New commentary paper highlights costs of defects in surgical care and calls for elimination of defects in value

A well-designed and well-executed holistic approach to eliminating defects in surgical care through creation of Centers of Excellence has potential to simultaneously decrease costs and increase value

Peer-Reviewed Publication

UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER

CLEVELAND – A commentary, published in the Nov. 3 issue of the journal NEJM Catalyst Innovations in Care Delivery, highlights how defects in surgical care could be diminished or eliminated for the benefit of patients and to lower costs in American health care spending.

“While prior reports have commented on individual defects in surgical care, we believe that the current article is the first to summarize the opportunity to reduce defects in surgical care,” said author David W. Dietz, MD, Chief, Division of Colorectal Surgery, and Vice President of System Surgery Quality, University Hospitals Cleveland Medical Center.

Using colorectal surgery to provide examples and national estimates of the costs of defects in surgical care, the paper summarizes a holistic approach to eliminating defects in surgical care and offers a framework for centers of excellence for removing them.

“Defects in health care are common and can be defined as behaviors, based on known evidence, that needlessly reduce the quality of care and patient experience or add to the annual total costs of care,” said Dr. Dietz.

“We are now entering a new era in medicine and surgery in which the focus will be elevated from the quality of care to its value,” he said. “High-value health care is achieved when excellent outcomes, including patient experience, are achieved at reasonable costs.  As surgery accounts for nearly half of all Medicare spending, surgeons will have a critical role in this journey.”

Co-author Peter Pronovost, MD, estimates the U.S. health care system spends $1.4 trillion annually—one-third of health care costs—on defects.  At his own institution, University Hospitals in Cleveland, where he is the Chief Clinical Transformation Officer, he found that focused efforts to reveal and reduce defects improved quality and reduced Medicare costs by 9 percent. Dr. Pronovost is also Professor, schools of Medicine, Nursing, and Management, Case Western Reserve University.

In their new paper, Drs. Dietz and Pronovost estimate that defects in colorectal surgery cost the American health care system more than $12 billion.  The authors discuss eight areas (or domains) of defects that waste money and/or contribute to lower value in care for colorectal surgery patients.

They are:

• Difficulty in Accessing Care, where patients may find navigating health systems difficult and unable to find information about the quality of surgeons or hospitals. “While this defect may or may not drive up costs, it results in low-value care by compromising patient experience and quality of life. For example, patients with rectal cancer who are treated by a non-specialist surgeon are much more likely to end up with a permanent colostomy,” said Dr. Pronovost.

• Difficulty Supporting Shared Decision-Making – Under the current fee-for-service system in the U.S. health system, surgeons have pressure to see more patients, making it difficult for them to spend adequate time answering questions and discussing treatment alternatives. While researchers have developed patient decision aids for diseases such as ulcerative colitis and colorectal cancer, these aids are rarely used in clinical practice. This situation leads to less-satisfactory outcomes.

• Inappropriate Care - One study estimates that 10 percent to 20 percent of all wasteful spending in U.S. health care is for overtreatment, overuse, and unnecessary care, accounting for $70 billion to $200 billion annually. For virtually every procedure studied, 30 percent are unnecessary if clinicians use rigorous appropriateness criteria. These services land squarely in the realm of no-value care because the patient cannot gain clinical benefits.

• Low-Value Site of Care - Many surgical procedures are performed at expensive inpatient facilities when they could be performed at an ambulatory center for 50 percent less. 

• Care at Low-Volume Hospitals by Low-Volume Surgeons - Outcomes of many major surgical procedures are strongly correlated with the annual volume performed at the hospital and by the surgeon. Yet many patients continue to be treated by low-volume hospitals and providers, even when a high-volume option is less than 30 miles away. When treated by low-volume providers, patients with rectal cancer are more likely to undergo abdominoperineal resection, to end up with a permanent colostomy, and to have worse survival.

• Care with Avoidable Complications - Colorectal surgery procedures are associated with some of the highest rates of postoperative complications across the country. A recent study showed that 70 percent of patients have at least one complication, with an associated cost increase of nearly 40 percent. The most serious complication of colorectal surgery—anastomotic leak—increases the cost of hospitalization by $8,000. A reduction in the rate of anastomotic leak from 15 percent to 10 percent nationally would save $20.4 million annually. If 75 percent of anastomotic leaks could be avoided after colorectal surgery, $32.1 million in health care costs could be saved annually in U.S.

• Avoidable Post-Acute Care - Discharge to post-acute care is a common practice for patients undergoing any major surgery. Reasons for post-acute care include advanced age, poor functional status, and preventable postoperative complications. One study showed significant variability between hospitals in terms of post-acute care spending for patients managed with colectomy.

• Preventable Readmissions - Readmissions after surgery represent potentially low-quality care and increased costs to the health system. Yet readmissions are also indicative of the patient’s health: either it is deteriorating or the patient gained no clinical benefit from the procedure. Such circumstances represent no-value care scenarios. Approximately 14 percent of patients who have undergone colorectal surgery are readmitted after being discharged. Commons reasons for readmission include surgical site infections, small bowel obstruction, and dehydration in patients undergoing ileostomy. One study examined readmissions after colorectal surgery from 2013 to 2016 and showed that 40 percent were preventable. The median cost per stay was $8,885 (based on 2002–2008 data); thus, $300 million in cost-savings could be achieved per year by preventing unnecessary readmissions.

