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A global overview of healthcare workers' turnover intention amid COVID-19 pandemic: a systematic review with future directions - Human Resources for...

People watch a baseball game at Jamsil Baseball Stadium in Seoul, Sunday. (Yonhap)

The outdoor mask mandate ended May 2, but was kept for outdoor gatherings of 50 or more people. The rule remained due to concerns amid the recent resurgence of COVID-19.

The government is expected to further ease the countrys antivirus measures for COVID-19. The government said it would soon introduce its future adjustments to other antivirus rules.

The antivirus measures that could be eased in the near future include the testing requirement for all passengers arriving in South Korea from overseas, a mandatory seven-day quarantine for patients with COVID-19 and limits on visits to nursing homes.

The country's indoor mask mandate, however, is expected to remain in place for a longer period of time due to a possible resurgence in COVID-19 infections during the fall and winter seasons.

The countrys PCR test requirement for all arriving passengers to the country might be lifted soon, as the effectiveness of the PCR test requirement has been questioned recently. Many visitors to the country have not keeping the rule, and the government has also found it difficult to keep track of them.

The South Korean government may consider lifting the PCR test mandate as other countries are moving away from such rules. Currently, South Korea is one of only 10 countries among Organization for Economic Co-operation and Development countries that still has testing requirements in place for travelers.

The PCR test requirement is currently the only antivirus measure remaining for international arrivals. On June 8, South Korea lifted its quarantine rule for international arrivals. The country also stopped requiring pre-departure COVID-19 tests on Sept. 3.

If lifted, there will be no antivirus measures for passengers entering the country.

Limitations on visiting nursing homes could be also eased soon as public calls for a change to them have been growing. On July 25, the government limited visits to local nursing homes amid a resurgence in the number of COVID-19 infections, consequently preventing some people from visiting their relatives.

The mandatory seven-day quarantine for patients infected with COVID-19 is another antivirus measure that is expected to be discussed among medical experts. The government is likely to gradually shorten the quarantine period as recent surveys suggest the overwhelming majority of people have formed COVID-19 antibodies in their system.

According to a recent government survey on some 10,000 people, 97.4 percent had COVID antibodies, 57.7 percent of whom had formed antibodies through infection.

The countrys health agency said a considerable number of people seem to have recovered from the virus without reporting their infections.

By Shim Woo-hyun (ws@heraldcorp.com)

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Outdoor mask mandate fully lifted, other COVID-19 rules in review - The Korea Herald

Hernia repair is one of the most commonly performed elective operations [1]. When the coronavirus disease 2019 (COVID-19) pandemic started in the Spring of 2020, most European countries temporarily stopped elective hernia repair operations or kept these to a minimum [2]. Understandably, with the speed of onset of the pandemic, the uncertainties around the spread of the virusand its effects on health care workers and patients alike, multiple recommendations and often varying guidelines were issued by countries and medical organisations [3].

The Board members of the European Hernia Society (EHS) assisted by the senior author of this paper (BE) published guidance around hernia surgery in the current pandemic andlooked at exit strategies as the pandemic diminished [4]. A conservative management approach to most hernias was seen as the safest option for many in the early months of the pandemic. For those presenting as an emergency, techniques like manual reduction under analgesia or sedationwere also advised, successfully allowing safe early discharge of the patient from the hospital [5]. The aim of this study was to evaluate the impact of COVID-19 on the pattern of elective and emergency hernia surgery undertaken in the Lothian region of Scotland.

This is a retrospective cohort analysis. The local surgical database (Lothian Surgical Audit - LSA) was searched for all adult hernia operations performed between the beginning of the lockdown in Scotland on 23March 2020 until the end of September 2020 [6]. Hernia repairs undertaken during the same time period in 2019 were also retrieved. A further local patient database (TRAK) was then used to determine the age and gender of the patients, thehernia location, the hernia repair technique (open or laparoscopic), and the urgency of the operation (elective or emergency). These data were collated and compared between the two study periods for differences in patient demographics, overall changes in the incidence of different techniques and urgency for total operations, and with further subgroup analyses by hernia location. The total hernia operations performed per whole month, with division into emergency and elective, were also drawn from the collated data to enable comparison over time within each study period. Statistical analysis was performed using the chi-squared test in R-Studio, with a p-value of <0.05 accepted as statistically significant [7].

A total of 570 hernia repair operations in 534 patients were undertaken in 2019. For the same time period, during 2020, there were 149 hernia operations in 142 patients. The mean age for all patients was 59.1 years in 2019 (range 19-94), and 57.7 years in 2020 (range 19-92).

The total number for each hernia type and the urgency of surgery (elective or emergency) are given in Table 1 below. Both the elective and emergency operation totals reduced from one study period to the next. The elective to emergency ratio was 5.95:1 (488 elective vs 82 emergency operations) for 2019and 1.4:1 (87 vs 62) for 2020. This equated to a 27.2% reduction in the proportion of hernia repairs performed electively, from 85.6% elective in 2019 to 58.4% in 2020 (p<0.001).

