed medical care by telephone or video. Among those, only 18.0% (95% CI, 16.1-19.9) had been offered telehealth before the pandemic. The majority of beneficiaries (92.2%; 95% CI, 91.2-93.1) had 1 or more types of equipment available for accessing telehealth, but only 44.9% (95% CI, 43.0-46.9) had had a telehealth visit since July 1, 2020. Older adults, minorities, those with a lower income, and non-English speakers had less availability of telehealth equipment. Patient characteristics were significantly (P < .05) associated with telehealth use, including age, sex, race/ethnicity, and equipment availability. CONCLUSION: Telehealth availability for Medicare beneficiaries increased substantially during the COVID-19 pandemic. Even with the improvement in telehealth offerings and use hastened by the pandemic, gaps in access and use still exist. Effectiveness and implementation research can find ways to close gaps in telehealth services between vulnerable and underrepresented populations and counterparts.

Measuring the Magnitude of Health Inequality Between 2 Population Subgroup Proportions.

In this paper, we evaluate 11 measures of inequality, d(p1, p2), between 2 proportions p1 and p2, some of which are new to the health disparities literature. These measures are selected because they are continuous, nonnegative, equal to 0 if and only if |p1 - p2| = 0, and maximal when |p1 - p2| = 1. They are also symmetrical [d(p1, p2) = d(p2, p1)] and complement-invariant [d(p1, p2) = d(1 - p2, 1 - p1)]. To study intermeasure agreement, 5 of the 11 measures, including the absolute difference, are retained, because they remain finite and are maximal if and only if |p1 - p2| = 1. Even when the 2 proportions are assumed to be drawn at random from a shared distribution-interpreted as the absence of an avoidable difference-the expected value of d(p1, p2) depends on the shape of the distribution (and the choice of d) and can be quite large. To allow for direct comparisons among measures, we propose a standard measurement unit akin to a z score. For skewed underlying beta distributions, 4 of the 5 retained measures, once standardized, offer more conservative assessments of the magnitude of inequality than the absolute difference. We conclude that, even for measures that share the highlighted mathematical properties, magnitude comparisons are most usefully assessed relative to an elicited or estimated underlying distribution for the 2 proportions.

County-Level Socioeconomic Disparities in Use of Medical Services for Management of Infections by Medicare Beneficiaries With Diabetes-United States, 2012.

OBJECTIVE: To assess county-level socioeconomic disparities in medical service usage for infections among Medicare beneficiaries with diabetes (MBWDs) who had fee-for-service health insurance claims during 2012. DESIGN: We used Medicare claims data to calculate percentage of MBWDs with infections. SETTING: Medicare beneficiaries. PARTICIPANTS: We estimated the percentage of MBWDs who used medical services for each of 3 groups of infections by sex and quintiles of the prevalence of social factors in the person's county of residence: anatomic site-specific infections; pathogen-specific infections; and HHST infections (human immunodeficiency virus/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted diseases, and tuberculosis). MAIN OUTCOME MEASURES: Using quintiles of county-specific socioeconomic determinants, we calculated absolute and relative disparities in each group of infections for male and female MBWDs. We also used regression-based summary measures to estimate the overall average absolute and relative disparities for each infection group. RESULTS: Of the 4.5 million male MBWDs, 15.8%, 25.3%, and 2.7% had 1 or more site-specific, pathogen-specific, and HHST infections, respectively. Results were similar for females (n = 5.2 million). The percentage of MBWDs with 1 or more infections in each group increased as social disadvantage in the MBWDs' county of residence increased. Absolute and relative county-level socioeconomic disparities in receipt of medical services for 1 or more infections (site- or pathogen-specific) were 12.9 or less percentage points and 65.5% or less, respectively. For HHST infections, percentage of MBWDs having 1 or more HHST infections for persons residing in the highest quintile (Q5) was 3- to 4-fold higher (P < .001) than persons residing in the lowest quintile (Q1). CONCLUSIONS: Infection burden among MBWDs is generally associated with county-level contextual socioeconomic disadvantage, and the extent of health disparities varies by infection category, socioeconomic factor, and quintiles of socioeconomic disadvantage. The findings imply ongoing need for efforts to identify effective interventions for reducing county-level social disparities in infections among patients with diabetes.

