Monday, September 27, 2021

FOR PROFIT MEDICINE

Introduction

In the US, COVID-19 is responsible for hundreds of thousands of excess deaths,¹ which has led to considerable interest in strategies to mitigate its impact.² Policy observers hypothesize that access to health insurance could improve COVID-19 survival by facilitating earlier access to testing and treatment.³ Concerningly, however, COVID-19 also led to a crisis of coverage in the US because rising unemployment led to many US adults losing their employer-sponsored health insurance coverage.⁴ This study compared deaths among individuals slightly younger and older than 65 years—when most US adults become eligible for Medicare⁵—to examine the relationship between access to health insurance coverage (vs no insurance) and COVID-19 mortality.

Methods

The Yale University institutional review board reviewed the study and deemed it exempt because we used only retrospective deidentified data; informed consent was waived according to the Regulations for the Protection of Human Subjects (45 CFR §46). The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Detailed mortality data for 2015 to 2020 was obtained from Datavant, an organization that augments Social Security Administration death master files with information from newspapers, funeral homes, and memorials to construct an individual-level database of more than 80% of US deaths annually. For each record, the data indicate the month of death and age of the deceased individual in months, allowing us to count deaths in a narrow band around age 65 years. We obtained death counts from the National Center for Health Statistics (NCHS; US Centers for Disease Control and Prevention).⁶

We used a regression discontinuity design, a common method in health care research, to assess whether the death count changed sharply at age 65 years (Medicare eligibility age) between March and December 2020 and for the same span of months in 2015 to 2019 for comparison. We fit a model of the number of deaths by age in quarters with a dummy variable for deaths occurring to persons 65 years or older. The dummy variable captured discontinuities (ie, jumps) in the death count associated with Medicare eligibility. A discontinuity at age 65 years in 2020, but not years prior, would suggest that Medicare eligibility affected COVID-19 mortality.

Statistical analysis was conducted using 2-tailed tests with Huber-White robust SEs to assess statistical significance, defined as P < .05. We also assessed the percent increase in deaths for 65- to 74-year-olds by calendar month in 2020 vs calendar month in 2015 to 2019 in the Datavant data and compared it with NCHS data. We reported the average percent increase during the pandemic period and plotted the percent increases by month. Data analyses were performed from December 14, 2020, to July 20, 2021, using Stata, version 16 (StataCorp LLC) and Python, version 3.8 (Python Software Foundation).

Results

This study examined 291 837 deaths among individuals 61 to 69 years old (116 806 [40.0%] women; 175 031 [60.0%] men) between March and December 2020. We did not find evidence of a discontinuity in the number of deaths at age 65 years during the 2020 study period (−21.3; 95% CI, −245.0 to 202.4; P = .85) nor during the 5 years prior (59.5; 95% CI, −90.1 to 209.1; P = .42; Figure 1). The results were similar when we narrowed the bandwidth around age 65 years or altered the functional form of the relationship between age and death counts (eMethods in the Supplement). The percent change in death counts from March to December 2020 relative to the same months in 2015 to 2019 was 28.1% in the Datavant data and 30.6% in the NCHS data (Figure 2).

Discussion

Eligibility for Medicare at age 65 years, which has been associated with an immediate and substantial reduction in the uninsurance rate and improvements in measures of access to care,⁵ was not associated with mortality during the COVID-19 pandemic. These null findings may reflect the influence of state and federal policies that directed payments to hospitals for COVID-19 treatment and eliminated cost sharing for COVID-19 testing, both of which aimed to broaden access to COVID-19 testing and treatment.³

A serious limitation of this study was that the mortality data, although detailed and recent, did not capture all deaths in the US (only approximately 80%) and did not include the cause of death nor the patient’s race or ethnicity. However, the excess death counts in the present study’s data were similar to those of other reliable sources. This cross-sectional regression discontinuity analysis found that entry into Medicare was not associated with the likelihood of death during the COVID-19 pandemic.

Article Information

Accepted for Publication: August 4, 2021.

Published: September 24, 2021. doi:10.1001/jamahealthforum.2021.2861

Corresponding Author: Jacob Wallace, PhD, Department of Health Policy and Management, Yale School of Public Health, 60 College St, New Haven, CT 06510 (jacob.wallace@yale.edu).

Author Contributions: Drs Wallace and Lollo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Wallace, Lollo.

Drafting of the manuscript: Wallace, Lollo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lollo.

Supervision: Wallace, Ndumele.

Conflict of Interest Disclosures: None reported.

Funding/Support: We gratefully acknowledge support from the Tobin Center for Economic Policy.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessary reflect the official views of the Tobin Center for Economic Policy.

