Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización / Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results

Objetivo: Investigar los factores asociados a una consulta ambulatoria previa (CAP), al acudir a un servicio de urgencias hospitalario (SUH), en los pacientes mayores de 65 años y su impacto sobre los resultados. Emplazamiento: Cincuenta y dos SUH españoles.ParticipantesPacientes mayores de 65 años que consultan a un SUH. Medidas principales y metodología: Se utilizó una cohorte (n=24.645) de pacientes mayores e 65 años atendidos en 52 SUH durante una semana. Se consignaron 5 variables sociodemográficas, 6 funcionales y 3 de gravedad y se analizó su asociación cruda y ajustada con la existencia o no de una CAP a la consulta al SUH. La variable de resultado primaria fue la necesidad de ingreso y secundarias la realización de exploraciones complementarias y tiempo de estancia en el SUH. Se analizó si la CAP influenció en los resultados. Resultados: El 28,5% de los pacientes tenía una CAP previa a su visita al SUH. Vivir en residencia, NEWS2≥5, edad ≥80 años, dependencia funcional, comorbilidad grave, vivir solo, deterioro cognitivo, sexo masculino y depresión se asociaron de forma independiente con la CAP. La CAP se asoció a mayor necesidad de hospitalización y menor tiempo de estancia en el SUH, pero no se observó un menor consumo de recursos diagnósticos. Conclusiones: Los pacientes que acuden al SUH tras una CAP tienen más necesidad de hospitalización, sugiriendo que son debidamente derivados, y las urgencias menores son solucionadas de forma efectiva en la CAP. Su estancia en el SUH previa a la hospitalización es menor, por lo que la CAP facilitaría su resolución clínica.(AU)

Objective: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. Site: Fifty-two Spanish EDs. Participants: Patients over 65 years consulting an ED. Main measurements and design: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. Results: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. Conclusion:Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.(AU)

Demandas urgentes en atención primaria. Comparativa antes y durante la pandemia / Urgent demands in primary care. Comparative before and during the pandemic

Objetivos: Conocer el porcentaje de situaciones verdaderamente urgentes que acuden al centro de salud basándose en el Triángulo de Evaluación Pediátrica. Como objetivo secundario también se ha analizado la presión asistencial comparando ambos periodos del estudio. Material y métodos: revisión de los triajes en 2 periodos de tiempo diferenciados, su clasifica-ción y motivos de consulta, así como edad, sexo del niño/a. Resultados: En el primer periodo estudiado de enero-febrero de 2020 las consultas urgentes supusieron un 31,5% del total, siendo el 95,91% de las mismas clasificadas como “no urgentes”. En el segundo periodo de enero-febrero de 2021, las citas urgentes fueron un 5,2% del total, contando con un porcentaje de “no urgentes” del 78,9%. La disminución de la demanda urgente entre ambos tramos ha sido del 26,3%. A destacar que durante el periodo pandémico disminuyó también la consulta programada. Conclusiones: El triaje por parte de enfermería se muestra útil para valorar la llegada de pacien-tes de manera urgente. Así mismo, la mayoría de demandas referidas como urgentes desde el punto de vista de los padres/madres/tutores, no lo son desde el punto de vista clínico. (AU)

Objectives: To know the percentage of truly urgent situations that come to the primary care center based on the Pediatric Evaluation Triangle. As a secondary objective, healthcare pressure was also analyzed by comparing both periods of the study. Material and methods: review of triages in 2 different periods of time, their classification and reasons for de-mand, as well as age and sex of the children. Results: In the first period studied f rom January-Febru-ary 2020, urgent consultations accounted for 31.5% of the total, with 95.91% of them classified as “non-urgent”. In the second period of January-February 2021, urgent ap-pointments were 5.2% of the total, with a percentage of “non-urgent” of 78.9%. The decrease in urgent demand between both sections has been 26.3%. It should be noted that during the pandemic period the scheduled consultation also decreased. Conclusions: Triage by nursing staff is useful to assess the arrival of patients urgently. Likewise, the majority of demands referred to as urgent f rom the point of view of the parents / guardians are not so f rom the clinical view. (AU)

