COVID-19 patients’ ZIP codes may affect hospitalization outcomes

1. COVID-19 patients’ ZIP codes may affect hospitalization outcomes

Patients from high-vulnerability neighborhoods presented to the hospital sicker, in need of more intensive care, but were not any more likely to die in the hospital

Policies needed to identify and address issues that contribute to these health disparities

Abstract: https://www.acpjournals.org/doi/10.7326/M21-2615

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A pooled cross-sectional study found that COVID-19 patients’ ZIP codes may affect clinical outcomes. Those in high-vulnerability neighborhoods presented to the hospital with more severe illness and more often required intensive care compared to those in low-vulnerability ZIP codes.  The authors suggest policies targeting socially vulnerable neighborhoods to improve access to COVID-19 testing, treatment, and vaccination, as well as to identify and address issues that contribute to such disparities. The study is published in Annals of Internal Medicine.

Differences in COVID-19 illness severity and outcomes, including rates of hospitalization and mortality, have been demonstrated to be related to patient race, ethnicity, and location. The study authors previously found that U.S. counties with higher levels of social vulnerability or disadvantage—based on socioeconomic status, housing, and other factors—experienced greater COVID-19 incidence and mortality.

Researchers from the University of Michigan studied health data for 2,678 patients hospitalized with COVID-19 at 38 Michigan hospitals to determine whether COVID-19 hospitalization outcomes are related to neighborhood-level social vulnerability, independent of patient-level clinical factors. Patient data was assessed in combination with a ZIP code-linked social vulnerability index (SVI), a composite measure of social disadvantage. The authors found that patients living in high-vulnerability ZIP codes had lower pulse oximetry readings and higher respiratory rates upon admission compared to patients living in less vulnerable ZIP codes. Once admitted, they were more likely to receive mechanical ventilation, experience acute organ dysfunction, and develop acute organ failure even after adjusting for individual patient clinical characteristics, suggesting that the neighborhood social disadvantage effects observed were independent of individual-level factors related to patients’ age and preexisting comorbid conditions. The authors noted that once the patients were hospitalized, however, they did not experience differences in hospital mortality or discharge disposition. According to the authors, these finding should inform future COVID-19 policies in socially vulnerable neighborhoods. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Vineet Chopra, MD, MSc, can be reached through Holli Keyser at holli.keyser@cuanschutz.edu. 

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2. New AMA billing guidelines may not yet ease burden of EHR time for many physicians

Abstract: https://www.acpjournals.org/doi/10.7326/M21-4402

Editorial: https://www.acpjournals.org/doi/10.7326/M21-0355   

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A new observational study has found that the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) new billing guidelines immediately affected the distribution of evaluation and management (E/M) patient visits but have had no impact on the amount of time providers spend writing notes in the electronic health record (EHR) or the overall length of notes. The findings are published in Annals of Internal Medicine.

Extensive documentation for reimbursement combined with low EHR usability contributes to high rates of physician burnout and job dissatisfaction. To combat this, the AMA and CMS recently made optional the history and physical examination elements of the physician note. The AMA also streamlined the logic in applying E/M visit codes based on medical decision making to facilitate less ambiguous synthesis of the complexity of problems, complexity of data, and risks for complications in each visit.

Researchers from the University of Pennsylvania conducted an observational study of 303,547 advanced practice providers and physicians across 389 organizations. The authors collected provider-level measures of weekly E/M billing and measures of EHR use between September 2020 and April 2021 from the Epic Systems Signal data warehouse. The authors analyzed eight measures of E/M visit volume and seven measures of EHR use to determine factors including the proportion of weekly E/M visits, total weekly new and established E/M patients, total active time per visit spent in the EHR, and EHR documentation length. The authors observed an overall increase in new and established patient E/M visits billed to levels 4 and 5, and a decrease in visits billed at level 3. However, the policy responses across specialties differed, with some specialties demonstrating substantially larger shifts in E/M billing. The authors also observed no overall change in time spent in the EHR or documentation length.  According to the authors, their findings suggest that the effects of the policy have thus far been limited to modifications of billing practices, despite the explicit intent to simplify reimbursement and reduce documentation burden. They also note that observing changes in billing practice without meaningful improvement in measures of EHR burden highlights a continued opportunity to identify and scale practices that more directly address salient pain points of EHR usability.

An editorial from the AMA argues that note length and active EHR time is not a perfect proxy of physician burden, and that the reason for a lack of change in active EHR time and note length cannot be known from the study. The author suggests that further studies on the quality of notes, along with qualitative interviews of physicians, will help determine which type of billing is used, whether cognitive burden was reduced, and why documentation time and note length have not yet been affected as intended.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Nate C. Apathy, PhD can be reached directly at nate.apathy@pennmedicine.upenn.edu or through Christine Weeks at weeksc@wharton.upenn.edu.

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