“Given the abundance of opportunities presented, a ‘whack-a-mole’ approach to address them individually seems inefficient and overwhelming,” said Dr. Pronovost. “However, a holistic approach through the creation of Centers of Excellence (COEs), if well designed and well executed, can address all of these defects”

Dr. Pronovost said, “COEs are a systematic attempt to design surgical care to eliminate all or most of these defects.  In COEs, we provide frictionless access; we provide patient navigation; we use explicit appropriateness criteria to ensure patients will benefit from the procedure; we ensure the procedure is done at the highest value site of service by a surgeon and at a hospital that has high volume; we use standard protocols, yet personalize when needed to eliminate preventable harm; we ensure patients go home rather than to a post-acute facility when possible.   As a result; quality and experience increase and cost decrease.”  University Hospitals has created COEs, for example, for joint replacement surgery, spine surgery, and atrial fibrillation ablation and is creating one for colorectal surgery.  

“If we are to finally improve the value of surgical care in the U.S., we need to ensure that surgeons are engaged in the process and that principles for quality improvement are also applied to identify and eliminate all defects in value in surgical care,” he said.

Other authors of the paper are William V. Padula, PhD, MS, Assistant Professor, Department of Pharmaceutical & Health Economics, School of Pharmacy; Fellow, Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles; and Hanke Zheng, MS, Graduate Research Assistant, Department of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles.

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About University Hospitals / Cleveland, Ohio
Founded in 1866, University Hospitals serves the needs of patients through an integrated network of 23 hospitals (including 5 joint ventures), more than 50 health centers and outpatient facilities, and over 200 physician offices in 16 counties throughout northern Ohio. The system’s flagship quaternary care, academic medical center, University Hospitals Cleveland Medical Center, is affiliated with Case Western Reserve University School of Medicine, Oxford University and the Technion Israel Institute of Technology. The main campus also includes the UH Rainbow Babies & Children's Hospital, ranked among the top children’s hospitals in the nation; UH MacDonald Women's Hospital, Ohio's only hospital for women; and UH Seidman Cancer Center, part of the NCI-designated Case Comprehensive Cancer Center. UH is home to some of the most prestigious clinical and research programs in the nation, with more than 3,000 active clinical trials and research studies underway. UH Cleveland Medical Center is perennially among the highest performers in national ranking surveys, including “America’s Best Hospitals” from U.S. News & World Report. UH is also home to 19 Clinical Care Delivery and Research Institutes. UH is one of the largest employers in Northeast Ohio with more than 30,000 employees. Follow UH on LinkedIn, Facebook and Twitter. For more information, visit UHhospitals.org.

 

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JOURNAL

NEJM Catalyst

METHOD OF RESEARCH

Literature review

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

Costs of Defects in Surgical Care: A Call to Eliminate Defects in Value

Combating antibiotic resistance

As bacterial infections impervious to drugs rise, so does the need to develop better antibiotics

Peer-Reviewed Publication

HARVARD MEDICAL SCHOOL

As long as antibiotics have existed, so too has antibiotic resistance—the inevitable result as infectious bacteria continually evolve to evade the very drugs designed to kill them.

Today, antibiotic resistance is considered a major global health threat. In the United States, The Centers for Disease Control and Prevention estimates that every year, at least 2.8 million people develop infections resistant to antibiotics, leading to more than 35,000 deaths. Yet, in recent decades, antibiotic development has been slow, and no new classes of antibiotics have reached the market. Meanwhile, widespread use of the limited number of antibiotics currently available has spurred more bacterial strains to develop resistance, with additional strains already resistant to available antibiotics being discovered, often in hospitals. This situation is expected only to worsen over time, resulting in more drug-resistant bacterial infections and deaths.

Maofu Liao, an associate professor of cell biology in the Blavatnik Institute at Harvard Medical School, spoke with Harvard Medicine News about antibiotic resistance and the challenges of developing new antibiotics.

Liao explained how his team’s research on protein structures in bacteria could inform antibiotic design and described a new pipeline his lab is establishing to improve the process.

In a newly published study in Science, Liao and colleagues demonstrated that their pipeline can effectively identify compounds that interfere with essential proteins in bacteria and thus may have potential as antibiotics.

HM News: What are some of the most pressing challenges with currently available antibiotics?

Liao: One issue is that most drug development efforts depend on industry, but antibiotics are time-consuming and expensive to develop—and often aren’t necessarily required for treatment and aren’t taken by patients on a regular basis. It’s hard to make the business case to industry that it’s worthwhile to develop new antibiotics when so much effort and money are required, and profit isn’t predictable or immediate. A second issue is the way we use antibiotics. For a long time, we have relied on single-use antibiotics, or a limited combination of antibiotics. This makes it easy for bacteria to acquire resistance. They can then transfer that capability to other bacteria that have not been exposed to antibiotics. So, we are using very limited tools that bacteria can easily overcome.       

