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Rapid antigen tests hold much promise for use in the school environment. However, the performance of these tests in non-clinical settings and among one of the main target populations in schools-asymptomatic children-is unclear. To address this gap, we examined the positive and negative concordance between the BinaxNOW™ rapid SARS-CoV-2 antigen assay and an RT-PCR test among children at a community-based Covid-19 testing site. We conducted rapid antigen (BinaxNOW™) and oral fluid RT-PCR (Curative Labs) tests on children presenting at a walk-up testing site in Los Angeles County from November 25, 2020 to December 9, 2020. Positive concordance was determined as the fraction of RT-PCR positive participants that were also antigen positive. Negative concordance was determined as the fraction of RT-PCR negative participants that were also antigen negative. Multivariate logistic regression models were used to examine the association between positive or negative concordance and participant age, race-ethnicity, sex at birth, symptoms and Ct values. 226 children tested positive on RT-PCR; 127 children or 56.2% (95% CI: 49.5% to 62.8%) of these also tested positive on the rapid antigen test. Positive concordance was higher among symptomatic children (64.4%; 95% CI: 53.4% to 74.4%) compared to asymptomatic children (51.1%; 95% CI: 42.5% to 59.7%). Positive concordance was negatively associated with Ct values and was 93.8% (95% CI: 69.8% to 99.8%) for children with Ct values less than or equal to 25. 548 children tested negative on RT-PCR; 539 or 98.4% (95% CI: 96.9% to 99.2%) of these also tested negative on the rapid antigen test. Negative concordance was higher among asymptomatic children. Rapid antigen testing can successfully identify most COVID infections in children with viral load levels likely to be infectious. Serial rapid testing may help compensate for limited sensitivity in early infection.

The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented strain on patients and health care professionals and institutions, but the association of the pandemic with use of preventive, elective, and nonelective care, as well as potential disparities in use of health care, remain unknown. To examine changes in health care use during the first 2 months of the COVID-19 pandemic in March and April of 2020 relative to March and April of 2019 and 2018, and to examine whether changes in use differ by patient's zip code-level race/ethnicity or income. This cross-sectional study analyzed health insurance claims for patients from all 50 US states who receive health insurance through their employers. Changes in use of preventive services, nonelective care, elective procedures, prescription drugs, in-person office visits, and telemedicine visits were examined during the first 2 months of the COVID-19 pandemic in 2020 relative to existing trends in 2019 and 2018. Disparities in the association of the pandemic with health care use based on patient's zip code-level race and income were also examined. Data from 5.6, 6.4, and 6.8 million US individuals with employer-sponsored insurance in 2018, 2019, and 2020, respectively, were analyzed. Patient demographics were similar in all 3 years (mean [SD] age, 34.3 [18.6] years in 2018, 34.3 [18.5] years in 2019, and 34.5 [18.5] years in 2020); 50.0% women in 2018, 49.5% women in 2019, and 49.5% women in 2020). In March and April 2020, regression-adjusted use rate per 10 000 persons changed by -28.2 (95% CI, -30.5 to -25.9) and -64.5 (95% CI, -66.8 to -62.2) for colonoscopies; -149.1 (95% CI, -162.0 to -16.2) and -342.1 (95% CI, -355.0 to -329.2) for mammograms; -60.0 (95% CI, -63.3 to -54.7) and -118.1 (95% CI, -112.4 to -113.9) for hemoglobin A1c tests; -300.5 (95% CI, -346.5 to -254.5) and -369.0 (95% CI, -414.7 to -323.4) for child vaccines; -4.6 (95% CI, -5.3 to -3.9) and -10.9 (95% CI, -11.6 to -10.2) for musculoskeletal surgery; -1.1 (95% CI, -1.4 to -0.7) and -3.4 (95% CI, -3.8 to -3.0) for cataract surgery; -13.4 (95% CI, -14.6 to -12.2) and -31.4 (95% CI, -32.6 to -30.2) for magnetic resonance imaging; and -581.1 (95% CI, -612.9 to -549.3) and -1465 (95% CI, -1496 to -1433) for in-person office visits. Use of telemedicine services increased by 227.9 (95% CI, 221.7 to 234.1) per 10 000 persons and 641.6 (95% CI, 635.5 to 647.8) per 10 000 persons. Patients living in zip codes with lower-income or majority racial/ethnic minority populations experienced smaller reductions in in-person visits (≥80% racial/ethnic minority zip code: 200.0 per 10 000 [95% CI, 128.9-270.1]; 79%-21% racial/ethnic minority zip code: 54.2 per 10 000 [95% CI, 33.6-74.9]) but also had lower rates of adoption of telemedicine (≥80% racial/ethnic minority zip code: -71.6 per 10 000 [95% CI, -87.6 to -55.5]; 79%-21% racial/ethnic minority zip code: -15.1 per 10 000 [95% CI, -19.8 to -10.4]). In this cross-sectional study of a large US population with employer-sponsored insurance, the first 2 months of the COVID-19 pandemic were associated with dramatic reductions in the use of preventive and elective care. Use of telemedicine increased rapidly but not enough to account for reductions in in-person primary care visits. Race and income disparities at the zip code level exist in use of telemedicine.