On analysis of the composition of all operations by type subgroup, incisional hernia repair saw a significant reduction(p<0.001) in the proportion performed versus other types from 2019, with just six such procedures performed in 2020 (4% of all operations) as compared to 82 for the same period in 2019 (14% of all operations). In contrast, proportionally more inguinal hernias were repaired, making up 56% of all repairs in 2020, a rise of 9% in 2019 (p=0.0502), although total numbers decreased from 270 to 84 operations. No other hernia types were repaired at significantly different rates overall across the two study periods (p>0.05), although when measured by the absolute number of operations performed, large decreases were observed for all hernia types, as shown in Table 1.

The inguinal hernia subgroup had a 24% rise in emergency operations from 21 to 26 procedures, despite a reduction from 270 to 84 total inguinal repairs. In combination with the overall reduction in the operative count, this equated to a significant increase in emergency inguinal hernia repairs against all operations, from 4%of all operations in 2019 to 17%in 2020 (p<0.001). No absolute increases in emergency operations were observed in the other hernia type subgroups.

There were just two elective hernia repairs carried out in the first three months of the 2020 study period (5.6% of all operations for April-June)compared to 265 (87.7%) for the same period in 2019 (p<0.001). The number of operations per whole month was relatively constant during April-August 2019, whereas it steadily rose throughout the same time frame the following year, starting from a total of only six operations in April 2020 (see Figure 1).

No statistically significant differences were observed in the rates of laparoscopic versus open operating techniques across the two study periods on any analysis, as shown in Table 2. This includes total operations (1% rise in laparoscopic, p=0.809)and various subgroup analyses: hernia types (Table 2), elective surgery (7% increase in laparoscopic, p=0.126), and emergency operations (4% rise, p=0.233).

The majority of herniarepairs were performed in menalthough the sex difference was less obvious when considering emergency patients only (Table 3). There was no significant difference in the male-to-female ratio of total repairs performed across the two study periods, 72.8% versus 67.8% male (p=0.209).

The average age for elective hernia repair in 2019 was 58.5 years (range 19-92), and it was 59.2 (range 19-89) in 2020. For emergency hernia repair, the average age for 2019 was 62.6 years (range 26-94), whilst in 2020, it was 55.5 (range 19-92).

This study has demonstrated that the volume of elective hernia surgery was markedly reduced in the six months following the onset of lockdown in the Lothian Region of Scotland, with the proportion of elective operations decreasing significantly from 85.6% to 58.4% (p<0.001).Elective operating in 2020 was just 18% of the 2019 total, with the reduction most marked in the first three months following lockdown, and the greatest impact seen on elective incisional hernia surgery, as noted in Table 1. Whilst there was a reduction in the number of emergency hernia operations in the six months following lockdown in 2020, this was not as marked as elective surgery(82% elective vs 24% emergency operation reduction from 2019 to 2020). The age and gender of the patients were similar over the two time periods, suggesting that there was no obvious discrimination in case selection against the elderly during the COVID-19 study period.

Reports from other countries have identified similar trends, although the absolute percentage reduction in elective hernia surgery has varied, partly due to the differing time periods of studyand different working practices. Herniamed data showed a reduction in elective hernia surgery to 25% of usual [8]while Motol University Hospital reported a reduction of 67% from the normal [9]. Similar findings have been an absolute reduction in emergency hernia surgery, although to a much lesser degree than elective surgery.

A notable exception is that of the Greek experience shared by Mulita et al., who found the overall number of emergency operations to be unaffected (perhaps due to differing local experiences of COVID-19 at the time), and additionally observed a significant increase in the number of strangulated or irreducible inguinal and incisional hernias seen, as well as increased hospital stay and operation time for those emergency presentations [10,11]. This indicates the average severity of presentation at this centre was worse during the COVID-19 era, which may, unfortunately, be a trend we experience in the future.

Despite the overall reduction in emergency surgery we experienced, possibly due to more widespread non-operative interventions [5], inguinal hernia repairs still saw a 24% rise from 21 to 26 emergency operations during the lockdown in our study (Table 1). This, in particular, is a cause for concern, given that emergency hernia surgery is recognised to carry an increased risk of morbidity and mortality [1,12]. Whilst this increase is not completely unexpected, inguinal hernias are generally thought to be at low risk for complications [13].

Current guidance for groin hernias advises watchful waiting can be appropriate in the asymptomatic population, supported by evidence of a low complication risk, the expectation that symptoms developing will trigger a change in management, and a not-insignificant risk of post-operative chronic pain [1]. In contrast, given a lack of evidence for complication risk (strangulation and incarceration) in symptomatic patients, the guidance advocates elective surgical intervention [1]. Whilst delaying elective hernia surgery at the height of the pandemic was unilaterally agreed to be the safest option, this was expected to be for months rather than years [4]. Since then, the UK has come out of lockdown only to re-enter in the winter of 2020-21. This data shows the scale of the delays to elective surgery during the lockdown, and how this evolves in terms of emergency presentation and complication rates long-term remains to be seen.

There were no significant changes in any analysis for femoral hernia repair. It is well-established that femoral hernias tend to present more frequently as emergencies than other types, and indeed in our data, 15 of 29 (52%) were emergency operations prior to the pandemic, which could explain this finding.