Another critical issue is how we develop antibiotics. With few exceptions, our efforts to identify new antibiotics mostly rely on chemical screens against bacterial growth. People do a screen and hope to find some magical compound that can kill the bacteria with great efficacy. Once they have that, they hand the compound to chemists who optimize it and hopefully develop it into a clinically useful antibiotic. Such screens cannot target specific proteins in bacteria, and may exclude compounds that have the potential to attack crucial bacterial proteins. Moreover, for antibiotics developed through such screens, we often don’t know the underlying mechanism of how they work, or why they stop working when resistance occurs. This is a critical gap in our current approach.

HM News: What are you studying in the realm of antibiotic resistance?

Liao: I have a longstanding interest in studying how proteins work, so I come into the field on the protein mechanism side. Inside humans, or any living organisms, there are many proteins that do many different things. In bacteria, some of these proteins are doing essential work—so if the proteins get disrupted, the bacteria are not happy and may even die. That’s something we’d like to exploit. First, we want to understand how these essential proteins inside bacteria work and then we want to use this information to direct our effort to kill the bacteria with antibiotics.

HM News: Can you provide more detail about the bacteria you study?

Liao: Most of our work is on E. coli, which is a model organism related to many pathogenic bacteria. E. coli is a type of Gram-negative bacteria, which means it has an extra membrane in addition to the regular membrane around the cell. That extra outer membrane is vital for keeping the microbe alive. It prevents a lot of things from entering the cell, including antibiotics, and plays a key role in antibiotic resistance. The outer membrane is made of lipids, but many of these lipid molecules are attached to long chains of polysaccharides, or sugars—so the membrane looks hairy, but those hairs are actually sugar chains. These are large, strange lipid molecules called lipopolysaccharides that have to be synthesized inside the cell and then transported to the outer membrane where they are assembled. We are studying the proteins involved in transporting these lipids from inside the cell to the outer surface. The proteins involved in the transport process are essential for E. coli survival and growth. If we can somehow interfere with the function of these transport proteins, we may affect bacterial growth and survival.

HM News: You are using a technique called Cryo-EM in your research. What are the benefits of this technique?

Liao: Cryo-EM is a microscopy technique used in structural biology, which is a field that aims to see small things in high resolution. Traditional structural biology relied on methods like X-ray crystallography to obtain high-resolution details of protein structure. However, with X-ray crystallography you have to put your protein in crystal contact instead of in solution, which makes it difficult to observe all the different conformations, or shapes, of the protein—only some of which may be relevant. Cryo-EM is more flexible because it doesn't require crystal contact. You freeze your protein sample in ice, put it into the microscope, and take many, many images. Those images can be put together and processed to obtain high-resolution structures of the protein in its different conformations. This method helps us obtain critical insights into how transporter proteins in E. coli work. We are able to look at the entire protein–lipid complex in high resolution to see how the protein interacts with its lipid substrate in a lot of detail. 

HM News: How can insights from cryo-EM improve antibiotic development?

Liao: We are trying to build an entirely new pipeline for antibiotic development. The pipeline starts with a chemical screen to find a compound that can stop the activity of essential proteins in bacteria. Once we have that, we use cryo-EM to obtain the high-resolution structure of the target protein bound to the compound. Then we know which pocket the compound binds on the protein and we gain high-resolution information about the binding pocket. We use the structural information about that so-called druggable pocket to do a virtual screen, potentially using artificial intelligence, to find other compounds with other chemical backbones—or scaffolds—that bind to the same pocket on the protein. So, we ask the question: What other compounds with other scaffolds can take advantage of this pocket that worked for the first compound? Next, we use cryo-EM to determine the structure of the protein bound to any new compound that was identified, and confirm the compound’s effect on protein activity and bacterial growth. We do that so we can validate our prediction and get more detailed information about how every part of the new compound interacts with the pocket; which parts are more important, which parts are less important. We also get information about the potential variations of the druggable pocket when the protein is bound to the new compound, so we can better understand the interplay between the protein and compound. This gives us a rational way to further optimize the compound as it is developed into an antibiotic. In our recent paper in Science, we successfully used this pipeline to identify a completely different compound that had the same effect on an essential transporter protein as our starting compound.

HM News: What is the long-term goal for your pipeline?

Liao: We are still doing the initial work to demonstrate the power of our pipeline, but as we focus on these essential transporter proteins, we hope this information can be used to develop better antibiotics. During our research, we realized that knowing the mechanism of a compound and having high-resolution information about how the compound interacts with a target protein really breaks open many possibilities of antibiotic drug development. It allows us to use more rational approaches to develop antibiotics efficiently. Our goal is to change the way we develop antibiotics. We would like to show that new ideas and new technologies can transform antibiotic discovery into a more systematic, rational, and robust process.

I hope that in the future, by changing the way we develop antibiotics, humans can eventually win the race of antibiotic resistance. I think we should develop a wide range of broad-spectrum and narrow-spectrum antibiotics: We should have multiple drugs to target multiple proteins inside bacteria and we should have multiple drugs to target the same essential protein through different mechanisms, such as different drug pockets. If we have a large array of useful antibiotics, bacteria should not be able to develop resistance so easily. Plus, then we can combine different antibiotics for different patients based on their particular disease and infection conditions to get the best results. First, we need the tools, then we can have clever ways to use them. But if we don’t have the tools in hand, there’s really nothing we can do.