The contribution of family history to the burden of diagnosed diabetes, undiagnosed diabetes, and prediabetes in the United States: analysis of the National Health and Nutrition Examination Survey, 2009-2014.

PURPOSE: Given the importance of family history in the early detection and prevention of type 2 diabetes, we quantified the public health impact of reported family health history on diagnosed diabetes (DD), undiagnosed diabetes (UD), and prediabetes (PD) in the United States. METHODS: We used population data from the National Health and Nutrition Examination Survey 2009-2014 to measure the association of reported family history of diabetes with DD, UD, and PD. RESULTS: Using polytomous logistic regression and multivariable adjustment, family history prevalence ratios were 4.27 (confidence interval (CI): 3.57, 5.12) for DD, 2.03 (CI: 1.56, 2.63) for UD, and 1.26 (CI: 1.09, 1.44) for PD. In the United States, we estimate that 10.1 million DD cases, 1.4 million UD cases, and 3.9 million PD cases can be attributed to having a family history of diabetes. CONCLUSION: These findings confirm that family history of diabetes has a major public health impact on diabetes in the United States. In spite of the recent interest and focus on genomics and precision medicine, family health history continues to be an integral component of public health campaigns to identify persons at high risk for developing type 2 diabetes and early detection of diabetes to prevent or delay complications.

Unequal Declines in Absolute and Relative Disparities in HIV Diagnoses Among Black Women, United States, 2008 to 2016.

OBJECTIVES: To assess changes in disparities of HIV diagnosis rates among Black women aged 18 years or older living in the United States. METHODS: We calculated estimated annual percent changes (EAPCs) in annual diagnosis rates, rate differences (absolute disparity), and rate ratios (relative disparity) for groups (total, US-born, and non-US-born) of Black women (referent was all White women) with diagnosed HIV infection, using data reported to the National HIV Surveillance System. RESULTS: Of 39 333 Black women who received an HIV diagnosis during 2008 to 2016, 21.4% were non-US-born. HIV diagnosis rates declined among all Black women, with the smallest decline among non-US-born groups (EAPC = -3.1; P ≤ .001). Absolute disparities declined for both US-born and non-US-born Black women; however, the relative disparity declined for Black women overall and US-born Black women, whereas it increased for non-US-born (including Caribbean- and Africa-born) Black women. CONCLUSIONS: Differences in disparities in HIV diagnoses exist between US-, and non-US-born (specifically Caribbean- and Africa-born) Black women. Accounting for the heterogeneity of the Black women's population is crucial in measuring and monitoring progress toward eliminating health disparities among Black women.

Functional Characteristics of Health Coalitions in Local Public Health Systems: Exploring the Function of County Health Councils in Tennessee.

CONTEXT: Partnerships are emerging as critically important vehicles for addressing health in local communities. Coalitions involving local health departments can be viewed as the embodiment of a local public health system. Although it is known that these networks are heavily involved in assessment and community planning activities, limited studies have evaluated whether health coalitions are functioning at an optimal capacity. OBJECTIVE: This study assesses the extent to which health coalitions met or exceeded expectations for building functional capacity within their respective networks. DESIGN: An evaluative framework was developed focusing on 8 functional characteristics of coalitions previously identified by Erwin and Mills. Twenty-nine indicators were identified that served as "proxy" measures of functional capacity within health coalitions. SETTING AND PARTICIPANTS: Ninety-three County Health Councils (CoHCs) in Tennessee. MAIN OUTCOME MEASURE(S): Diverse member representation; formal rules, roles, and procedures; open, frequent interpersonal communication; task-focused climate; council leadership; resources; active member participation; and external linkages were assessed to determine the level of functionality of CoHCs. Scores across all CoHCs were analyzed using descriptive statistics such as frequency distributions, measures of central tendency, and measures of variability. Data were analyzed using SAS 9.3. RESULTS: Of 68 CoHCs (73% response rate), the total mean score for the level of functional characteristics was 30.5 (median = 30.5; SD = 6.3; range, 18-44). Of the 8 functional characteristics, CoHCs met or exceeded all indicators associated with council leadership, tasked-focused climate, and external linkages. Lowest scores were for having a written communications plan, written priorities or goals, and opportunities for training. CONCLUSION: This study advances the research on health coalitions by establishing a process for quantifying the functionality of health coalitions. Future studies will be conducted to examine the association between health coalition functional capacity, local health departments' community health assessment and planning efforts, and changes in community health status.

Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the Advancement of Health Equity.

Reduction of health disparities and advancement of health equity in the United States require high-quality data indicative of where the nation stands vis-à-vis health equity, as well as proper analytic tools to facilitate accurate interpretation of these data. This article opens with an overview of health equity and social determinants of health. It then proposes a set of recommended practices in measurement of health disparities, health inequities, and social determinants of health at the national level to support the advancement of health equity, highlighting that (1) differences in health and its determinants that are associated with social position are important to assess; (2) social and structural determinants of health should be assessed and multiple levels of measurement should be considered; (3) the rationale for methodological choices made and measures chosen should be made explicit; (4) groups to be compared should be simultaneously classified by multiple social statuses; and (5) stakeholders and their communication needs can often be considered in the selection of analytic methods. Although much is understood about the role of social determinants of health in shaping the health of populations, researchers should continue to advance understanding of the pathways through which they operate on particular health outcomes. There is still much to learn and implement about how to measure health disparities, health inequities, and social determinants of health at the national level, and the challenges of health equity persist. We anticipate that the present discussion will contribute to the laying of a foundation for standard practice in the monitoring of national progress toward achievement of health equity.

Trends in Disparity by Sex and Race/Ethnicity for the Leading Causes of Death in the United States-1999-2010.

CONTEXT: Temporal trends in disparities in the leading causes of death within and between US demographic subgroups indicate the need for and success of interventions to prevent premature death in vulnerable populations. Studies that report recent trends are limited and outdated. OBJECTIVE: To describe temporal trends in disparities in death rates by sex and race/ethnicity for the 10 leading causes of death in the United States during 1999-2010. DESIGN: We used underlying cause of death data and population estimates from the National Vital Statistics System to calculate age-adjusted death rates for the 10 leading causes of death during 1999-2010. We measured absolute and relative disparities by sex and race/ethnicity for each cause and year of death; we used weighted linear regression to test for significance of trends over time. RESULTS: Of the 10 leading causes of death, age-adjusted death rates by sex and race/ethnicity declined during 1999-2010 for 6 causes and increased for 4 causes. But sex and racial/ethnic disparities between groups persisted for each year and cause of death. In the US population, the decreasing trend during 1999-2010 was greatest for cerebrovascular disease (-36.5%) and the increasing trend was greatest for Alzheimer disease (52.4%). For each sex and year, the disparity in death rates between Asian/Pacific Islanders (API) and other groups varied significantly by cause of death. In 2010, the API-non-Hispanic black disparity was largest for heart disease, malignant neoplasms, cerebrovascular diseases, and nephritis; the API-American Indian/Alaska Native disparity was largest for unintentional injury, diabetes mellitus, influenza and pneumonia, and suicide; and the API-non-Hispanic white disparity was largest for chronic lower respiratory diseases and Alzheimer disease. CONCLUSIONS: Public health practitioners can use these findings to improve policies and practices and to evaluate progress in eliminating disparities and their social determinants in vulnerable populations.

Vital signs: leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States - 2009-2013.