Consequences of the COVID-19 pandemic on lung cancer care and patient health in a German lung cancer center: results from a cross-sectional questionnaire.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a global COVID-19 pandemic, leading to worldwide changes in public health measures. In addition to changes in the public sector (lockdowns, contact restrictions), hospitals modified care to minimize risk of infection and to mobilize resources for COVID-19 patients. Our study aimed to assess the impact of these measures on access to care and behaviour of patients with thoracic malignancies. METHODS: Thoracic oncology patients were surveyed in October 2020 using paper-based questionnaires to assess access to ambulatory care services and tumor-directed therapy during the COVID-19 pandemic. Additionally, behaviour regarding social distancing and wearing of face masks were assessed, as well as COVID-19 exposure, testing and vaccination. Results are presented as absolute and relative frequencies for categorical variables and means with standard deviation for numerical variables. We used t-test, and ANOVA to compare differences in metric variables and Chi2-test to compare proportions between groups. RESULTS: 93 of 245 (38%) patients surveyed completed the questionnaire. Respiration therapy and physical therapy were unavailable for 57% to 70% of patients during March/April. Appointments for tumor-directed therapy, tumor imaging, and follow-up care were postponed or cancelled for 18.9%, 13.6%, and 14.8% of patients, respectively. Patients reported their general health as mostly unaffected. The majority of patients surveyed did not report reducing their contacts with family. The majority reduced contact with friends. Most patients wore community masks, although a significant proportion reported respiratory difficulties during prolonged mask-wearing. 74 patients (80%) reported willingness to be vaccinated against SARS-CoV-2. CONCLUSIONS: This survey provides insights into the patient experience during the second wave of the COVID-19 pandemic in Munich, Germany. Most patients reported no negative changes to cancer treatments or general health; however, allied health services were greatly impacted. Patients reported gaps in social distancing, but were prepared to wear community masks. The willingness to get vaccinated against SARS-CoV-2 was high. This information is not only of high relevance to policy makers, but also to health care providers.

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021.

Importance: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance: Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis.

BACKGROUND AND PURPOSE: Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. METHODS: This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. RESULTS: A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08). CONCLUSIONS: CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.

An open repository of real-time COVID-19 indicators.

The COVID-19 pandemic presented enormous data challenges in the United States. Policy makers, epidemiological modelers, and health researchers all require up-to-date data on the pandemic and relevant public behavior, ideally at fine spatial and temporal resolution. The COVIDcast API is our attempt to fill this need: Operational since April 2020, it provides open access to both traditional public health surveillance signals (cases, deaths, and hospitalizations) and many auxiliary indicators of COVID-19 activity, such as signals extracted from deidentified medical claims data, massive online surveys, cell phone mobility data, and internet search trends. These are available at a fine geographic resolution (mostly at the county level) and are updated daily. The COVIDcast API also tracks all revisions to historical data, allowing modelers to account for the frequent revisions and backfill that are common for many public health data sources. All of the data are available in a common format through the API and accompanying R and Python software packages. This paper describes the data sources and signals, and provides examples demonstrating that the auxiliary signals in the COVIDcast API present information relevant to tracking COVID activity, augmenting traditional public health reporting and empowering research and decision-making.

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019.

BACKGROUND: Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. OBJECTIVE: To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. DESIGN: Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. SETTING: Traditional fee-for-service Medicare. PATIENTS: 20% sample of Medicare beneficiaries. MEASUREMENTS: Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. RESULTS: The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. LIMITATION: Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. CONCLUSION: Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. PRIMARY FUNDING SOURCE: National Institute on Aging.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

PURPOSE: We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. MATERIALS AND METHODS: We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. RESULTS: We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). CONCLUSIONS: This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

The Impact of the COVID-19 Pandemic on Spine Surgery in Central Europe: A Questionnaire-Based Study.