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JOURNAL

Science

DOI

10.1126/science.abi9009 

ARTICLE TITLE

Distinct allosteric mechanisms of first-generation MsbA inhibitors

ARTICLE PUBLICATION DATE

23-Sep-2021

OLDER DRUG CHEAPER TOO

Popular heart failure drug no better than older drug in sickest patients

Study suggests older drug may be safer for an advanced form of heart failure

Peer-Reviewed Publication

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE

A new study led by researchers at Washington University School of Medicine in St. Louis suggests that a widely used heart failure drug named sacubitril/valsartan is no better than valsartan alone in patients with severe heart failure. The study also provides evidence that the treatment with valsartan may be slightly safer for patients with advanced heart failure.

The study was published online Nov. 3 in JAMA Cardiology.

Heart failure is one of the leading causes of hospitalization in the United States, with about two heart failure hospitalizations occurring every minute. It is often triggered by damage to the heart from, for example, a heart attack or a viral infection. A complex clinical syndrome, heart failure leads to increased retention of salt and water by the kidneys. This results in a buildup of fluid in the lungs, causing shortness of breath and fatigue. The body’s response to heart damage is to activate hormonal regulatory systems that attempt to restore normal blood flow to vital organs. Over time, these hormonal systems can lead to secondary damage to the heart and the circulation, resulting in worsening heart failure. Most drugs used to treat heart failure block the harmful effects of high levels of the compensatory hormones.

The study, called the LIFE trial, focused on advanced heart failure patients with reduced pumping capacity, referred to as Heart Failure with a Reduced Ejection Fraction (HFrEF).

“Patients with the most severe heart failure are often not included in clinical trials because they’re so severely ill they don’t qualify to participate,” said first author and Washington University cardiologist Douglas L. Mann, MD, the Tobias and Hortense Lewin Professor of Medicine. “We wanted to study these patients because their condition is so much worse than that of patients with mild or moderate heart failure. It’s basically a different disease. Because medical therapies are limited in these patients, the only treatment options are cardiac transplantation or left ventricular assist devices. Our hope was that treatment with sacubitril/valsartan would prevent the need to transplant patients or use expensive mechanical circulatory assist devices.”

The combination drug sacubitril/valsartan was shown to be more effective than the standard of care — treatment with an angiotensin converting enzyme inhibitor — in a previous large clinical trial involving more than 8,000 heart failure patients with a reduced ejection fraction, but only 60 patients in that trial (less than 1%) had severe disease.

The current LIFE trial included 335 patients with advanced heart failure with a reduced ejection fraction. On average, these patients’ hearts pumped only one-third of the blood volume they should have been pumping. Such patients have chronic shortness of breath and fatigue, even at rest while receiving optimal medical therapy. Half were randomly assigned to receive sacubitril/valsartan along with standard medical therapy for heart failure; the other half received valsartan alone plus standard medical therapy. Neither patients nor researchers knew which patients were in each group. Both drugs are pills taken by mouth. The duration of the study was 24 weeks.

To compare the effectiveness of the drugs, the researchers measured changes in a biomarker that is easily detectable in the blood, called N-terminal pro-Brain Natriuretic Peptide (NT-proBNP). Levels of the biomarker were measured before the patients started treatment and at various times over 24 weeks of therapy. Levels of the biomarker reflect the amount of congestion that heart failure patients have. Decreased levels are associated with improved heart failure symptoms, and increased levels reflect worsening heart failure and increased likelihood of death. The major finding was that there was no statistically significant difference in levels of the biomarker over 24 weeks in the patients taking sacubitril/valsartan, as compared to patients receiving valsartan. This finding was observed across all of the subgroups that were examined.

Compared with valsartan alone, the sacubitril/valsartan treatment group also did not show any improvement in the total number of days alive, days out of the hospital and days that were free from complications of heart failure. Sacubitril/valsartan and valsartan also showed no differences in heart failure hospitalizations, deaths from cardiovascular causes or deaths from any cause. There was a statistically significant increase in potassium levels in the patients receiving sacubitril/valsartan; however, the elevated potassium levels were not life-threatening.

“The findings of the trial were really surprising to us,” said Mann, also a professor of cell biology & physiology. “In every other trial involving sacubitril/valsartan, the drug showed a benefit over the standard of care, including lowering NT-proBNP levels. Even though we didn’t have a large enough sample size in the trial to see clinically meaningful differences in the endpoints between the two groups, every clinical outcome that we measured favored treatment with valsartan alone. Since the results of the trial did not show significant differences in favor of one treatment strategy over the other, we cannot say that valsartan is better than sacubitril/valsartan for patients with advanced heart failure. But as a doctor, I often have to make treatment decisions for my patients based on clinical trial evidence that does not clearly show statistically significant differences between treatment groups. For the most severe heart failure patients, sacubitril/valsartan does not appear to provide an advantage over valsartan, which is a generic drug that is far less expensive to use and was not associated with elevated potassium levels and thus is easier to monitor over time.”

