COVID-19 Scan for Aug 03, 2020

News brief

Telehealth is a boon—except for many older Americans unable to use it

Telemedicine is booming amid the COVID-19 pandemic, but many older US adults—particularly those who are low-income, male, black or Hispanic, older than 65 years, less educated, living in rural areas, or have disabilities or poor health—are unable to access remote services, cutting them off from healthcare.

In a research letter published today in JAMA Internal Medicine, researchers from the University of California at San Francisco (UCSF) analyzed data from 4,525 patients in the 2018 National Health and Aging Trends Study of Medicare recipients 65 years and older. They looked at issues in which poor hearing or eyesight, problems speaking clearly, possible or probable dementia, lack of Internet-enabled devices or knowledge, or no email or texting use in the previous month could interfere with effective remote visits.

The authors estimated that 38% of all older Americans (13 million), and 72% of those 85 and older, were not prepared for remote healthcare visits because of inexperience with the necessary technology or physical disabilities. Even when another person helped them, 32% of older adults (10.8 million) still weren't able to visit remotely, and 20% (6.7 million) couldn't manage a phone visit because they had dementia or difficulty hearing or communicating.

Adults of advanced age, who often have disabilities and underlying conditions, account for one quarter of US clinic visits, the authors noted. The US Department of Health and Human Services and other agencies have promoted telehealth as a way to reach patients staying home to avoid COVID-19 infection. But patients must have the resources and knowledge to access the Internet, use audiovisual equipment, and communicate without the interpersonal cues usually present during in-person visits.

In a UCSF news release, lead author Kenneth Lam, MD, called for in-home visits for patients with dementia and further innovation in devices, services, and policy to ensure remote access to healthcare for older Americans. "This includes devices with better designed user interfaces to get connected, digital accommodations for hearing and visual impairments, services to train older adults in the use of devices and, for some clinicians, keeping their offices open during the pandemic," he said.

In the study, median patient age was 79.6 years, 69% were white, 21% were black, and 6% were Hispanic.
Aug 3 JAMA Intern Med research letter
Aug 3 UCSF news release

A fourth of Medicare patients lack digital access for telehealth in pandemic

The proportion of Medicare recipients who lacked digital access for remote visits with their healthcare providers in 2018 was highest in patients of color and in those who were 85 years and older, had low incomes, received Medicaid, or had a disability or no more than a high school education, according to a separate research letter published today in JAMA Internal Medicine.

Examining data from 54,749,082 community-dwelling Medicare beneficiaries from the American Community Survey, researchers from the University of Pittsburgh and Harvard Medical School showed that 41.4% lacked a desktop or laptop computer with a high-speed Internet connection, while 40.9% didn't have a smartphone with a wireless data plan, and 26.3% lacked both, revealing wide gaps in access to healthcare amid the current pandemic.

Lack of Internet access varied according to demographics and socioeconomic status, with no digital access in 50.1% of those with incomes at least 100% below the federal poverty level, versus 11.5% of those with incomes at least 400% above that level.

The authors said that Medicare's payment for audio-only visits at the same rate as video and in-person clinic visits may be tied to improved access to care for those without digital access, but the inability to have a video interaction may be linked to increased disparities in access to care.

Expanding programs such as the Federal Communications Commission's Lifeline, which provides lower-cost phone or Internet service to those with incomes 135% or more below the federal poverty level, could help address health inequities. "However, Lifeline does not pay for devices, and patients may also need assistance using technology for video visits," the authors wrote. "Addressing these factors associated with digital access in populations with low socioeconomic status will be important as the use of telemedicine increases."
Aug 3 JAMA Intern Med research letter

US ED visits fell, hospitalizations rose early in pandemic, study shows

While there was a dramatic uptick on hospitalizations during the first 4 months of COVID-19 in the United States, emergency department (ED) visits declined by 42% to 64%—mostly in early March, a study led by Mayo Clinic and Yale University researchers has found.

The study, also published today in JAMA Internal Medicine, involved data from an ongoing trial of opioid use disorder prescribing practices in 24 EDs in five healthcare systems in Colorado, Connecticut, Massachusetts, New York, and North Carolina from Jan 1 to Apr 30.

Declines in ED cases ranged from 41.5% in Colorado to 63.5% in New York. The fewest ED visits occurred the week of Apr 8, after which numbers increased but did not return to baseline.

Hospital admissions rose 36% at Yale New Haven Health during that time, while Mount Sinai Health in New York saw an 149% increase. Hospitalizations at Baystate Health in Massachusetts rose 51.7%, while they increased 29.4% at University of Colorado Health and 22% at University of North Carolina Health.

The authors noted that the changes in ED visits and hospitalization occurred at the same time as state stay-at-home orders and intense coronavirus media coverage. They said that the ED reductions could have been caused by the reluctance of patients with serious illnesses to seek care, avoidance of seeking care for non-emergency care, or increased use of telemedicine.

"The largest declines were seen in the areas that had a lot of COVID-19 cases," lead author Molly Jeffery, PhD, said in a Mayo Clinic press release. "If you think about that, it means that even more people with problems other than COVID-19 must have avoided the ED during this period."