Post-acute sequelae of COVID-19 infection (PASC) is a widely reported phenomenon wherein symptoms of COVID-19 infection persist for four weeks or more beyond acute infection. Risk factors at baseline (prior to infection) for the development of PASC are not well understood. This study aimed to identify baseline demographic, physical and mental health characteristics associated with the development of PASC. We identified 351 participants who reported contracting COVID-19 and 145 that experienced PASC symptoms. Baseline physical health, mental health, and demographic data were collected for all participants. Risk factors for the development of PASC were identified using multivariable logistic regression. PASC was associated with lower income, Hispanic ethnicity, younger age, and respiratory conditions (asthma or COPD). Worse self-reported mental health status, a diagnosis of depression, and a higher patient health questionnaire-2 (PHQ-2) score were also associated with PASC. We then used latent class analysis and identified two subtypes of PASC, one with fewer PASC symptoms ( n  = 112) and another with many PASC symptoms ( n  = 33). Risk factors for membership in each class were different, but a past diagnosis of depression predicted membership in both classes compared to those without PASC. A diagnosis of depression was more strongly associated with the “many symptoms” class compared to the “few symptoms” class. We find that several mental health and demographic risk factors are linked to PASC. More research is necessary to understand both the two subtypes of PASC identified in our analysis, and the underlying relationship between COVID-19 infection and PASC.

During the COVID-19 pandemic, protective behaviors like mask wearing or social distancing were encouraged to limit viral spread. While pandemic fatigue is tied to the reduction of protective behaviors over time, little evidence exists examining predictors of long-term protective behaviors after recovering from COVID-19. This study investigates the association between COVID-19 infection status and future use of protective behaviors. We analyzed data from 676 adults who completed questionnaires in May 2021 and January 2023 as part of the Los Angeles Pandemic Surveillance Cohort Study. Measures included self-reported COVID-19 infection status and symptom severity, and mask wearing, hand washing, social distancing and perceived susceptibility to COVID-19. We performed Wilcoxon signed-rank tests, ordinal logit regression models, and mediation analysis to assess behavior change, associations, and whether perceived susceptibility mediated the effects. The use of protective behaviors declined significantly from baseline to follow-up. Self- reported asymptomatic or mild COVID-19 infection was associated with less social distancing (aOR=0.57, 95% CI [0.35, 0.92]), less mask wearing (aOR=0.63, 95% CI [0.40, 0.99]), and lower perceived susceptibility (aβ = -0.17, 95% CI [-0.33, -0.02]) at follow-up. Moderate or severe COVID-19 infection was associated with less mask wearing (aOR=0.55, 95%CI [0.38, 0.81]). Perceived susceptibility to COVID-19 mediated 15% of the effect of mild COVID-19 infection on mask wearing (indirect effect aβ = -0.16, 95% CI [-0.31, -0.02]). These results provide novel insights into the drivers of decreased use of protective behaviors over the course of the pandemic, particularly after an asymptomatic or mild COVID-19 infection. More research is needed on the effect of COVID-19 infection on long-term adherence to preventive measures against future pandemics.

This study examines the association between changes in mental health before and during the COVID-19 pandemic and COVID-19 mortality across geographic areas and by race/ethnicity. A cross-sectional survey was conducted in Los Angeles County between April and May 2021. The study used the Patient Health Questionnaire-2 to assess major depression risk. Participants' home ZIP codes were classified into low, middle, and high COVID-19 mortality impacted areas (CMIA). While there were existing mental health disparities due to differences in demographics and social determinants of health across CMIA in 2018, the pandemic exacerbated the disparities, especially for residents living in high CMIA. Non-White residents in high CMIA reported the largest deterioration in mental health. Differences in mental health by CMIA persisted after controlling for resident characteristics. Living in an area with higher COVID-19 mortality rates may have been associated with worse mental health, with Non-White residents reporting worse mental health outcomes in the high mortality area. It is crucial to advocate for greater mental health resources in high COVID-19 mortality areas especially for racial/ethnic minorities.