The researchers speculate that the severity of heart failure in the patients in the trial may have resulted in a loss of the beneficial effects of neprilysin inhibition, which would explain why sacubitril/valsartan was no different than valsartan. Experimental and clinical studies have shown that the excessive activation of hormonal systems in severe advanced heart failure can override the drugs that are used to block these systems in order to restore normal balance.

“The evidence suggests that sacubitril/valsartan helps heart failure patients with mild or moderate heart failure but is no better than valsartan for patients with severe disease,” Mann said. “Although we were not able to show a benefit for sacubitril/valsartan in the LIFE trial, we believe that results of the trial will be helpful to the clinicians who provide care for this vulnerable population of advanced heart failure patients. We clearly need to do a better job of preventing heart failure from progressing to an advanced stage, and we need more research to develop better medical therapies for the patients who do progress to advanced stages.”

Lead collaborators on this national clinical trial include researchers at Harvard Medical School and Duke University.

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This work was supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), grant numbers U10 HL084904, U10 HL110297, U10 HL110342, U10 HL110309, U10 HL110262, U10 HL110338, U10 HL110312, U10 HL110302, U10 HL110336 and U10 HL110337. Novartis Pharmaceutical Corp. provided the drugs used in the study and partial funding through its investigator-initiated trial program CLCZ696BUS04T.

Mann serves on the steering committee for the PARADISE-MI trial (comparing sacubitril/valsartan to enalapril) for Novartis.

Mann DL, et al for the LIFE Investigators. Effect of treatment with sacubitril/valsartan in patients with advanced heart failure and reduced ejection fraction: a randomized clinical trial. JAMA Cardiology. Nov. 3, 2021.

Washington University School of Medicine’s 1,700 faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is a leader in medical research, teaching and patient care, consistently ranking among the top medical schools in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.

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JOURNAL

JAMA Cardiology

DOI

10.1001/jamacardio.2021.4567 

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Effect of Treatment With Sacubitril/Valsartan in Patients With Advanced Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial

ARTICLE PUBLICATION DATE

3-Nov-2021

COI STATEMENT

Mann serves on the steering committee for the PARADISE-MI trial (comparing sacubitril/valsartan to enalapril) for Novartis.

Study reveals ‘drastic changes’ in daily routines during UK lockdowns

Peer-Reviewed Publication

UNIVERSITY OF CAMBRIDGE

Some spent an extra hour a day on chores and childcare during lockdowns, while others got an added daily hour of solo leisure time – and most of us reduced time spent on paid work by around half an hour a day.  

This is according to a new study of “time-use diaries” kept by 766 UK citizens from across the social spectrum during three points in time: the last month of normality, the first lockdown, and the last lockdown in March of this year.   

Economists from the University of Cambridge and Queen Mary University of London collected data that charted time spent on activities during both typical work and nonwork days to map changes to the rhythm of life for millions.

The study, published today in the journal PLOS ONE, found marked differences between genders, particularly parents of young children, and that increases in odd working hours and downtime spent alone were detrimental to wellbeing.

“The lockdowns resulted in drastic changes to patterns of time use, disrupting routines and blurring the distinction between work and family life,” said co-author Dr Ines Lee from Cambridge’s Faculty of Economics.

“We have hopefully seen the end of lockdowns, but our study holds lessons for hybrid working, as splitting time between home and office becomes more common.”

“Employers should promote better work-life balance in the post-pandemic world. This could include limits on emails outside working hours, home-working schedules that suit parents, and options for younger workers left isolated by reduced in-person networking,” said Lee.  

The researchers looked at amounts of time each individual spent on activities in four broad categories: employment (excluding commutes); “housework” (from shopping to childcare); leisure (e.g. hobbies or home entertainment); subsistence (meals, sleeping, personal care).

While previous studies have focused on the initial lockdown, this is one of the first to examine the effects of repeated COVID-19 containment measures on our lives and routines.

For those employed before and during lockdowns*, people with at least one young child spent an average of 43 fewer minutes a day on their paid job in the first lockdown, and 32 fewer minutes in the third, compared to pre-pandemic. 

For those without young children it was an average decrease of 28 minutes and 22 minutes a day on paid work respectively.

Women with young children spent around an hour less on paid work a day than men and women without young children. This was mainly a reduction in time spent on actual work tasks rather than, for example, meetings.

During the first lockdown, the average time women spent on housework increased by 28 minutes a day, while for men the average time spent on subsistence activities (e.g. sleeping and eating) increased by 30 minutes. By 2021 these changes had evened out.

Life with small children during this year’s lockdown meant an extra hour of housework a day over pre-pandemic levels. Mothers of young kids did 67 more minutes of housework a day than fathers. Only women saw an increase in cooking and cleaning (time spent on caring duties was spread across genders).

The study suggests that parents often forfeited leisure time. Living with young kids was associated with a drop in leisure activities of almost an hour a day in both lockdowns – and income levels made no difference to this loss of downtime.

For those without young kids, leisure time increased – but much of it was spent alone. By the third lockdown, people with no small children had around an extra hour of solitary leisure time a day over pre-pandemic levels.