Additional Information: The software code used to produce results in the manuscript and supplementary materials is available in a public repository at https://github.com/Yale-Medicaid/covid-rd. The data, technology, and services used in the generation of these research findings were generously supplied pro bono by the COVID-19 Research Database partners acknowledged at https://covid19researchdatabase.org/

References

Woolf SH, Chapman DA, Sabo RT, Zimmerman EB. Excess deaths from COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021. JAMA. 2021;325(17):1786-1789. doi:10.1001/jama.2021.5199
Article PubMed Google Scholar Crossref

Ayanian JZ. Tallying the toll of excess deaths from COVID-19. JAMA Health Forum. 2020;1(7):e200832. doi:10.1001/jamahealthforum.2020.0832
Article Google Scholar

King JS. COVID-19 and the need for health care reform. N Engl J Med. 2020;382(26):e104. doi:10.1056/NEJMp2000821PubMed Google Scholar

Cutler D. How will COVID-19 affect the health care economy? JAMA. 2020;323(22):2237-2238. doi:10.1001/jama.2020.7308
Article PubMed Google Scholar Crossref

Wallace J, Jiang K, Goldsmith-Pinkham P, Song Z. Changes in racial and ethnic disparities in access to care and health among US adults at age 65 years. JAMA Intern Med. Published online July 26, 2021;e213922. doi:10.1001/jamainternmed.2021.3922
Article PubMed

National Center for Health Statistics. Weekly Counts of Deaths by Jurisdiction and Age Group. Updated January 6, 2021. Accessed January 11, 2021. https://data.cdc.gov/NCHS/Weekly-counts-of-deaths-by-jurisdiction-and-age-gr/y5bj-9g5w/

New study examines association between nurses’ well-being, workplace wellness cultures and shift length during COVID-19

College of Nursing-led study published in Nursing Administration Quarterly

Peer-Reviewed Publication

MEDIASOURCE

A new study from The Ohio State University College of Nursing quantifies how the COVID-19 pandemic, coupled with variable workplace wellness cultures and long shifts caring for patients, has severely impacted nurses working on the front lines.

The study was published online ahead-of-print in Nursing Administration Quarterly.

“Clinician burnout and mental health problems were an epidemic in nurses and other healthcare clinicians even before the pandemic hit; COVID-19 exacerbated the problem,” said Bernadette Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, vice president for health promotion, university chief wellness officer and dean of the College of Nursing, who also served as lead author on this study. “What this study did is shed light on the current scope of the problem and how healthcare systems can fix system issues known to cause clinician burnout and invest in evidence-based strategies and resources to help clinicians live healthier lives.”

Melnyk and her team surveyed 264 nurses associated with Trusted Health, which places travel nurses at hospitals and healthcare systems across the country, between August – October 2020. Among the key findings:

Physical and mental health:
- The vast majority reported physical health (74.6%) and mental health (80.7%) at a five or lower on a 10-point scale.
  - 53.8% reported that the pandemic made their physical health worse.
  - 79.2% reported that the pandemic made their mental health worse.
- Substantial percentages of nurses surveyed reported:
  - Depressive symptoms: 29.5%
  - Anxiety: 37.5%
  - Stress: 78.5%
  - Burnout: 65.5%
Healthy lifestyle behaviors that a majority of nurses surveyed reported were negatively affected by the pandemic:
- More than one-third (38.6%) reported increased alcohol intake.
- Only about one-third (34.8%) slept seven or more hours a night.
- Only about one in five (22.3%) reported 150 minutes or more of moderate physical activity per week.
- Only 8% of the nurses consumed five or more daily servings of fruits and vegetables.
Workplace wellness support:
- Those nurses who reported that their workplaces supported higher wellness during the pandemic were:
  - Five times more likely to get at least seven hours of sleep nightly
  - 16 times more likely to eat 5+ servings of fruits and vegetables
  - Less likely to report a negative impact of the pandemic on healthy lifestyle behaviors
  - Three-to-nine times as likely to report good physical and mental health, no/little stress and no burnout
Shift length:
- Those nurses who reported working 12 or more hours per shift during the pandemic were more likely to:
  - Sleep fewer than seven hours per night
  - Get less physical activity
  - Consume fewer servings of fruits and vegetables
  - Use tobacco
  - Experience burnout symptoms
  - Report worsening physical and mental health

In response to these findings, Melnyk and the team referred to a recent systematic review indicating that “effective interventions to improve mental/physical health, well-being and healthy lifestyle behaviors in physicians and nurses include mindfulness, health coaching, deep abdominal breathing, gratitude, cognitive-behavioral therapy/skills building and visual triggers.” Many of these types of interventions are in practice at The Ohio State University and the Wexner Medical Center, with programs such as Mindfulness in Motion, the Buckeye Paws pet therapy initiative and the STAR (Stress, Trauma and Resilience) mental health program available to all clinicians. The Office of the Chief Wellness Officer and College of Nursing also offer the MINDSTRONG™/MINDBODYSTRONG™ cognitive-behavioral skills-building program and the Health Athlete energy management program, which is based on the Johnson & Johnson Human Performance Institute® Performance program.