Whilst the total number of emergency hernia operations also reduced, it is possible that this was because of increased non-operative therapies undertaken in the early period of the nationwide lockdown. Such a reduction in emergency hernia surgery has also been noted in other countries [14]. Nevertheless, it is likely that for many of those whose operations were cancelled or remain delayed, there is persisting impaired quality of life in a number of facets including the ability to work and play. As is the case for so many health care systems, including the Lothian Region of Scotland, the ability to catch up with the burden of hernia surgery care remains to be seen.

The proportion of elective laparoscopic hernia operations performed in our series increased from 21.3% in 2019 to 28.7% in 2020, but this was not significant (p=0.126). Similarly, there were no significant changes in operative practice noted on any laparoscopic subgroup analysis. Although there was debate regarding the safety of laparoscopic surgery during COVID-19, for fear of spreading infection with insufflation of body cavities [15], there was no consensus policy initially, and as the pandemic progressed evidence suggested this was not a significant concern [4].

Unfortunately, the COVID-19 infection rate for our 2020 cohort is not available, as inpatient testing was in its infancy at the beginning of the lockdown period. Regardless, it is likely not possible to determine if post-operative infections were truly a result of inpatient admissiondue to a combination of the incubation period of the virus, a high background rate of community infection at the time, and the fact that these operations often have short hospital stays. Whilst we, therefore, cannot comment from our data on the safety of undergoing surgery at that time, especially given there were just two elective hernia procedures in our region during the height of the pandemic (April-June 2020), the increased risks of post-operative complications with both active and resolved COVID-19 infection have been studied elsewhere [16], and additionally, the NHS infection prevention and control policies were deemed to be effective [17].

This is a study of the organisational challenges experienced by elective surgical services during a pandemic, rather than patient outcomes. However, a comparison of short-term outcomes across our two cohorts would have multiple confounding factors affecting the ability to draw meaningful conclusions; notably that they are not matched nor of similar size, that higher risk and frailer patients were more likely to have succumbed to COVID-19 infection and not present for surgery, as well as any intentional patient selection bias, and that rates of non-operative management are expected to be different between the two cohorts.

The main limitation of this study was that by its very nature, the total number of operations in 2020 is small, which impacted the ability to draw wider conclusions, particularly on subgroup analysis. Additionally, this study assessed the incidence of emergency presentation only by those that resulted in operative intervention. Lastly, this is an analysis of a single region and so the results may not be representative of other locations, particularly those with different patient demographics.

The COVID-19 pandemic led to a marked reduction in the number of elective hernia repairs (especially incisional hernia surgery), with the effect most pronounced over the first three months of lockdown. Despite an overall reduction in total emergency operative figures, possibly due to the more widespread use of non-operative strategies, there was still an immediate increase in emergency inguinal hernia repairs during the lockdown. Further studies are needed to evaluate if the delays will result in a long-term increase in the rates of emergency presentation.Regardless, the elective waiting list backlog is expected to placea significant burden upon services for years to comeas the country recovers, which may also impact surgical training.

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The Impact of the COVID-19 Pandemic on Hernia Surgery: The South-East Scotland Experience - Cureus

A caretaker working in Scotland got COVID-19 in November 2020. After his initial illness, he continued to experience effects of the disease in fits and starts, struggling to return to work at full capacity. The caretaker had long COVID-19, and his case in front of a Scottish employment tribunal is one of the first to confirm that long COVID-19 might be considered a disability that is protected under the U.K.'s Equality Act 2010.

The Equality Act and Long COVID-19

There are three considerations that the Equality Act 2010 uses to determine if a condition is a protected disability:

While not everyone's experience of long COVID-19 qualifies them under these requirements, some people's circumstances do. The caretaker's tribunal decision took into account that long COVID-19 symptoms can fluctuate over time, still qualifying the caretaker as having a disability that lasted at least 12 months.

"We're very keen to work with employers, to help them to understand that in fact, in many cases, long COVID will make the worker a disabled person under the Equality Act 2010," said Deirdre Costigan, national officer at UNISON, the U.K.'s largest public service union, headquartered in London.

Whether long COVID-19 can be consistently covered by the Equality Act is unclear, because there is such a wide variety of symptoms and the disease is still new and understudied. "There have been calls for long COVID to be added to the legislation as a deemed disability, but the difficulty, the resistance with that is long COVID is impacting different people in different ways," said Julie Temple, an attorney with Birkett Long in Essex, England.

How Employers Should React to Long COVID-19

Convincing employers to make adjustments for employees with long COVID-19 isn't always straightforward.

"Sometimes employers don't believe something unless it's been tested in court," Costigan said. "So the fact that in this recent case the tribunal accepted that the individual was a disabled person due to their long COVID was a really positive result."

While some employers might require more legislative encouragement to accommodate workers with long COVID-19, many others are trying to adapt to the disability. "Employers are becoming more aware of [long COVID-19], and some are very aware of what their obligations are and will do their very best to accommodate individuals and try and keep them within the business," Temple said.