However, in terms of quality – the self-reported “enjoyment” of given activities – this solo leisure time felt less pleasurable during the last lockdown than it had prior to the pandemic.

The third lockdown also saw around 20% of individuals spend more time working unusual hours (outside 0830-1730) compared to the pre-pandemic period, which reduced the reported enjoyment of their day overall.

Those earning £5k a month or more, worked almost two extra hours a day than people earning less than £1k a month by the last lockdown. High earners also spent less time on subsistence activities during both lockdowns.

Overall, the third lockdown felt a bit more miserable than the first, according to the research.

While there was little change in the enjoyment of various activities in the early days of Covid, with men even reporting slightly higher “quality” of time during lockdown one, by March of this year enjoyment of activities was around 5% lower than pre-pandemic levels across the board.

Dr Eileen Tipoe, co-author from Queen Mary University of London, said: “It is no surprise that having to do more work outside of typical working hours meant that people were substantially unhappier during the third lockdown.

“And it was concerning to find that women, and especially those with young children, were disproportionately affected by lockdown – for example being less likely to be employed and the fact that only women spent more time cooking and cleaning.”

-ENDS-

 NOTES:

* Before Covid arrived, 86% of the sample was employed, but this fell to 63% in the first lockdown and 74% in the third. Mothers of young children were significantly less likely to be employed than fathers by the third lockdown.

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JOURNAL

PLoS ONE

DOI

10.1371/journal.pone.0258917 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Changes in the quantity and quality of time use during the COVID-19 lockdowns in the UK: Who is the most affected?

ARTICLE PUBLICATION DATE

3-Nov-2021

Study: In much of the US, virtual school did not lower COVID-19 case rates in surrounding communities

Analysis shows no difference in COVID-19 rates between U.S. counties where school was held in-person and those that had virtual school, except in the South

Peer-Reviewed Publication

UNIVERSITY OF UTAH HEALTH

Since March 2020, parents, educators, and politicians have debated whether to send children to school in person during the COVID-19 pandemic. New research suggests that in most regions, with the exception of the South, opening schools for in-person learning was not associated with an increase in COVID-19 case rates in the community. The results of the nationwide study, published in Nature Medicine, included 895 school districts across the United States.

“The results suggest it is possible for schools to operate safely and in-person without increasing case rates in the community,” says Richard Nelson, Ph.D., associate professor of epidemiology at University of Utah Health and co-senior author with Westyn Branch-Elliman, M.D., of the VA Boston Healthcare System. “But the flip side is true, too. In some areas, in-person school did appear to be a source of community spread.”

The researchers analyzed data gathered during the 12 weeks from July to September 2020 by region, and categorized them as the Northeast, Midwest, South, and Mountain West. The Pacific West was not included because nearly all public schools were virtual. The study found that:

• In every region analyzed, COVID-19 cases increased during the weeks following the start of school.
• The South was the only region where case rates were higher in counties with in-person or hybrid school as compared to counties with virtual learning, after controlling for other contributing factors.
• In all other regions, community case rates during the period following school opening were similar regardless of whether school was virtual, hybrid, or in-person.

“We know that cases increased substantially last fall throughout the country,” Nelson says. “In some areas of the country, school mode was a contributing factor to those increasing rates, whereas in other areas it was not.”

In the South, which included 191 counties from Delaware to Texas, traditional in-person school was associated with an increase in community cases of COVID-19 beginning two weeks after the school reopened. The increase was chiefly among people between the ages of 0-9, or 20 and older. Data were not available for stratification that would allow the scientists to analyze impacts on different school-age groups (e.g. elementary, middle, and high school).

The researchers controlled for local policies, including closings of workplaces and public transportation, canceling of public events, COVID testing and contact tracing policies, and mask requirements.

However, because people follow policies imperfectly, another important piece of data the researchers considered was community mobility. This is data collected from Google location history that reflects how much people are actually moving around the community in four categories: residences, workplaces, grocery/pharmacy, and retail/recreation locations.

In communities where people are moving around more, there is more social interaction outside of school and thus more opportunity for infection to spread, Nelson explains. “Traditional school in an area where there’s lots of movement looks different than traditional school where there’s not much movement in the community, in terms of case rates,” Nelson says. “For this reason, it is important to take community-level mobility into account when evaluating the impact that schools had on cases.”

Together, the data suggest that the impact of traditional and hybrid school on community spread varied throughout the country, Nelson says. Further investigation into factors that may have contributed to community spread in the South could help determine the most effective mitigation measures for in-person school.

Branch-Elliman explains that it’s possible that regional differences in community-level and in-school mitigation strategies, or other factors such as environmental conditions, may have played a role. “It is important to appreciate that schools are not islands,” Branch-Elliman says. “They exist as part of a broader community network.”

At the time the study data were collected, vaccinations were not available and the Delta variant had not yet emerged in the U.S. Additional research will also need to investigate how these factors affect the spread of COVID-19.

# # #

The research was published as “The Impact of School Opening Model on SARS-CoV-2 Community Incidence and Mortality” and was supported by the National Institutes of Health.