OBJECTIVE: The severe acute respiratory coronavirus 2 (SARS-CoV2) crisis led to many restrictions in daily life and protective health care actions in all hospitals to ensure basic medical supply. This questionnaire-based study among spinal surgeons in central Europe was generated to investigate the impact of coronavirus disease 2019 (COVID-19) and consecutively the differences in restrictions in spinal surgery units. METHODS: An online survey consisting of 32 questions on the impact of the COVID-19 pandemic and the related restrictions on spinal surgery units was created. Surgical fellows and consultants from neurosurgical, orthopedic, and trauma departments were included in our questionnaire-based study with the help of Austrian, German, and Swiss scientific societies. RESULTS: In a total of 406 completed questionnaires, most participants reported increased preventive measurements at daily clinical work (split-team work schedule [44%], cancellation of elective and/or semielective surgeries [91%]), reduced occurrence of emergencies (91%), decreased outpatient work (45%) with increased telemedical care (73%) and a reduced availability of medical equipment (75%) as well as medical staff (30%). Although most physicians considered the political restrictive decisions to be not suitable, most considered the medical measures to be appropriate. CONCLUSIONS: The COVID-19 pandemic resulted in comparable restrictive measures for spinal surgical departments in central Europe. Elective surgical interventions were reduced, providing additional resources reserved for severe acute respiratory coronavirus 2-positive patients. Although similar restrictions were introduced in most participants' departments, the supply of personal protective equipment and the outpatient care remained insufficient and should be re-evaluated intensively for future global health care crises.

Increased Utilization of Virtual Visits and Electronic Approaches in Clinical Research During the COVID-19 Pandemic and Thereafter.

OBJECTIVES: To assess the impact of the COVID-19 pandemic on clinical research and the use of electronic approaches to mitigate this impact. METHODS: We compared the utilization of electronic consenting, remote visits, and remote monitoring by study monitors in all research studies conducted at Mayo Clinic sites (Arizona, Florida, and Minnesota) before and during the COVID-19 pandemic (ie, between May 1, 2019 and December 31, 2020). Participants are consented through a participant-tracking system linked to the electronic health record. RESULTS: Between May 2019, and December 2020, there were 130,800 new consents across every modality (electronic and paper) to participate in a non-trial (107,176 [82%]) or a clinical trial (23,624 [18%]). New consents declined from 5741 in February 2020 to 913 in April 2020 but increased to 11,864 in November 2020. The mean (standard deviation [SD]) proportion of electronic consent increased from 22 (2%) before to 45 (20%) during the pandemic (P=.001). Mean (SD) remote electronic consenting increased from 0.3 (0.5%) to 29 (21%) (P<.001). The mean (SD) number of patients with virtual visits increased from 3.5 (2.4%) to 172 (135%) (P=.003) per month between pre-COVID (July 2019 to February 2020) and post-COVID (March to December 2020) periods. Virtual visits used telemedicine (68%) or video (32%). Requests for remote monitor access to complete visits increased from 44 (17%) per month between May 2019 and February 2020 to 111 (74%) per month between March and December 2020 (P=.10). CONCLUSION: After a sharp early decline, the enrollment of new participants and ongoing study visits recovered during the COVID-19 pandemic. This recovery was accompanied by the increased use of electronic tools.

Impact of COVID-19 lockdown on routine oncology versus emergency care at a high volume cancer centre.

BACKGROUND: We investigated the influence of population-wide COVID-19 lockdown measures implemented on 16, March 2020 on routine and emergency care of cancer outpatients at a tertiary care cancer centre in Vienna, Austria. METHODS: We compared the number/visits of cancer outpatients receiving oncological therapies at the oncologic day clinic (DC) and admissions at the emergency department (ED) of our institution in time periods before (pre-lockdown period: 1 January - 15 March 2020) and after (post-lockdown period: 16 March- 31 May 2020) lockdown implementation with the respective reference periods of 2018 and 2019. Additionally, we analysed Emergency Severity Index (ESI) score of unplanned cancer patient presentations to the ED in the same post-lockdown time periods. Patient outcome was described as 3-month mortality rate (3-MM). RESULTS: In total, 16 703 visits at the DC and 2664 patient visits for the respective time periods were recorded at the ED. No decrease in patient visits was observed at the DC after lockdown implementation (P = .351), whereas a substantial decrease in patient visits at the ED was seen (P < .001). This translates into a 26%-31% reduction of cancer-related patient visits per half month after the lockdown at the ED (P < .001 vs. 2018 + 2019). There was no difference in the distribution of ESI scores at ED presentation (P = .805), admission rates or 3-MM in association with lockdown implementation (P = .086). CONCLUSION: We demonstrate the feasibility of maintaining antineoplastic therapy administration during the COVID-19 pandemic. However, our data underline the need for adapted management strategies for emergency presentations of cancer patients.