No Enforcement Mechanism

There isn't an effective enforcement mechanism for the Equality Act 2010, and employment tribunals are backed up by a year or two. Also, tribunal decisions are not binding, though appeal decisions are.

"I would encourage employees and employers to try to work together. It's perhaps easier for employees, in some industries and in some roles, to work from home, and to therefore minimize the impact that long COVID might have had," Temple said.

Still, the employment tribunal decision involving the caretaker is already paving the way for future cases that will take long COVID-19 into account. "There will be more case law on this," Costigan said. "I think that will make it a bit easier for union reps to be able to argue that their members with long COVID are disabled."

Katie Nadworny is a freelance writer in Istanbul.

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Long COVID-19 Ruled a Disability in the UK - SHRM

Governor Reynold's new ad sparks controversy over open boarders and covid-19 response  KGAN TV

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Governor Reynold's new ad sparks controversy over open boarders and covid-19 response - KGAN TV

Change will come into effect at the end of the month.

Health and social care workers will no longer be required to test for COVID-19 every week as asymptomatic testing is paused by 28 September.

The four UK Chief Medical Officers agreed it is safe to halt weekly staff testing, visitor and carer testing and hospital admission testing following a change to the Covid-19 alert level and, importantly, a high uptake of vaccinations.

Stakeholders were informed of the change to the guidance on 14 September and some healthcare and social care settings may therefore choose to pause regular testing before the end of the month.

It is the latest restriction to be lifted in health and social care settings following the decision earlier this month to remove the requirement for facemasks in social care homes.

Testing will remain in place for admissions into care homes and to support appropriate clinical diagnosis and treatment for hospital patients and care home residents.

Unpaid carers and visitors to care homes and hospitals will no longer need to undertake routine testing, but those planning to see family or friends in these settings are advised follow the Covid Sense guidelines and steer clear if they are unwell.

Health Secretary Humza Yousaf said:

The huge success of our world-leading vaccination programme means we are now able to pause routine asymptomatic testing in most high-risk settings.

This is the latest step in our return to normal life, but we must apply Covid Sense to keep these freedoms and ease the pressure on the NHS over winter.

Vaccination remains our best line of defence against COVID-19 and I urge everyone who is eligible for the winter vaccination programme to take up the offer of an appointment when its offered.

BACKGROUND

COVID sense | NHS inform

Outbreak testing and symptomatic testing for healthcare workers in patient facing roles will continue. Changes to testing will be kept under regular clinical review.

Coronavirus (COVID-19): staff testing in NHS Scotland - gov.scot (www.gov.scot)

Updated guidance on facemasks in social care settings

Scotlands vaccination programme has so far seen more than 12 million Covid-19 vaccine doses administered in Scotland.

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Pausing asymptomatic Covid-19 testing - gov.scot - The Scottish Government

ANNMARIE TIMMINS| New Hampshire Bulletin

When COVID-19 hospitalizations hit 433 in January,hospitals were so desperate for spacethey treated some patients in hallways and sent others to neighboring states. But even as the number of COVID-19 patients has plummeted, hospital beds remain in high demand.

On Sunday, the most recent data available, just 10 percent of regular beds and 20 percent of ICU beds were available in the state, according to the Department of Health and Human Servicesdata tracker(covid19.nh.gov/dashboard/hospitals.) In certain parts of the state, those numbers were even lower.

The reasons are many, and the impact varies hospital to hospital.

Asked whats driving high occupancy rates, health care officials across the state cited various factors, from workforce challenges to more local options for specialty care that once required a trip to Boston. One hospital spokesperson cited an increase in behavioral health patients. Notably, the issue that gets the most attention and blame, delayed care, wasnt on their lists.

While they are seeing patients who are sicker because they put off care during the pandemic, they said there is no reliable data to quantify how often thats happening.

Things that someone would have put off that could lead to hospitalization, like heart failure, fluid management, management of diabetes, or vascular problems, are really difficult to timestamp because they kind of happen at one point or another, said Dr. Kevin Desrosiers, chief medical officer at Elliot Hospital in Manchester. And its hard to know if this is the result of a chronic lack of management or just an acute event.

The state Department of Health and Human Services reports daily occupancy rates at 26 hospitals and four specialty hospitals on its COVID-19 dashboard. When coronavirus patients were filling hospital beds, the data helped illustrate the intense demand on hospitals.

Its harder to interpret the rate now that COVID-19 hospitalizations have fallen below 100 most days, a number that includes active infections and patients recovering from the disease. Thats due to a few reasons. There is no universal ideal hospital occupancy rate to use as a comparison. And the same occupancy rate means different things at different hospitals, depending on their size, staffing, and acuity of their patients health problems.

Parkland Medical Center in Derry was at 95 percent capacity recently, with an average daily census of 47, said spokesman Ryan Lawrence. Unlike some hospitals, it can look to two other hospitals in its HCA Healthcare network when its tight on beds: Portsmouth Regional Hospital and Frisbie Memorial Hospital in Rochester. But like other hospitals, staffing beds has been a challenge as increasing numbers of health care workers have left their jobs.