Beyond these activities, Melnyk advocates strongly for building cultures where well-being is supported and healthy lifestyle behaviors are the norm.

“That healthcare leaders should be alarmed by the findings of our study is an understatement,” Melnyk said. “These trends do not only affect the well-being of our clinicians; they are also associated with the quality and safety of care that clinicians provide to patients.

“Our clinicians cannot continue to pour from an empty cup. Fixing issues known to cause burnout and creating wellness cultures that bring evidence-based programs and resources to bear are the absolute best ways to make positive change and make it sustainable.”

Other authors on the study include Andreanna Pavan Hsieh, MPH; Alai Tan, PhD; Alice M. Teall, DNP, APRN-CNP, FAANP; Dan Weberg, PhD, RN, MHI, BSN; Jin Jun, PhD, RN; Kate Gawlik, DNP, APRN-CNP, RN; and Jacqueline Hoying, PhD, RN.

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JOURNAL

Nursing Administration Quarterly

DOI

10.1097/NAQ.0000000000000499

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Associations Among Nurses' Mental/Physical Health, Lifestyle Behaviors, Shift Length, and Workplace Wellness Support During COVID-19

Dr. Daniel Pauly’s extraordinary life and work revealed in new book

Book Announcement

UNIVERSITY OF BRITISH COLUMBIA

Dr. Daniel Pauly is the world’s most-cited fisheries scientist, but life for the UBC professor has been far from easy. The biracial son of a French woman and an American GI, he was born in Paris and kidnapped as a child to be a live-in servant for a Swiss family. He escaped to Germany at 17 and put himself through high school by attending evening classes after a full day’s work.

Dr. Pauly went on to blow the whistle on the devastation caused to marine ecosystems by the global fishing industry, and to become a marine scientist whose work received worldwide recognition.

Now, readers can learn more in his biography, The Ocean’s Whistleblower, available this week. Dr. Pauly discusses his extraordinary life and work, including what the future holds for our warming seas.

The Ocean’s Whistleblower delves into intimate details of your life. Why did you decide to share them with the world?

What’s important is that this biography not only talks about my difficult youth as a biracial person in Switzerland and Europe, which is a tear-jerker but it would have been shallow, so it also talks about my research. Given my background, science was a place where I could grow, where I could be. I escaped into science because where I grew up, there were many reasons for me to spiral into a dark place; the family that raised me were petty criminals. What I ended up doing was developing a stiff spine, and since they never made me feel like I was one of them, not doing what they did became a way to build an identity.

Later on, I realized I didn’t want to live in Europe, where I was constantly questioned about my origins. I worked in the developing world for 20 years, then found a respite in Canada where I could continue the work that I began in the Philippines and Indonesia in peace.

Collaborating on this book was one way of closing the chapter on what I did while presenting the science and perhaps motivating other people.

Growing up, you survived by taking odd jobs such as doing quality control at a paint factory or working at a psychiatric hospital. What did you learn in these jobs that you still apply today?

During those days, I went to high school every weekday from 5:00 p.m. to 9:00 p.m. after a full day of work. By the end of the 4-year course, of the 115 students that started, only 15 of us remained and we made it not because we were smarter, but because we didn’t think about it. The people who asked themselves every evening, ‘should I go or not?’, didn’t make it.

This approach is what enabled me to complete big-data work such as including all known fish species on FishBase, the online, free encyclopedia of all fish or publishing the Global Atlas of Marine Fisheries, which has 400 pages, 273 of which were one-page summaries of the fisheries of all the world’s coastal countries and territories. How does one finish such a monstrous work? Well, you start with one and then you do two, three, four until you’ve done them all.

You developed the ‘shifting baselines syndrome’ concept, now widely used including in fields beyond fisheries. What makes it so universal?

This concept explains how knowledge of environmental disaster fades over time, leading to a misguided understanding of change on our planet. I made a point that observations in the past can be as valid as observations in the present and that if you only look at trends in your lifetime, you will miss the broader picture.

Shifting baselines is the flipside of adaptation. If we humans liked the past too much, we wouldn’t be able to move forward. Our ability to forget intergenerationally is an adaptive trait that made us very successful as an invasive species. However, that same ability means that we forget about entities, for example, animal species, that disappear. This can be very negative because when you lose something you don’t remember existed, you don’t even try to re-establish it. We are seeing this everywhere on our planet.