Trends in victim, incident and care characteristics of a Dutch sexual assault center.

Worldwide, one in three women have experienced sexual violence, causing various physical and mental health problems such as depression, posttraumatic stress disorder and medically unexplained symptoms. Much has changed in the last decade. The use of the Internet, smartphones and apps has increased enormously, sexual violence is discussed more and more openly in the media. These changes have provided a platform for victims of sexual violence which has profoundly influenced the disclosing process and the victims' help-seeking behavior. Nevertheless, the question remains whether the number of victims seeking help from a professional institution has gone up. Therefore, our study aims to investigate if there have been changes in victim, incident and care characteristics among victims of a Dutch Center for Sexual Violence. We used data of victims attending the center between 2013 and 2020, including registered police file registrations instead of victim's reporting statements. Victims were divided into a cohort of early years (2013-2016) and recent years (2017-2020). In 2017-2020, a total of 270 victims attended the center compared to 83 victims in 2013-2016. The percentage of self-referrers increased from 10% to 30% in recent years; the use of psychotropic drugs among victims decreased from 24% to 11%; and more victims were willing to receive psychosocial follow-up care (64% versus 79%). The percentage of male victims remains low at approximately 5% of all victims in both cohorts. Background characteristics such as age and mental disability have hardly changed between 2013 and 2020. The proportion of known perpetrators remains high with approximately 80% in both cohorts, and the proportion of perpetrators who met victims on the Internet remains unchanged with approximately 6% in both cohorts. To improve our understanding of the influence of societal changes on help-seeking behavior, the monitoring of victim, incident and care characteristics remains crucial in the future.

Trends in visits to substance use disorder treatment facilities in 2020.

OBJECTIVE: To describe weekly changes in the number of substance use disorder treatment (SUDT) facility visits in 2020 compared to 2019 using cell phone location data. METHODS: We calculated the percentage weekly change in visits to SUDT facilities from the week of January 5 through the week of October 11, 2020, relative to the week of January 6 through the week of October 13, 2019. We stratified facilities by county COVID-19 incidence per 10,000 residents in each week and by 2018 fatal drug overdose rate. Finally, we conducted a multivariable linear regression analysis examining percent change in visits per week as a function of county-level COVID-19 tercile, a series of calendar month indicators, and the interaction of county-level COVID-19 tercile and month. We repeated the regression analysis replacing COVID-19 tercile with overdose tercile. RESULTS: Beginning the eleventh week of 2020, the number of visits to SUDT facilities declined substantially, reaching a nadir of 48% of 2019 visits in early July. In contrast to January, there were significantly fewer visits in 2020 compared to 2019 in all subsequent months (p < 0.01 in all months). Multivariable regression results found that facilities in the tercile of counties experiencing the most COVID-19 cases had a significantly greater reduction in the number of SUDT visits in 2020 for the months of June through August than facilities in counties with the fewest COVID-19 rates (p < 0.05). The study found no statistically significant difference in the change in the number of visits by facilities in counties with historically different overdose rates. DISCUSSION: Our findings support the hypothesis that a reduction has occurred in the average weekly number of visits to SUDT facilities. The size of the effect differs based on the number of COVID-19 cases but not on historical overdose rate.

Trends in Health Care Utilization and Expenditures in the United States Across 5 Decades: 1977-2017.

