Team and leadership factors and their relationship to burnout in emergency medicine during COVID-19: A 3-wave cross-sectional study.

Objective: We examined the relationship of team and leadership attributes with clinician feelings of burnout over time during the corona virus disease 2019 (COVID-19) pandemic. Methods: We surveyed emergency medicine personnel at 2 California hospitals at 3 time points: July 2020, December 2020, and November 2021. We assessed 3 team and leadership attributes using previously validated psychological scales (joint problem-solving, process clarity, and leader inclusiveness) and burnout using a validated scale. Using logistic regression models we determined the associations between team and leadership attributes and burnout, controlling for covariates. Results: We obtained responses from 328, 356, and 260 respondents in waves 1, 2, and 3, respectively (mean response rate = 49.52%). The median response for feelings of burnout increased over time (2.0, interquartile range [IQR] = 2.0-3.0 in wave 1 to 3.0, IQR = 2.0-3.0 in wave 3). At all time points, greater process clarity was associated with lower odds of feeling burnout (odds ratio [OR] [95% confidence interval (CI) = 0.36 [0.19, 0.66] in wave 1 to 0.24 [0.10, 0.61] in wave 3). In waves 2 and 3, greater joint problem-solving was associated with lower odds of feeling burnout (OR [95% CI] = 0.61 [0.42, 0.89], 0.54 [0.33, 0.88]). Leader inclusiveness was also associated with lower odds of feeling burnout (OR [95% CI] = 0.45 [0.27, 0.74] in wave 1 to 0.41 [0.24, 0.69] in wave 3). Conclusions: Process clarity, joint problem-solving, and leader inclusiveness are associated with less clinician burnout during the COVID-19 pandemic, pointing to potential benefits of focusing on team and leadership factors during crisis. Leader inclusiveness may wane over time, requiring effort to sustain.

How psychological safety and feeling heard relate to burnout and adaptation amid uncertainty.

BACKGROUND: Psychological safety-the belief that it is safe to speak up-is vital amid uncertainty, but its relationship to feeling heard is not well understood. PURPOSE: The aims of this study were (a) to measure feeling heard and (b) to assess how psychological safety and feeling heard relate to one another as well as to burnout, worsening burnout, and adaptation during uncertainty. METHODOLOGY: We conducted a cross-sectional survey of emergency department staff and clinicians (response rate = 52%; analytic N = 241) in July 2020. The survey measured psychological safety, feeling heard, overall burnout, worsening burnout, and perceived process adaptation during the COVID-19 crisis. We assessed descriptive statistics and construct measurement properties, and we assessed relationships among the variables using generalized structural equation modeling. RESULTS: Psychological safety and feeling heard demonstrated acceptable measurement properties and were correlated at r = .54. Levels of feeling heard were lower on average than psychological safety. Psychological safety and feeling heard were both statistically significantly associated with lower burnout and greater process adaptation. Only psychological safety exhibited a statistically significant relationship with less worsening burnout during crisis. We found evidence that feeling heard mediates psychological safety's relationship to burnout and process adaptation. CONCLUSION: Psychological safety is important but not sufficient for feeling heard. Feeling heard may help mitigate burnout and enable adaptation during uncertainty. PRACTICE IMPLICATIONS: For health care leaders, expanding beyond psychological safety to also establish a feeling of being heard may further reduce burnout and improve care processes.

Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015.

Importance: Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage. Objective: To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015. Design, Setting, and Participants: This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021. Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Main Outcomes and Measures: Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders. Results: Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04). Conclusions and Relevance: In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Masked and distanced: a qualitative study of how personal protective equipment and distancing affect teamwork in emergency care.

BACKGROUND: Newly intensified use of personal protective equipment (PPE) in emergency departments presents teamwork challenges affecting the quality and safety of care at the frontlines. OBJECTIVE: We conducted a qualitative study to categorize and describe barriers to teamwork posed by PPE and distancing in the emergency setting. METHODS: We conducted 55 semi-structured interviews between June 2020 and August 2020 with personnel from two emergency departments serving in a variety of roles. We then performed a thematic analysis to identify and construct patterns of teamwork challenges into themes. RESULTS: We discovered two types of challenges to teamwork: material barriers related to wearing masks, gowns and powered air-purifying respirators, and spatial barriers implemented to conserve PPE and limit coronavirus exposure. Both material and spatial barriers resulted in disrupted communication, roles and interpersonal relationships, but they did so in unique ways. Material barriers muffled information flow, impeded team member recognition and role/task division, and reduced belonging and cohesion while increasing interpersonal strain. Spatial barriers resulted in mediated communication and added physical and emotional distance between teammates and patients. CONCLUSION: Our findings identify specific aspects of how intensified PPE use disrupts teamwork and can inform efforts to ensure care quality and safety in emergency settings as PPE use continues during and, potentially beyond, the coronavirus disease-2019 pandemic.

Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults.

Importance: There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical. Objective: To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance. Design, Setting, and Participants: This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL. Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Main Outcomes and Measures: The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020. Results: The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid. Conclusions and Relevance: In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

Comparison of Income Eligibility for Medicaid vs Marketplace Coverage for Insurance Enrollment Among Low-Income US Adults.

Importance: The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option. Objective: To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado. Design Setting and Participants: Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020. Main Outcome and Measures: The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage. Results: The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively. Conclusions and Relevance: In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

COVID-19-Related Insurance Coverage Changes and Disparities in Access to Care Among Low-Income US Adults in 4 Southern States.

Importance: It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid. Objective: To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status. Design Setting and Participants: This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021. Exposures: COVID-19 pandemic and prior Medicaid expansion status. Main Outcomes and Measures: Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access. Results: Of 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state). Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, -9.5%; 95% CI, -19.0 to -0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status. Conclusions and Relevance: In this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.

Support for vector control strategies in the United States during the Zika outbreak in 2016: The role of risk perception, knowledge, and confidence in government.

Limiting the spread and impact of Zika was a major global priority in 2016, which required a variety of vector control measures. The success of vector control campaigns is varied and often dependent on public or political will. This paper examines the change over time in the United States population's support for vector control and the factors that predicted support for three vector control strategies (i.e., indoor spraying, outdoor spraying, and use of larvacide tablets) during the 2016 Zika outbreak in the United States. Data is from a nationally representative random digit dial sample conducted at three time points in 2016. Bivariate and multivariate regression analyses were used, treating data as a pooled cross-sectional sample. Results show public support for vector control strategies depends on both perceived risk for disease and knowledge of disease characteristics, as well is confidence in government to prevent the threat. Support varied based on vector control method: indoor spraying, aerial spraying, and use of larvacide tables. Results can aide public health officials in implementing effective vector control campaigns depending on the vector control strategy of choice. Results have implications for ways to design effective prevention campaigns in future emerging infectious disease threats.