Lawrence said HCA Healthcare is trying to recruit and retain staff by increasing wages for nursing and support staff. It has also expanded its staffing pipeline, he said, by offering tuition reimbursement, nurse residency programs, and $800,000 in scholarships for people pursuing careers as a nurse or licensed nursing assistant.

Desrosiers said admissions at Elliot Hospital, which has 296 beds, were increasing before the pandemic. Prior to 2019, the hospital typically had 180 patients a day during the summer, a slower season. That jumped to more than 300 at the peak of the pandemic. But even when the hospital had eight to 10 COVID-19 patients in the summer of 2020 and the following spring, admissions rarely dropped below 220, Desrosiers said.

He pointed to new health care options available to patients.

The hospital opened its new cancer center before the pandemic, making it easier for people to get medical and radiation oncology in one place. It has renovated its emergency room, and is offering more outpatient medical care.

It has a 30-bed neonatal intensive care unit, giving families who would have traveled to Boston a local option. Similarly, it has stepped up its care for adults by having intensive care physicians on site seven days a week, 24 hours a day, Desrosiers said. And the hospital now offers high end neurosurgery and is expanding its vascular surgical care.

So as weve been able to increase our complexity and build the infrastructure to support it, we certainly have seen an increase in demand, he said.

Like Lawrence, Desrosiers said health care is available only if there are health care workers to provide it.

The key for us is really working hard to make sure were staying ahead of (workforce challenges), he said. So, really understanding whats happening in the market, what people are looking to do, and how we can retain some of our own staff. I think for us, its been about really trying to create a great place to work and make sure that were competitive with wages.

Managing occupancy has hospital leadership also thinking about improving efficiency.

Its really just about making sure that were constantly focusing on our processes to make sure that patients are getting all the care they need at the right time, minimize any sort of waiting, and then making sure patients can kind of flow through the system, Desrosiers said. Were constantly looking hourly, you know, what the beds, what the census looks like, and how many patients we expect to have a discharge. And working hard with our discharge partners, whether the patients are going home with services or going to a skilled nursing facility, that all of those pieces need to line up correctly.

That includes lining up transportation, sorting out insurance coverage, and keeping other administrative tasks on track to ensure patients arent occupying a bed longer than they need to.

The resource is certainly going to be there, Desrosiers said. The question is, When will it be? Now or an hour from now? We want to prevent long waits for people, so were doing everything we can to make sure we are as efficient as we can be and serve those patients right when they need care. Thats definitely a challenge.

This story was originally published byNew Hampshire Bulletin.

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Hospital beds are full but not with COVID-19 patients - Seacoastonline.com

Certain states are proposing that out-of-state telemedicine care should be more accessible, which researchers believe is a trend that will continue.

The relaxation of out-of-state telemedicine restrictions could make it more convenient for certain populations to access medical care, according to a study published in JAMA Health Forum. The study authors also identified mental illness as the reason for many out-of-state telemedicine visits.

We find that during a period where licensure regulations were temporarily waived, out-of-state telemedicine visits were common and used most by patients who live near state borders or in rural communities, those receiving primary care services and mental health treatment, and those receiving cancer care, the researchers wrote in the report.

During the pandemic, most states temporality allowed medical practitioners in one state to treat patients living in another, which made it easier to access care, regardless of whether the practitioner was licensed in that state. Federal- and state-level debate persists about whether this policy should continue, according to the study authors.

A proposed solution is telemedicine licensures, which would allow medical practitioners to practice in all states that are part of the Medicare program. Another proposed solution is for states to join the Interstate Medical Licensure Compact, which would decrease the time it takes for a practitioner to receive an out-of-state medical license.

From January 2021 to June 2021, researchers conducted a cross-sectional study of all telemedicine visits made by patients who have traditional Medicare. They used these data to understand how out-of-state telemedicine was being used during the COVID-19 pandemic and who it would impact.

Researchers counted 8,392,092 telemedicine visits during this time. Among these patients, 422,547 (5%) had at least 1 out-of-state visit. Additionally, individuals living within 15 miles of another states border accounted for more than half (57.2%) of all out-of-state telemedicine visits.

Just over 62% of all out-of-state visits were with the same clinician that the individual saw at a previous in-person visit. There were noticeable differences in telemedicine use among certain demographics.

Among those with a telemedicine visit, people in rural communities were more likely to receive out-of-state telemedicine care (33.8% vs 21.0%), and there was high of out-of-state telemedicine use for cancer care (9.8% of all telemedicine visits for cancer care), the study authors wrote.

Limitations of the study include the population sample, who were only Medicare recipients. Additionally, the researchers determined out-of-state visits based on home address and the clinicians practicing office, which might not reflect where the clinician is billed or is mainly based. The team also did not account for the differences between in-state and out-of-state telemedicine visits.

The findings of this cross-sectional study suggest that licensure restrictions of out-of-state telemedicine would have had the largest effect on patients who lived near a state border, those in rural locales, and those who received primary care or mental health treatment, the study authors wrote.