Additional centers that participated in the study include Binghamton University, Boston University School of Medicine, Brown University, Beth Israel Deaconess Medical Center, Iowa City VA Health Care System, University of Iowa, VA Salt Lake City Health Care System, and Harvard Medical School

About University of Utah Health

University of Utah Health  provides leading-edge and compassionate care for a referral area that encompasses Idaho, Wyoming, Montana, and much of Nevada. A hub for health sciences research and education in the region, U of U Health has a $428 million research enterprise and trains the majority of Utah’s physicians and health care providers at its Colleges of Health, Nursing, and Pharmacy and Schools of Dentistry and Medicine. With more than 20,000 employees, the system includes 12 community clinics and five hospitals. U of U Health is recognized nationally as a transformative health care system and regionally a provider of world-class care.

---

JOURNAL

Nature Medicine

DOI

10.1038/s41591-021-01563-8 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

The impact of school opening model on SARS-CoV-2 community incidence and mortality

ARTICLE PUBLICATION DATE

27-Oct-2021

Please do not feed the monkey running wild around Tokyo, authorities ask

Casey Baseel

11/2/2021


Primate seen in two of Tokyo’s prime sightseeing wards.

Tokyo’s Shibuya Ward is one of the most interesting and colorful parts of the city. Filled with shops, parks, restaurants, theaters, and museums, there’s always something interesting to see in Shibuya.

And on Tuesday that included a monkey running around the streets.

▼ As a bonus, this monkey video is also a cat video!

   

The primate was first spotted in the morning near a preschool in Shibuya’s Tomigaya neighborhood, a few blocks south of the Yoyogi-Hachiman train station. While this part of the ward isn’t as urbanized as the area around Shibuya Station and its famed scramble intersection, it’s actually even closer to the geographical center of downtown, and farther away from any of the forested mountains where wild monkeys typically make their homes in Japan.

▼ Shibuya’s Tomigaya

As for what the animal was up to, it seemed to be primarily interested in ordinary monkey business, as various witnesses observed it climbing around on power lines and scampering up building exteriors, occasionally munching on fruits or berries it discovered, grooming itself, and lounging about and yawning.

Later in the day, the monkey had apparently had its fill of Toigaya and decided to check out the rest of what Tokyo has to offer, moving first to the Yoyogi neighborhood (also in Shibuya Ward) before making its way farther north to Shinjuku Ward’s Nishi Shinjuku district, periodically with ward employees attempting to capture it and locals, both on-site and online, enjoying the show and leaving comments such as:

“Dude, that monkey sounds like it’s really enjoying its day out in Tokyo!”
“Is it following a sightseeing course?”
“Has it been living in the city this whole time? If so, it had better be paying its resident taxes.”
“Well, there is a section of Shibuya that’s called Sarugakucho” [which means “Monkey Fun Town”].
“That’s one tough cat that it can just sleep like that with a monkey creeping up on it.”

As of Tuesday evening, the monkey has yet to be caught, and while no injuries have been reported, officials are asking residents to be cautious and to refrain from offering the animal snacks or other food should they encounter it. With SoraNews24 headquarters being located in Shinjuku, though, we will, of course, offer it an interview should it choose to come by the office.

Source: NHK News Web via Hachima Kiko, Twitter/@nhk_news (1, 2)
Top image: Pakutaso

Settlement services woefully underfunded: new report

Immigration, Refugees and Citizenship Canada (IRCC ) is out of touch with the needs of local communities when it comes to funding programs to help newcomers, states a new report by the Association for Canadian Studies (ACS).

“They sit and make decisions from the ivory tower in Ottawa,” said the report in a summary of views from four focus groups comprising newcomer settlement service workers.

The focus group narrative report — Envisioning the Future of the Immigrant Serving Sector — centered around finding solutions to key challenges faced by new immigrants and service providers, which have been exacerbated by the onset of COVID-19.

The most highly discussed topic centred around restrictive and short-term IRCC funding agreements resulting in less innovation and sustainability in the sector.

Participants cited a lack of sustainability within the sector due to strict funding agreements and to the precarious nature of not knowing whether or not a program will continue to receive funding.

While the IRCC has switched to five-year funding agreements, the agreements still need to be negotiated each year, the forum heard.

“The IRCC has ultimate control over deciding which projects receive funding, and many participants felt as though sometimes the IRCC is out of touch with the needs of local communities.”

For instance, The Regional Municipality of York reported that the last funding cycle cut back significantly on employment services due to many newcomers entering Canada through express entry. Immigrants of this class are often expected to be workforce ready.

But many still struggle to find adequate employment due to barriers such as lack of credential recognition, the re-licensure process, underemployment, as well as lack of childcare and/or transportation.

Other examples brought forward by the focus groups include a youth program funded by the IRCC which was not able to provide any field trips for the youths due to the funding for the program not covering any transportation costs.

The South Okanagan Immigrant and Community Services (SOICS) reported that honoraria to support newcomers contributing their time are not covered by the IRCC funding it gets.

Other costs involving building closer relationships with the Indigenous communities through contact and hospitality, are also not covered by IRCC funding.

“There is a bit of a disconnect between the policy side and the operational side of our system when it comes to funding settlement services,” said a focus group participant.

Inconsistencies in funding models was another key issue.