To reassure patients that EDs use more stringent infection-control practices than ever now, the authors said that people who are seriously ill or injured should seek care because they could otherwise experience worsening symptoms, disability, or death. "Public health authorities and health care systems should provide guidance and resources to help patients determine the best place to receive care as the available health care capacity changes during the pandemic," the authors wrote in the study.
Aug 3 JAMA Intern Med study
Aug 3 Mayo Clinic press release

News Scan for Aug 03, 2020

News brief

One more sick in DRC Ebola outbreak, 73 total, with 31 deaths

Ebola has sickened one more person in the Democratic Republic of the Congo (DRC) Equateur province outbreak, upping the total to 73 cases, the World Health Organization (WHO) African regional office said today on Twitter.

No new deaths were reported, keeping the fatality count at 31.

The outbreak was first detected in early June and marks the DRC's 11th Ebola outbreak. It is occurring in the same area as the country's ninth outbreak in 2018, which ended in only a few months with 54 cases, 33 of them fatal.
Aug 3 WHO African regional office tweet

CDC: Onions likely source of Salmonella in almost 400-case outbreak

Almost 400 people in 34 states have been sickened with Salmonella Newport, likely tied to onions sold by Thomson International Inc., the Centers for Disease Control and Prevention (CDC) said late last week.

The multistate outbreak includes 396 cases, with 59 people requiring hospitalization. So far there have been no deaths. Oregon has the most cases, with 71, followed by Utah (61) and California (49). Illnesses started on dates ranging from Jun 19 to Jul 12.

"The traceback information collected identified Thomson International, Inc. of Bakersfield, CA as a likely source of red onions in this outbreak," the CDC said in an update. "Due to the way onions are grown and harvested, other types of onions, such as white, yellow, or sweet, may also be contaminated."

The Public Health Agency of Canada (PHAC) is also investigating a 120-case outbreak of Salmonella illnesses genetically linked to the US outbreak. On Jul 30, PHAC said red onions grown in the United States were the likely source of that outbreak.
Jul 31 CDC update
Jul 31 CIDRAP News scan on PHAC update

Online program tied to less inappropriate antibiotic use for pediatric ARTIs

As many as one third of outpatient antibiotic prescriptions written for pediatric acute respiratory tract infections (ARTIs) are inappropriate, but a distance learning course consisting of three program modules aimed at family clinicians was associated with a 7% drop in overall antibiotic prescribing rates for all ARTI visits, according to a study published today in Pediatrics.

The study took place in 19 pediatric practices in 2015 to 2019, and visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to 11 years without recent antibiotic use were included.

Clinicians were assigned to use the Dialogue Around Respiratory Illness Treatment (DART) Quality Improvement Program—an evidence-based online communication skills and antibiotic prescribing education training program developed by the authors. The program focuses on how clinicians can communicate their decision not to prescribe antibiotics to a patient's family, as well as more generally on antibiotic overuse.

A total of 72,723 ARTI visits by 29,762 patients were included in the study. Antibiotic prescribing declined by 7% 2 to 8 months after physicians completed DART. The program resulted in sustained reductions in antibiotic prescribing during viral ARTI visits and sustained decreases in second-line antibiotic prescribing during streptococcal pharyngitis and sinusitis visits, but it did not result in sustained reductions in antibiotic prescribing during all pharyngitis visits, the authors said.

In an accompanying commentary, US experts not involved in the study said the DART program tackles one of the biggest hurdles in pediatric antibiotic overuse: parents. "The reasons for inappropriate antibiotic prescribing in ambulatory pediatrics are multifactorial, including patient pressures and demand, actual or perceived parental satisfaction, provider knowledge, and provider time constraints," they said. "An effective approach to decreasing inappropriate antibiotic prescribing must therefore address each of these contributing factors."
Aug 3 Pediatrics study
Aug 3 Pediatrics commentary

Longhorned tick identified in Ohio

The Ohio Department of Agriculture (ODA) late last week announced that the Asian longhorned tick, a rapidly spreading invasive species, has been found on a stray dog from Gallia County.

In a statement, the ODA said the tick was identified on May 28 by The Ohio State University, with findings confirmed by the US Department of Agriculture National Veterinary Services Laboratory in Ames, Iowa.

The tick was first identified in New Jersey in 2017. A ProMED Mail post on the Ohio detection said the number of states that have identified longhorned ticks has now reached 13. All but Arkansas are in the eastern United States.

Longhorned ticks haven't been known to sicken people yet in the United States, but they are aggressive biters that are known to carry pathogens that sicken humans and livestock. Researchers last summer described the first known human to have been bitten by a longhorn tick, a man from New York who was likely exposed in his yard and did not become ill.

Female Haemaphysalis longicornis ticks produce massive offspring without mating. In Australia and New Zealand, infestations from the species have been reported to decrease production in dairy cattle by 25%.
Jul 31 ODA press release
Aug 2 ProMED Mail post
Jun 3, 2019, CIDRAP News story "First US human bite from worrying longhorned tick noted"

H7N7 avian flu strikes layer farm in Australia

Agriculture officials in Australia recently reported a highly pathogenic H7N7 avian flu outbreak at a free-range layer farm in Victoria state, according to a Jul 31 notification from the World Organization for Animal Health (OIE).

The outbreak began on Juy 24 in Lethbridge, affecting birds in one of two sheds at the farm. The virus killed 1,669 of 43,500 susceptible birds, and the rest were culled to curb the spread of the virus. So far, the source hasn't been identified, but it may involve contact with wild species, according to the report.

Australia's most recent previous outbreak involving the strain occurred in 2014.
Jul 31 OIE report on H7N7 in Australia