Reference

Mehrotra, Ateev, Huskamp, Haiden, Nimgaonkar, Alok, et al. Receipt of Out-of-State Telemedicine Visits Among Medicare Beneficiaries During the COVID-19 Pandemic. September 16, 2022. JAMA Health Forum. 2022;3(9):e223013. doi:10.1001/jamahealthforum.2022.3013

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Study: Out-of-State Telemedicine Visits Were Common During the COVID-19 Pandemic - Pharmacy Times

Sample designSample recruitment and response rate

A detailed presentation of CPENS methodology is provided by Michaud et al.1. Briefly, a general population probability-based random sample (GPRS) from all provinces was used to recruit respondents via telephone to the online survey. For this study, the sample was created using two approaches. A random digit dialing approach (i.e., GPRS) for the general population across the country where the sample was pulled randomly by province proportionally to their size nationally, and by postal codes of the First Nations and remote areas in order to oversample those specific groups. Non-respondents that did not complete the survey were sent a reminder message at 3 and 6days after the initial recruitment. Of the 22,892 potentially eligible participants, 11,492 were recruited to the survey, for a recruitment rate of 50.6%. Of the 11,492 recruited participants, 6647 completed the online survey, for an overall response rate among eligible respondents of 29.0%. To achieve a representative sample of rural, urban, and suburban areas, survey data were weighted with the most recent Statistics Canada census data. This also corrected for over and under sampled groups in certain geographic locations. There was no evidence of extreme values in the weighted data that would indicate a sampling bias. The margin of error for the study was1.2%, at a 95% confidence level (i.e., 19 times out of 20).

The sampling frame was set to target respondents from remote/rural, suburban and urban areas in all ten Canadian provinces using the forward sortation area (FSA) postal code information22. Respondents indicated the geographic region that best corresponded to the area in which they lived based on population size. Because some postal codes can be both rural and urban, geographic region in the statistical analysis was based on self-reported geographic region.

The questionnaire included content to evaluate noise perception, annoyance, and expectations of quiet, health-related and socio-demographic variables. The average length of time to complete the online questionnaire was just under 10min. The questionnaire was designed by Health Canada and pre-tested in both English and French. For the pretesting, 299 people were recruited by phone (212 in English and 87 in French). This led to 72 completed online surveys (61 English, and 11 French). Minor changes made to the survey after pre-testing did not affect the pre-test data, allowing results collected during the pre-test to be included in the final analysis. The English and French versions of the survey are available through Libraryand Archives Canada23.

In CPENS, participants were asked to indicate how they have been personally affected by the COVID-19 pandemic with respect to physical health, mental health, annoyance toward environmental noise, annoyance toward indoor noise, stress in their life, and overall well-being. Response categories for these six outcome variables were as follows: much worse, somewhat worse, unchanged, somewhat improved, and much improved. For modelling, the responses were grouped as: somewhat/much worse and unchanged/somewhat/much improved. When reporting prevalence rates the responses were grouped into the three following categories: somewhat/much worse, unchanged and somewhat/much improved. A number of other variables were collected in CPENS that were considered to be potentially associated to the six evaluated outcomes. These included the demographic variables such as age, gender, education, income and Indigenous status. Age in years was divided into three groups (1834, 3554, 55 +). The following gender categories were defined (female, male, other/prefer not to say). Education was rated as: up to high school diploma or equivalent, certificate or diploma, bachelor's degree or post graduate degree. A certificate or diploma could be from a registered apprenticeship, or other trade, college, CEGEP (i.e., Quebec College) or other non-university, university below bachelor's level. Total household income in Canadian dollars was grouped as follows: under $40K, $40K to just under $80K, $80K to just under $150K, $150K and above. Indigenous status was grouped as follows: Self identify as First Nation/ Mtis/Inuk (Inuit), or Do not self identify. Province of residence as well as geographic region were also considered as potential predictor variables since the response to the pandemic differed by province as well as geographic region. Due to the smaller sample sizes, the Prairie Provinces (i.e., Manitoba and Saskatchewan), were grouped together as were the Atlantic Provinces (i.e., New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland & Labrador). The remaining provinces (British Columbia, Alberta, Ontario and Quebec) were classified independently. Self-reported geographic region was defined as rural/remote (i.e.,<1000 to 10,000 inhabitants), suburban (i.e., a mixed-use or residential area, existing either as part of a city or urban area, or as a separate residential community within commuting distance of a city) and urban (i.e., 10,000+ inhabitants).

A respondents current work or school situation was also considered. Respondents self-identified as follows: working or attending school outside their home; working or attending school inside their home; retired; unemployed; and a portion of those indicating other could be grouped as on paid leave (i.e., sick, maternity, and disability). More than one option could be selected; therefore, each situation was considered separately as a Yes/No response.