Health care is believed to be suffered from a \"cost disease,\" in which a heavy reliance on labor limits opportunities for efficiencies stemming from technological improvement. Although recent evidence shows that U.S. hospitals have experienced a positive trend of productivity growth, skilled nursing facilities are relatively \"low-tech\" compared to hospitals, leading some to worry that productivity at skilled nursing facilities will lag behind the rest of the economy. To assess productivity growth among skilled nursing facilities (SNFs) in the treatment of conditions which frequently involve substantial post-acute care after hospital discharge. We constructed an analytic file with the records of Medicare beneficiaries that were discharged from acute-care hospitals to SNFs with stroke, hip fracture, or lower extremity joint replacement (LEJR) between 2006 and 2014. We populated each record for 90 days starting at the time of SNF admission, detailing for each day the treatment site and all associated costs. We used ordinary least square regression to estimate growth in SNF productivity, measured by the ratio of \"high-quality SNF stays\" to total treatment costs. The primary definition of a high-quality stay was a stay that ended with the return of the patient to the community within 90 days after SNF admission. We controlled for patient demographics and comorbidities in the regression analyses. Our sample included 1,076,066 patient stays at 14,394 SNFs with LEJR, 315,546 patient stays at 14,154 SNFs with stroke, and 739,608 patient stays at 14,588 SNFs with hip fracture. SNFs improved their productivity in the treatment of patients with LEJR, stroke, and hip fracture by 1.1%, 2.2%, and 2.0% per year, respectively. That pattern was robust to a number of alternative specifications. Regressions on year dummies showed that the productivity first decreased and then increased, with a lowest point in 2011. Over the study period, quality continued to rise, but dominated by higher costs at first. Costs then started to decrease, driving productivity to grow. There has been substantial productivity growth in recent years among SNFs in the U.S. in the treatment of post-acute-care-intensive conditions.

At the beginning of the COVID-19 pandemic in the US, traffic sharply fell due to social distancing policies in many locations. Correspondingly, many regions observed an increase in traffic volume (traffic recovery) as the pandemic eased in 2022. We examine how vaccination rates influence traffic recovery in Los Angeles County (LAC), controlling for differences in case counts, demographics, and socioeconomic factors across areas with different vaccination rates. We use arterial road sensor data as a proxy for the traffic volume within each ZIP code, alongside their respective demographic and socioeconomic characteristics. We find that a higher vaccination rate is statistically significantly associated with a larger traffic recovery, a finding that remains consistent across all explored models. This implies that an increased vaccination rate could reduce the public’s perception of the risks of disease infection, leading to a larger traffic recovery. Moreover, we found that variables including population, income, race, work industry, and commuting preferences were correlated with vaccination rates. This highlights potential inequalities based on race, income, and industry sectors in the COVID-19 vaccination and a return to normal traffic flow.

Background: Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home, or undergo postacute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Because 15% of Medicare expenditures are for these types of postacute care, it is important to understand their relative costs and the health outcomes they produce. Objective: To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003. Research Design: This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across postacute care sites, and we use instrumental variables estimation to account for unobserved patient selection. Study Outcomes: Mortality, return to community residence, and total Medicare postacute payments by 120 days after acute care discharge. Results: Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home. Conclusions: When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for postacute care. However, given the marginal cost of an IRF stay compared with returning home, the gains to these patients should be considered in light of the additional costs.

Some models of vaccination behavior imply that an individual's willingness to vaccinate could be negatively correlated with the vaccination rate in her community. The rationale is that a higher community vaccination rate reduces the risk of contracting the vaccine-preventable disease and thus reduces the individual's incentive to vaccinate. At the same time, as for many health-related behaviors, individuals may want to conform to the vaccination behavior of peers, counteracting a reduced incentive to vaccinate due to herd immunity. Currently there is limited empirical evidence on how individual vaccination decisions respond to the vaccination decisions of peers. In the fall of 2014, we used a rapid survey technology to ask a large sample of U.S. adults about their willingness to use a vaccine for Ebola. Respondents expressed a greater inclination to use the vaccine in a hypothetical scenario with a high community vaccination rate. In particular, an increase in the community vaccination rate from 10% to 90% had the same impact on reported utilization as a nearly 50% reduction in out-of-pocket cost. These findings are consistent with a tendency to conform with vaccination among peers, and suggest that policies promoting vaccination could be more effective than has been recognized.

Prevention of COVID-19 with vaccine requires multiple doses and updated boosters to maintain protection; however currently there are no tests that can measure immunity and guide clinical decisions about timing of booster doses. This study examined the association between the risk of COVID-19 breakthrough infections and receptor binding domain (RBD) antibody levels and receipt of booster of COVID-19 vaccines. A community sample of Los Angeles County adults were surveyed between 2021 and 2022 to determine if they had a self-reported breakthrough infection. Predictors included RBD antibody levels, measured by binding antibody responses to the ancestral strain at baseline and self-reported booster shot during the study period. Of the 859 participants, 182 (21%) reported a breakthrough infection. Irrespective of the level of antibodies, the risk of breakthrough infection was similar, ranging from 19 to 23% ( P  = 0.78). The risk of breakthrough infections was lower among participants who had a booster shot ( P  = 0.004). The protective effect of a booster shot did not vary by antibody levels prior to receiving the booster. This study found no association between RBD antibody levels and risk of breakthrough infections, while the receipt of booster was associated with lower risk of breakthrough infections, which was independent of pre-booster antibody levels. Therefore, antibody levels might not be a useful guide for clinical decisions about timing of booster doses.