BACKGROUND: Health care expenditures in the United States are high and rising, with significant increases over the decades. The delivery, organization, and financing of the health care system has evolved over time due to technological innovation, policy changes, patient preferences, altering payment mechanisms, shifting demographics, and other factors. OBJECTIVE: The objective of this study was to examine trends over time in health care utilization and expenditures in the United States. RESEARCH DESIGN: This analysis employs descriptive statistics to examine 5 decades of health care utilization and expenditure data from the Agency for Healthcare Research and Quality (AHRQ) for 1977-2017. MEASURES: Measures include utilization and expenditures (not charges) for inpatient, emergency department, outpatient physician, outpatient nonphysician, office-based physician, dental, and out-of-pocket retail prescription drugs. RESULTS: We demonstrate that while health care expenditures have increased significantly overall and by type of care, utilization trends are less pronounced. The population of the United States grew 53% between 1977 and 2017, while annual total expenditures on health care increased by 208%. Amidst attention to out-of-pocket exposure for unexpected medical care bills, out-of-pocket payments for care have declined from 32% in 1977 to 12% in 2017 but increased in amount. CONCLUSIONS: This article provides the first extended snapshot of the dynamics of health care utilization and expenditures in the United States. Aspects of health care are much different today than in previous decades, yet the inpatient setting still dominates the expenditures.

Impact of COVID-19 on cancer care in India: a cohort study.

BACKGROUND: The COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. METHODS: We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. FINDINGS: Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities). INTERPRETATION: The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Pre-existing Disparities and Potential Implications for the Rapid Expansion of Telemedicine in Response to the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Concerns exist regarding exacerbation of existing disparities in health care access with the rapid implementation of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic. However, data on pre-existing disparities in telemedicine utilization is currently lacking. OBJECTIVE: We aimed to study: (1) the prevalence of outpatient telemedicine visits before the COVID-19 pandemic by patient subgroups based on age, comorbidity burden, residence rurality, and median household income; and (2) associated diagnosis categories. RESEARCH DESIGN: This was a retrospective cohort study. SUBJECT: Commercial claims data from the Truven MarketScan database (2014-2018) representing n=846,461,609 outpatient visits. MEASURES: We studied characteristics and utilization of outpatient telemedicine services before the COVID-19 pandemic by patient subgroups based on age, comorbidity burden, residence rurality, and median household income. Disparities were assessed in unadjusted and adjusted (regression) analyses. RESULTS: With overall telemedicine uptake of 0.12% (n=1,018,092/846,461,609 outpatient visits) we found that pre-COVID-19 disparities in telemedicine use became more pronounced over time with lower use in patients who were older, had more comorbidities, were in rural areas, and had lower median household incomes (all trends and effect estimates P<0.001). CONCLUSION: These results contextualize pre-existing disparities in telemedicine use and are crucial in the monitoring of potential disparities in telemedicine access and subsequent outcomes after the rapid expansion of telemedicine during the COVID-19 pandemic.

Avoidable Acute Care Use for Vaccine-Preventable Illnesses Among Medicaid Beneficiaries With Lupus.

OBJECTIVE: Nearly 25% of patients with systemic lupus erythematosus (SLE) are hospitalized yearly, often for outcomes that may have been avoided if patients had received sustained outpatient care. We examined acute care use for vaccine-preventable illnesses to determine sociodemographic contributors and modifiable predictors. METHODS: Using US Medicaid claims from 29 states (2000-2010), we identified adults (18-65 years) with prevalent SLE and 12 months of enrollment prior to the first SLE code (index date) to identify baseline data. We defined acute care use for vaccine-preventable illnesses as emergency department (ED) or hospital discharge diagnoses for influenza, pneumococcal disease, meningococcal disease, herpes zoster, high-grade cervical dysplasia/cervical cancer, and hepatitis B after the index date. We estimated the incidence rate of vaccine-preventable illnesses and used Cox regression to assess risk (with hazard ratios and 95% confidence intervals) by sociodemographic factors and health care utilization, adjusting for vaccinations, comorbidities, and medications. RESULTS: Among 45,654 Medicaid beneficiaries with SLE, <10% had billing claims for vaccinations. There were 1,290 patients with ≥1 ED visit or hospitalization for a vaccine-preventable illness (6.6 per 1,000 person-years); 93% of events occurred in unvaccinated patients. Patients who were Black compared to White had 22% higher risk. Greater outpatient visits were associated with lower risk. CONCLUSION: Medicaid beneficiaries with SLE who are not vaccinated are at risk for potentially avoidable acute care use for vaccine-preventable illnesses. Racial disparities were noted, with a higher risk among Black patients compared to White patients. Greater outpatient use was associated with reduced risk, suggesting that access to ambulatory care may reduce avoidable acute care use.