Other variables considered included, sleep disturbance (for any reason at home over the previous 12months), classified as highly sleep disturbed (rating 8 to 10) versus not highly sleep disturbed (rating 0 to 7). Similarly, sensitivity to noise was defined as highly sensitive to noise (rating 8 to 10) versus not highly sensitive to noise (rating 0 to 7). Participants were asked to rate their overall physical health relative to someone of their age, and their overall mental health (no reference to age). For both of these questions the responses included the following: poor; fair; good; very good; and excellent. These were collapsed as: poor/fair and good/very good/excellent. Heart disease including high blood pressure, anxiety or depression, sleep disorder, and hearing loss were also evaluated as diagnosed by a healthcare professional, not diagnosed but suffer from the condition, or does not apply. Affirming a diagnosis was assumed to indicate the condition was current, and not one that historically existed, but no longer current.

Weighted frequencies and cross-tabulations were used to explore the distribution of demographics and characteristics of the population by Indigenous status and geographic region. Cross-tabulations of each of the health-related outcomes and noise annoyance variables affected by the pandemic with Indigenous status and geographic region were also considered. Chi-square tests of independence compared Indigenous status to non-Indigenous respondents, as well as geographic regions.

Initial univariate logistic regression models were used to investigate the relationship between each of the health-related outcomes, including noise annoyance variables and other variables of interest, as mentioned above. Unadjusted odds ratios (ORs) are reported for each relationship in Supplemental Material (see Table S1). Finally, a multivariate logistic regression model was developed using stepwise regression techniques with a significance level of the chi-square for entering an effect into the model equal to 20% and the significance level of the chi-square for an effect to remain in the model of 5%. Adjusted ORs are reported for the final models for each evaluated outcome affected by the pandemic. Confidence intervals (CI) of ORs including the value 1 indicate insufficient evidence to observe an association between the outcome evaluated and variable under investigation.

Statistical analysis was performed using SAS Enterprise Guide 7.15 (SAS Institute Inc., Cary, NC). A 0.05 statistical significance level was implemented throughout unless otherwise stated. In addition, Bonferroni corrections were made to account for all pairwise comparisons to ensure that the overall Type I (false positive) error rate was less than 0.05. Estimates with a coefficient of variation (CV) between 16.6 and 33.3% were designated E and must be interpreted with caution due to the high sampling variability associated with it; CV estimates that exceeded 33.3% were designated F indicating that these data could not be released due to questionable validity. No results are reported for cell frequencies less than 10.

This study was approved by the Health Canada and Public Health Agency of Canada Review Ethics Board (Protocol no. REB 2020-038H). Informed consent is implied in the voluntary response to the survey questionnaire. This research was conducted in accordance with all relevant Government of Canada guidelines and regulations for conducting online surveys.

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Implications of the COVID-19 pandemic on self-reported health status and noise annoyance in rural and non-rural Canada | Scientific Reports -...

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Strokes, seizures, memory and movement disorders among problems that develop in first year after infection

A comprehensive analysis of federal data by researchers at Washington University School of Medicine in St. Louis shows people who have had COVID-19 are at an elevated risk of developing neurological conditions within the first year after infection. Movement disorders, memory problems, strokes and seizures are among the complications.

If youve had COVID-19, it may still be messing with your brain. Those who have been infected with the virus are at increased risk of developing a range of neurological conditions in the first year after the infection, new research shows. Such complications include strokes, cognitive and memory problems, depression, anxiety and migraine headaches, according to a comprehensive analysis of federal health data by researchers at Washington University School of Medicine in St. Louis and the Veterans Affairs St. Louis Health Care system.

Additionally, the post-COVID brain is associated with movement disorders, from tremors and involuntary muscle contractions to epileptic seizures, hearing and vision abnormalities, and balance and coordination difficulties as well as other symptoms similar to what is experienced with Parkinsons disease.

The findings are published Sept. 22 in Nature Medicine.

Our study provides a comprehensive assessment of the long-term neurologic consequences of COVID-19, said senior author Ziyad Al-Aly, MD, a clinical epidemiologist at Washington University. Past studies have examined a narrower set of neurological outcomes, mostly in hospitalized patients. We evaluated 44 brain and other neurologic disorders among both nonhospitalized and hospitalized patients, including those admitted to the intensive care unit. The results show the devastating long-term effects of COVID-19. These are part and parcel of long COVID. The virus is not always as benign as some people think it is.

Overall, COVID-19 has contributed to more than 40 million new cases of neurological disorders worldwide, Al-Aly said.

Other than having a COVID infection, specific risk factors for long-term neurological problems are scarce. Were seeing brain problems in previously healthy individuals and those who have had mild infections, Al-Aly said. It doesnt matter if you are young or old, female or male, or what your race is. It doesnt matter if you smoked or not, or if you had other unhealthy habits or conditions.

Few people in the study were vaccinated for COVID-19 because the vaccines were not yet widely available during the time span of the study, from March 2020 through early January 2021. The data also predates delta, omicron and other COVID variants.

A previous study in Nature Medicine led by Al-Aly found that vaccines slightly reduce by about 20% the risk of long-term brain problems. It is definitely important to get vaccinated but also important to understand that they do not offer complete protection against these long-term neurologic disorders, Al-Aly said.

The researchers analyzed about 14 million de-identified medical records in a database maintained by the U.S. Department of Veterans Affairs, the nations largest integrated health-care system. Patients included all ages, races and sexes.