A participant noted that there is a lack of job security and consistency for settlement workers due to funding agreements and program-based funding not covering pensions, long-term employment, or steady salaries.

Several respondents also critiqued the fact that IRCC funding models focus on outputs rather than impact and outcomes and meeting targets, rather than modernizing, innovating, and measuring long-term successes.

‘Counting the numbers’ is particularly unhelpful for rural settlement agencies who do not have large numbers, in which case the quality of settlement support should be the primary focus, said the report.

Similarly, one participant of a large, rural agency felt as though they were penalized for not having enough clients, especially during the pandemic, when fewer clients were able to travel to in-person sessions or find child care.

While discussing solutions for improving funding models, forum participants gave importance to engaging private organizations like banks, universities and social development initiatives.

One example cited involved Immigrant Services Calgary, which has been successful in securing a loan through a program called UCeed Social Impact Fund that was organized through the University of Calgary and Innovate Calgary.

Another solution raised was to scale up small, innovative, successful projects to larger organizations after they have been proven effective, rather than creating large-scale programs that cannot be down-scaled for smaller rural communities.

Multiple participants also discussed the need for increased staffing, as well as retention of service providers who leave to pursue more financially rewarding employment.

“Staff retention is a huge piece for us and that kind of goes more with the wages of the settlement sector,” one participant said.

The report, segmented into four sections — building capacity, best practices, funding models and improving attraction/accessibility of settlement services — provides a base to expand on the solutions uncovered, according to the Association for Canadian Studies, which conducted the research in collaboration with the WES Mariam Assefa Fund.

“We ultimately intend to pilot projects to address the issues and test solutions and recommendations to improve settlement and economic outcomes,” the study concluded.

Fabian Dawson, Local Journalism Initiative Reporter, New Canadian Media

RESIGN KENNEY RESIGN

Alberta, with largest oil industry, sends fewer to COP than any other energy province

EDMONTON — The province with Canada's largest oil and gas industry has sent one of the country's smallest delegations to the COP26 international climate conference where emissions from that sector are under scrutiny.

© Provided by The Canadian Press

It's a missed opportunity, said one Alberta observer.

"It's incredibly good to be there and learn from these events," said Keith Brownsey, a political scientist at Mount Royal University. "It's smart, but apparently we don't think it's all that smart."

New Democrat Opposition Leader Rachel Notley said the United Conservative government has let Albertans down.

"Alberta workers need a seat at that table and the UCP made the decision to leave it empty," she said Wednesday.

A preliminary list of those attending the COP26 meetings in Glasgow, Scotland, shows that of 200 Canadian delegates, two are from the Alberta government. They are officials from Emissions Reduction Alberta, an agency funding emissions-reducing technologies, and are the province's only representatives.

Almost every province has sent more delegates or higher-level representatives to the meetings, which are setting the world's path to reduce greenhouse gas emissions from fossil fuels.

Newfoundland has nine people at the meetings and Manitoba has six. Ontario has four, as does the Northwest Territories. Quebec has 36 representatives.

Five provinces sent environment ministers. Prince Edward Island sent the director and coordinator of its environment department.

Inuit and Métis groups have more representation than Albertans.

 So do groups such as the Climate Action Network.

 Oilsands giant Suncor Energy has its own delegates.

There are also more Mounties at the meetings than representatives of the province with, arguably, the most at stake of any Canadian jurisdiction.

On Wednesday, Premier Jason Kenney defended his decision to send a small 

2 PERSON delegation to what he called earlier in the week a "gabfest."

"We will continue to vigorously defend Alberta's interests in emissions reduction and economic growth to ensure a strong future, but being part of a crowd of 30,000 is not an effective way of doing so," he said.

Kenney said it's more effective to have one-on-one meetings with financial and political leaders.

"We'll continue to have those direct conversations with key decision-makers."

Brownsey said the government has missed an important chance to gather information, make contacts and tell Alberta's story to the rest of the world.

"What goes on at COP has a dramatic impact on us in Alberta," he said.

"Even the Saudis were there, talking about how they were going to reduce emissions. And we sent two delegates?"

Brownsey said being at the conference allows delegates to better understand the positions of other countries.

"We don't know what's going on. We can read the official documents, but it's in the off-hours you find out what these groups are really thinking."

As well, Brownsey said not showing up leaves the field to a federal Liberal government with which Alberta's United Conservatives are often at odds.

"You complain about them, but do nothing to counter them."

Notley, who represented Alberta as premier during the COP21 meeting in Paris, said showing up would have been a good chance to work with Ottawa's new environment minister. She said such meetings allow Albertans to tell their own story.

"I remember a friend sending me a bunch of things from The Guardian (a U.K. newspaper) talking about all the progressive things the province of Alberta was doing. That story's not being told in our absence."

Notley said Alberta has missed a window to pitch the province as an investment destination for renewable energy.

"With all the investment money there, why isn't somebody telling the story about the promise that is our renewable energy industry?"

So far, the COP26 conference has seen announcements from Canada on emissions caps for oil and gas. Banks, insurers and investors managing $160 trillion have pledged to emphasize green investing.

This report by The Canadian Press was first published Nov. 3, 2021.

Bob Weber, The Canadian Press