BACKGROUND: Hispanics and Latinos (Hispanics) are estimated to represent 17.7% of the U.S. population. Published national health estimates stratified by Hispanic origin and nativity are lacking. METHODS: Four national data sets were analyzed to compare Hispanics overall, non-Hispanic whites (whites), and Hispanic country/region of origin subgroups (Hispanic origin subgroups) for leading causes of death, prevalence of diseases and associated risk factors, and use of health services. Analyses were generally restricted to ages 18-64 years and were further stratified when possible by sex and nativity. RESULTS: Hispanics were on average nearly 15 years younger than whites; they were more likely to live below the poverty line and not to have completed high school. Hispanics showed a 24% lower all-cause death rate and lower death rates for nine of the 15 leading causes of death, but higher death rates from diabetes (51% higher), chronic liver disease and cirrhosis (48%), essential hypertension and hypertensive renal disease (8%), and homicide (96%) and higher prevalence of diabetes (133%) and obesity (23%) compared with whites. In all, 41.5% of Hispanics lacked health insurance (15.1% of whites), and 15.5% of Hispanics reported delay or nonreceipt of needed medical care because of cost concerns (13.6% of whites). Among Hispanics, self-reported smoking prevalences varied by Hispanic origin and by sex. U.S.-born Hispanics had higher prevalences of obesity, hypertension, smoking, heart disease, and cancer than foreign-born Hispanics: 30% higher, 40%, 72%, 89%, and 93%, respectively. CONCLUSION: Hispanics had better health outcomes than whites for most analyzed health factors, despite facing worse socioeconomic barriers, but they had much higher death rates from diabetes, chronic liver disease/cirrhosis, and homicide, and a higher prevalence of obesity. There were substantial differences among Hispanics by origin, nativity, and sex. IMPLICATIONS FOR PUBLIC HEALTH: Differences by origin, nativity, and sex are important considerations when targeting health programs to specific audiences. Increasing the proportions of Hispanics with health insurance and a medical home (patientcentered, team-based, comprehensive, coordinated health care with enhanced access) is critical. A feasible and systematic data collection strategy is needed to reflect health diversity among Hispanic origin subgroups, including by nativity.

Differences in healthy life expectancy for the US population by sex, race/ethnicity and geographic region: 2008.

BACKGROUND: Healthy life expectancy (HLE) varies among demographic segments of the US population and by geography. To quantify that variation, we estimated the national and regional HLE for the US population by sex, race/ethnicity and geographic region in 2008. METHODS: National HLEs were calculated using the published 2008 life table and the self-reported health status data from the National Health Interview Survey (NHIS). Regional HLEs were calculated using the combined 2007-09 mortality, population and NHIS health status data. RESULTS: In 2008, HLE in the USA varied significantly by sex, race/ethnicity and geographical regions. At 25 years of age, HLE for females was 47.3 years and ∼2.9 years greater than that for males at 44.4 years. HLE for non-Hispanic white adults was 2.6 years greater than that for Hispanic adults and 7.8 years greater than that for non-Hispanic black adults. By region, the Northeast had the longest HLE and the South had the shortest. CONCLUSIONS: The HLE estimates in this report can be used to monitor trends in the health of populations, compare estimates across populations and identify health inequalities that require attention.

Classification tree analysis of race-specific subgroups at risk for a central venous catheter-related bloodstream infection.

BACKGROUND: Studies of racial disparities in patient safety events often do not use race-specific risk adjustment and do not account for reciprocal covariate interactions. These limitations were addressed by using classification tree analysis separately for black patients and white patients to identify characteristics that segment patients who have increased risks for a venous catheter-related bloodstream infection. METHODS: A retrospective, cross-sectional analysis of 5,236,045 discharges from 103 Florida acute hospitals in 2005-2009 was conducted. Hospitals were rank ordered on the basis of the black/white Patient Safety Indicator (PSI) 7 rate ratio as follows: Group 1 (white rate higher), Group 2, (equivalent rates), Group 3, (black rate higher), and Group 4, (black rate highest). Predictor variables included 26 comorbidities (Elixhauser Comorbidity Index) and demographic characteristics. Four separate classification tree analyses were completed for each race/hospital group. RESULTS: Individual characteristics and groups of characteristics associated with increased PSI 7 risk differed for black and white patients. The average age for both races was different across the hospital groups (p < .01). Weight loss was the strongest single delineator and common to both races. The black subgroups with the highest PSI 7 risk were Medicare beneficiaries who were either < or = 25.5 years without hypertension or < or = 39.5 years without hypertension but with an emergency or trauma admission. The white subgroup with the highest PSI 7 risk consisted of patients < or = 45.5 years who had congestive heart failure but did not have either hypertension or weight loss. DISCUSSION: Identifying subgroups of patients at risk for a rare safety event such as PSI 7 should aid effective clinical decisions and efficient use of resources and help to guide patient safety interventions.

Health Care Use among Medicare Beneficiaries with HIV and Depression during the COVID-19 Pandemic-United States, 2020.