They created a controlled data set of 154,000 people who had tested positive for COVID-19 sometime from March 1, 2020, through Jan. 15, 2021, and who had survived the first 30 days after infection. Statistical modeling was used to compare neurological outcomes in the COVID-19 data set with two other groups of people not infected with the virus: a control group of more than 5.6 million patients who did not have COVID-19 during the same time frame; and a control group of more than 5.8 million people from March 2018 to December 31, 2019, long before the virus infected and killed millions across the globe.

People who have had COVID-19 are at an elevated risk of developing neurological conditions within the first year after infection, according to a detailed analysis of federal data by researchers at Washington University School of Medicine in St. Louis. Movement disorders, memory problems, strokes and seizures are among the complications.

The researchers examined brain health over a year-long period. Neurological conditions occurred in 7% more people with COVID-19 compared with those who had not been infected with the virus. Extrapolating this percentage based on the number of COVID-19 cases in the U.S., that translates to roughly 6.6 million people who have suffered brain impairments associated with the virus.

Memory problems colloquially called brain fog are one of the most common brain-related, long-COVID symptoms. Compared with those in the control groups, people who contracted the virus were at a 77% increased risk of developing memory problems. These problems resolve in some people but persist in many others, Al-Aly said. At this point, the proportion of people who get better versus those with long-lasting problems is unknown.

Interestingly, the researchers noted an increased risk of Alzheimers disease among those infected with the virus. There were two more cases of Alzheimers per 1,000 people with COVID-19 compared with the control groups. Its unlikely that someone who has had COVID-19 will just get Alzheimers out of the blue, Al-Aly said. Alzheimers takes years to manifest. But what we suspect is happening is that people who have a predisposition to Alzheimers may be pushed over the edge by COVID, meaning theyre on a faster track to develop the disease. Its rare but concerning.

Also compared to the control groups, people who had the virus were 50% more likely to suffer from an ischemic stroke, which strikes when a blood clot or other obstruction blocks an arterys ability to supply blood and oxygen to the brain. Ischemic strokes account for the majority of all strokes, and can lead to difficulty speaking, cognitive confusion, vision problems, the loss of feeling on one side of the body, permanent brain damage, paralysis and death.

There have been several studies by other researchers that have shown, in mice and humans, that SARS-CoV-2 can attack the lining of the blood vessels and then then trigger a stroke or seizure, Al-Aly said. It helps explain how someone with no risk factors could suddenly have a stroke.

Overall, compared to the uninfected, people who had COVID-19 were 80% more likely to suffer from epilepsy or seizures, 43% more likely to develop mental health disorders such as anxiety or depression, 35% more likely to experience mild to severe headaches, and 42% more likely to encounter movement disorders. The latter includes involuntary muscle contractions, tremors and other Parkinsons-like symptoms.

COVID-19 sufferers were also 30% more likely to have eye problems such as blurred vision, dryness and retinal inflammation; and they were 22% more likely to develop hearing abnormalities such as tinnitus, or ringing in the ears.

Our study adds to this growing body of evidence by providing a comprehensive account of the neurologic consequences of COVID-19 one year after infection, Al-Aly said.

Long COVIDs effects on the brain and other systems emphasize the need for governments and health systems to develop policy, and public health and prevention strategies to manage the ongoing pandemic and devise plans for a post-COVID world, Al-Aly said. Given the colossal scale of the pandemic, meeting these challenges requires urgent and coordinated but, so far, absent global, national and regional response strategies, he said.

Ziyad Al-Aly, MD, has lead multiple studies on long COVID as a clinical epidemiologist at Washington University School of Medicine in St. Louis and the Veterans Affairs St. Louis Health Care system. His research has included the devastating effects of the virus on the heart, kidneys and mental health.

Xu E, Xie Y, Al-Aly Z. Long-term Neurologic Outcomes of COVID-19. Nature Medicine. Sept. 22, 2022. DOI: https://doi.org/10.1038/s41591-022-02001-z

This research was funded by the U.S. Department of Veterans Affairs; the American Society of Nephrology; and KidneyCure. The data that support the findings of this study are available from the U.S. Department of Veterans Affairs. VA data are made freely available to researchers behind the VA firewall with an approved VA study protocol.

About Washington University School of Medicine

WashU Medicine is a global leader in academic medicine, including biomedical research, patient care and educational programs with 2,700 faculty. Its National Institutes of Health (NIH) research funding portfolio is the fourth largest among U.S. medical schools, has grown 54% in the last five years, and, together with institutional investment, WashU Medicine commits well over $1 billion annually to basic and clinical research innovation and training. Its faculty practice is consistently within the top five in the country, with more than 1,790 faculty physicians practicing at over 60 locations and who are also the medical staffs of Barnes-Jewish and St. Louis Childrens hospitals of BJC HealthCare. WashU Medicine has a storied history in MD/PhD training, recently dedicated $100 million to scholarships and curriculum renewal for its medical students, and is home to top-notch training programs in every medical subspecialty as well as physical therapy, occupational therapy, and audiology and communications sciences.

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COVID-19 infections increase risk of long-term brain problems Washington University School of Medicine in St. Louis - Washington University School of...