Faculty Bibliography

BACKGROUND:City-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households. METHODS:We obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown. FINDINGS/RESULTS:Among individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22-96%); Q3 vs. Q1: 48% (17-89%); Q4 vs. Q1: 66% (30-211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7-76%). INTERPRETATION/CONCLUSIONS:By increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households.

Background: Clinical trials are important to improve evidencebased care for persons living with dementia (PLWD) and for their care partners (dyads). Barriers to research recruitment are numerous, including care partners concerns' of ill health, cognitive impairment (CI) severity, and denial of need. The aim of this study is to determine whether a performance- or informant-based screening test for CI is associated with trial enrollment and whether mode of administration influences one's decision to participate.
Method(s): We used cross-sectional data from patients and caregivers who visited the EDs of New York University (NYU) and Indianapolis University (IU) during screening for the Program of Intensive Support in Emergency Departments (ED) for Care Partners of Cognitively Impaired Patients (POISED), which is testing a care management intervention. We offered CI screening to patients >75 years using the Mini-Cog and if unable to do this, we offered their care partners the Short Portable Informant Questionnaire of Cognitive Decline (IQ-CODE). We used chi-square tests and logistic regression to determine whether likelihood of enrollment differed between screening tests and mode of administration: in-person versus telephone.
Result(s): We screened 8860 patients or care partners (dyads) between 3/3/2018-4/1/2021, of which n=2840 at NYU and n=660 at IU had positive screens. Of these 3500 dyads, 2142 had a positive Mini-Cog (<2) and 1358 had a positive IQ-CODE (>3.40). We enrolled 13.9% (n=297) of positive Mini-Cogs and 14.5% (n=309) of positive in-person IQ-CODEs. During the pandemic we conducted all IQCODEs by phone and enrolled 34% (n=196) of those who screened positive. Adjusting for age, sex, and gender, compared to Mini-Cog screening, only those having positive IQCODES by phone were more likely to enroll (adjusted odds ratio (AOR): 3.75 (95% CI: 2.76, 5.11).
Conclusion(s): Higher enrollment using informant-based telephone screening after discharge suggests that care partner recognition of a problem and perhaps having less distraction from the ED visit may increase trial enrollment. Whether the pandemic was the predomant factor encouraging enrollment is unknown

BACKGROUND:Older adults account for a large proportion of emergency department visits, but those with serious life-limiting illness may benefit most from referral to home and community services instead of hospitalization. We aim to document emergency provider perspectives on facilitators and barriers to accessing home and community services for older adults with serious life-limiting illness. METHODS:We conducted interviewer-administered semi-structured interviews with emergency providers from health systems across the United States to obtain provider perspectives on facilitators and barriers to accessing home and community services. We completed qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize provider responses. RESULTS:We interviewed 8 emergency nurses and 10 emergency physicians across 11 health systems. Emergency providers were familiar with local home and community services. Facilitators to accessing these services include care management and social workers. Barriers include services that are not accessible full-time to receive referrals, insurance/payment, and the busy nature of the emergency department. The most helpful reported services were hospice, physical therapy, occupational therapy, and visiting nursing services. Home-based palliative care and full-time emergency department-based care management and social work were the services most desired by providers. Providers expressed support for improving access to home and community services in the hopes of decreasing unnecessary emergency visits and inpatient admissions, and to provide patients with greater options for supportive care. CONCLUSION/CONCLUSIONS:Obtaining the perspective of emergency providers highlights important considerations to accessing HCS for older-adults with serious life-limiting illness from the emergency department. This study provides foundational information for futures studies and initiatives for improving access to home and community services directly from the emergency department.