Access and use of health care services are essential to health and well-being for people with HIV and HIV-related comorbidities. Health care use during the COVID-19 pandemic among Medicare beneficiaries (MBs) with concurrent HIV and depression has not been investigated. We used 2020 Medicare data to assess the percentage of MBs with claims for HIV and depression who also received hospitalization, outpatient diagnostic services, drug treatment, and outpatient procedures. We assessed person-level association between service receipt and HIV and depression, adjusting for known risk factors. MBs with claims for HIV and depression were more likely than those with neither claim to have claims for short-stay hospitalization, long-stay hospitalization, outpatient diagnostic services, prescription drugs, or outpatient procedures, supplies, and products. Non-White beneficiaries were more likely than White beneficiaries to be hospitalized but were less likely to receive drug treatment, outpatient diagnostic services, or outpatient procedures, supplies, and products during the pandemic. Significant disparities in health care use by race/ethnicity existed among MBs. Policymakers and practitioners can use these findings to implement public health policies and programs that reduce disparities in health care access and optimize use among vulnerable populations during a public health emergency.

Association Between a First-Degree Family History and Self-Reported Personal History of Obesity, Diabetes, and Heart and Blood Conditions: Results From the All of Us Research Program.

Background Family history reflects the complex interplay of genetic susceptibility and shared environmental exposures and is an important risk factor for obesity, diabetes, and heart and blood conditions (ODHB). However, the overlap in family history associations between various ODHBs has not been quantified. Methods and Results We assessed the association between a self-reported family history of ODHBs and their risk in the adult population (age ≥20 years) of the AoU (All of Us) Research Program, a longitudinal cohort study of diverse participants across the United States. We conducted a family history-wide association study to systematically assess the association of a first-degree family history of 15 ODHBs in AoU. We performed stratified analyses based on racial and ethnic categories, education, household income and gender minority status, and quantified associations by type of affected relatives. Of 125 430 participants, 76.8% reported a first-degree family history of any ODHB, most commonly hypertension (n=64 982, 51.8%), high cholesterol (49 753, 39.7%), and heart attack (29 618, 23.6%). We use the FamWAS method to estimate 225 familial associations among 15 ODHBs. The results include overlapping associations between family history of different types of cardiometabolic conditions (such as type 2 diabetes and coronary artery disease), and their risk factors (obesity, hypertension), where adults with a family history of 1 ODHB exhibited 1.1 to 5.6 times (1.5, on average) the odds of having a different ODHB. Conclusions Our findings inform the utility of family history data as a risk assessment and screening tool for the prevention of ODHBs and to provide additional insights into shared risk factors and pathogenic mechanisms.

Hospitalization Associated With Comorbid Psychiatric and Substance Use Disorders Among Adults With COVID-19 Treated in US Emergency Departments From April 2020 to August 2021.