What research or work are you are most proud of? What does the future hold for our warming oceans?

The shifting baselines and the fishing down marine food webs concept, which describes how in certain parts of the ocean, fisheries have depleted large predatory fish and are increasingly catching smaller, and previously spurned, species lower in the food web, are well known, but the most challenging is the Gill Oxygen Limitation Theory (GOLT), which was termed ‘Pauly’s folly’ when I proposed it as a student in Germany. It posits that the gill area per volume must decline as fish grow and there must be a size at which they don’t get enough oxygen.

After creating the Sea Around Us research initiative at UBC’s Institute for the Oceans and Fisheries (IOF), my postdoctoral fellow Dr. William Cheung (now director of IOF) built on this work and developed a model to predict the movements of fish in the context of ocean warming. Not only did his model explain why fish move poleward, but he also used my oxygen theory to predict that they will shrink in size by 20 to 30 per cent if ocean temperatures continue to climb.

So, what I realize now is that global warming is offering my story a huge boost. Basically, ‘Pauly’s folly’ is becoming a significant explanation for what fish do in the face of global warming. This is one of those things where it is a sad way to be right.

Lockdowns and less travel may have altered the behavior of birds

Study uses eBird reports to compare sightings over multiple years

Peer-Reviewed Publication

CORNELL UNIVERSITY

Bald Eagle — IMAGE: BALD EAGLE view more
CREDIT: LYNNE MARSHO, COURTESY CORNELL LAB OF ORNITHOLOGY

Ithaca, New York & Winnipeg, Manitoba—Eighty percent of bird species examined in a new study were reported in greater numbers in human-altered habitats during pandemic lockdowns. Researchers compared online eBird observations from the United States and Canada from before and during the pandemic. They focused on areas within about 100 km of urban areas, major roads, and airports. Their findings were just published in the journal Science Advances.

“A lot of species we really care about became more abundant in human landscapes during the pandemic,” says study senior author Nicola Koper at the University of Manitoba, which led the research. “I was blown away by how many species were affected by decreased traffic and activity during lockdowns.”

Reports of Bald Eagles increased in cities with the strongest lockdowns. Ruby-throated Hummingbirds were three times more likely to be reported within a kilometer of airports than before the pandemic. Barn Swallows, a threatened species in Canada, were reported more often within a kilometer of roads than before the pandemic.

A few species decreased their use of human-altered habitat during the pandemic. Red-tailed Hawk reports decreased near roads, perhaps because there was less roadkill when traffic declined. But far more species had increased counts in these human-dominated landscapes.

The authors filtered pandemic and pre-pandemic eBird reports so that the final data sets had the same characteristics, such as location, number of lists, and level of birdwatcher effort.

“We also needed to be aware of the detectability issue,” explains co-author Alison Johnston from the Cornell Lab of Ornithology. “Were species being reported in higher numbers because people could finally hear the birds without all the traffic noise, or was there a real ecological change in the numbers of birds present?”

CAPTION

Ruby-throated Hummingbird

CREDIT

Jim Hendrickson, courtesy Cornell Lab of Ornithology

The study tested whether better detectability might be a factor in the larger bird numbers reported. If it was, the scientists expected that to be more noticeable for smaller birds, which are harder to detect beneath traffic noise. However, effects were noticed across many species, from hawks to hummingbirds, suggesting that the increased numbers were not only caused by increased detectability in the quieter environments.

Vast amounts of data from a likewise vast geographic area were vital for this study. The researchers used more than 4 million eBird observations of 82 bird species from across Canada and the U.S.

“Having so many people in North America and around the world paying attention to nature has been crucial to understanding how wildlife react to our presence,” says lead author Michael Schrimpf, a postdoctoral fellow at the University of Manitoba. “Studies such as this one rely on volunteer birdwatchers, so if you enjoy watching wildlife, there are many projects out there, like eBird and iNaturalist, that can use your help.”

Reference:

Reduced human activity during COVID-19 alters avian land use across North America. Michael B. Schrimpf, Paulson G. Des Brisay, Alison Johnston, Adam C. Smith, Jessica Sánchez-Jasso, Barry G. Robinson, Miyako H. Warrington, Nancy A. Mahony, Andrew G. Horn, Matthew Strimas-Mackey, Lenore Fahrig, Nicola Koper. 2021. Science Advances. DOI: 10.1126/sciadv.abf5073.

This study was funded by Natural Sciences and Engineering Research Council of Canada with in-kind support provided by Environment and Climate Change Canada and the Cornell Lab of Ornithology.

CAPTION

Barn Swallow

CREDIT

Brian E. Kushner, courtesy Cornell Lab of Ornithology