Importance: During the COVID-19 pandemic, US emergency department (ED) visits for psychiatric disorders (PDs) and drug overdoses increased. Psychiatric disorders and substance use disorders (SUDs) independently increased the risk of COVID-19 hospitalization, yet their effect together is unknown. Objective: To assess how comorbid PD and SUD are associated with the probability of hospitalization among ED patients with COVID-19. Design, Setting, and Participants: This retrospective cross-sectional study analyzed discharge data for adults (age ≥18 years) with a COVID-19 diagnosis treated in 970 EDs and inpatient hospitals in the United States from April 2020 to August 2021. Exposures: Any past diagnosis of (1) SUD from opioids, stimulants, alcohol, cannabis, cocaine, sedatives, or other substances and/or (2) PD, including attention-deficit/hyperactivity disorder (ADHD), anxiety, bipolar disorder, major depression, other mood disorder, posttraumatic stress disorder (PTSD), or schizophrenia. Main Outcomes and Measures: The main outcome was any hospitalization. Differences in probability of hospitalization were calculated to assess its association with both PD and SUD compared with PD alone, SUD alone, or neither condition. Results: Of 1 274 219 ED patients with COVID-19 (mean [SD] age, 54.6 [19.1] years; 667 638 women [52.4%]), 18.6% had a PD (mean age, 59.0 years; 37.7% men), 4.6% had a SUD (mean age, 50.1 years; 61.7% men), and 2.3% had both (mean age, 50.4 years; 53.1% men). The most common PDs were anxiety (12.9%), major depression (9.8%), poly (≥2) PDs (6.4%), and schizophrenia (1.4%). The most common SUDs involved alcohol (2.1%), cannabis (1.3%), opioids (1.0%), and poly (≥2) SUDs (0.9%). Prevalence of SUD among patients with PTSD, schizophrenia, other mood disorder, or ADHD each exceeded 21%. Based on significant specific PD-SUD pairs (Q < .05), probability of hospitalization of those with both PD and SUD was higher than those with (1) neither condition by a weighted mean of 20 percentage points (range, 6 to 36; IQR, 16 to 25); (2) PD alone by 12 percentage points (range, -4 to 31; IQR, 8 to 16); and (3) SUD alone by 4 percentage points (range, -7 to 15; IQR, -2 to 7). Associations varied by types of PD and SUD. Substance use disorder was a stronger predictor of hospitalization than PD. Conclusions and Relevance: This study found that patients with both PD and SUD had a greater probability of hospitalization, compared with those with either disorder alone or neither disorder. Substance use disorders appear to have a greater association than PDs with the probability of hospitalization. Overlooking possible coexisting PD and SUD in ED patients with COVID-19 can underestimate the likelihood of hospitalization. Screening and assessment of both conditions are needed.

Severity Outcomes among Adult Patients with Primary Immunodeficiency and COVID-19 Seen in Emergency Departments, United States, April 2020-August 2021.

Primary immunodeficiencies (PIs) are a group of diseases that increase susceptibility to infectious diseases. Few studies have examined the relationship between PI and COVID-19 outcomes. In this study, we used Premier Healthcare Database, which contains information on inpatient discharges, to analyze COVID-19 outcomes among 853 adult PI and 1,197,430 non-PI patients who visited the emergency department. Hospitalization, intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and death had higher odds in PI patients than in non-PI patients (hospitalization aOR: 2.36, 95% CI: 1.87-2.98; ICU admission aOR: 1.53, 95% CI: 1.19-1.96; IMV aOR: 1.41, 95% CI: 1.15-1.72; death aOR: 1.37, 95% CI: 1.08-1.74), and PI patients spent on average 1.91 more days in the hospital than non-PI patients when adjusted for age, sex, race/ethnicity, and chronic conditions associated with severe COVID-19. Of the largest four PI groups, selective deficiency of the immunoglobulin G subclass had the highest hospitalization frequency (75.2%). This large study of United States PI patients provides real-world evidence that PI is a risk factor for adverse COVID-19 outcomes.

Using lifetime risk estimates in personal genomic profiles: estimation of uncertainty.

Personal genome tests are now offered direct-to-consumer (DTC) via genetic variants identified by genome-wide association studies (GWAS) for common diseases. Tests report risk estimates (age-specific and lifetime) for various diseases based on genotypes at multiple loci. However, uncertainty surrounding such risk estimates has not been systematically investigated. With breast cancer as an example, we examined the combined effect of uncertainties in population incidence rates, genotype frequency, effect sizes, and models of joint effects among genetic variants on lifetime risk estimates. We performed simulations to estimate lifetime breast cancer risk for carriers and noncarriers of genetic variants. We derived population-based cancer incidence rates from Surveillance, Epidemiology, and End Results (SEER) Program and comparative international data. We used data for non-Hispanic white women from 2003 to 2005. We derived genotype frequencies and effect sizes from published GWAS and meta-analyses. For a single genetic variant in FGFR2 gene (rs2981582), combination of uncertainty in these parameters produced risk estimates where upper and lower 95% simulation intervals differed by more than 3-fold. Difference in population incidence rates was the largest contributor to variation in risk estimates. For a panel of five genetic variants, estimated lifetime risk of developing breast cancer before age 80 for a woman that carried all risk variants ranged from 6.1% to 21%, depending on assumptions of additive or multiplicative joint effects and breast cancer incidence rates. Epidemiologic parameters involved in computation of disease risk have substantial uncertainty, and cumulative uncertainty should be properly recognized. Reliance on point estimates alone could be seriously misleading.