key: cord-0737833-zb4phu9p authors: Naidich, Jason J.; Boltyenkov, Artem; Wang, Jason J.; Chusid, Jesse; Rula, Elizabeth; Hughes, Danny; Sanelli, Pina C. title: Imaging Utilization During the COVID-19 Pandemic Highlights Socioeconomic Health Disparities date: 2020-10-28 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.10.016 sha: 2550b6bc72f2a53adc9c20b3e000121214aba8ba doc_id: 737833 cord_uid: zb4phu9p OBJECTIVE The devastating impact from the coronavirus disease 2019 (COVID-19) pandemic highlights long-standing socioeconomic health disparities in the United States. The purpose of this study was to evaluate socioeconomic factors related to imaging utilization during the pandemic. METHODS Retrospective review of consecutive imaging examinations was performed from January 1, 2019, to May 31, 2020, across all service locations (inpatient, emergency, outpatient). Patient level data were provided for socioeconomic factors (age, gender, race, insurance status, residential zip code). Residential zip code was used to assign median income level. The weekly total imaging volumes in 2020 and 2019 were plotted from January 1 to May 31 stratified by socioeconomic factors to demonstrate the trends during the pre-COVID-19 (January 1 to February 28) and post-COVID-19 (March 1 to May 31) periods. Independent-samples t tests were used to statistically compare the 2020 and 2019 socioeconomic groups. RESULTS Compared with 2019, the 2020 total imaging volume in the post-COVID-19 period revealed statistically significant increased imaging utilization in patients who are aged 60 to 79 years (P = .0025), are male (P < .0001), are non-White (Black, Asian, other, unknown) (P < .05), are covered by Medicaid or uninsured (P < .05), and have income below $80,000 (P < .05). However, there was a significant decrease in imaging utilization among patients who are younger (<18 years old) (P < .0001), are female (P < .0001), are White (P = .0003), are commercially insured (P < .0001), and have income ≥$80,000 (P < .05). DISCUSSION During the pandemic, there was a significant change in imaging utilization varying by socioeconomic factors, consistent with the known health disparities observed in the prevalence of COVID-19. These findings could have significant implications in directing utilization of resources during the pandemic and subsequent recovery. Artem Boltyenkov, PhD, MBA, academic affiliation non-partnership track employee, Visiting Scholar at the Feinstein Institutes for Medical Research -Substantially contributed to the conception and design of the study -Substantially contributed to the data curation and organization -Substantially contributed to the statistical analyses -Substantially contributed to the writing and revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Boltyenkov reports personal fees from Siemens Medical Solutions USA, Inc., outside the submitted work, and is a shareholder of Siemens Healthineers. Jason J. Wang, PhD, academic affiliation non-partnership track employee -Substantially contributed to the design of the study -Substantially contributed to the data curation and organization -Substantially contributed to the statistical analyses -Substantially contributed to the revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Wang has nothing to disclose. Jesse Chusid, MD, MBA, academic affiliation non-partnership track employee, Senior Vice President of Imaging Services, Northwell Health -Substantially contributed to the design of the study -Substantially contributed to the data supervision -Substantially contributed to the revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Chusid has nothing to disclose. Elizabeth Rula, PhD, non-partnership track employee, Executive Director of the Harvey L. Neiman Health Policy Institute -Substantially contributed to the conception and design of the study -Substantially contributed to the revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Rula reports employment at the Harvey L. Neiman Health Policy Institute. Danny Hughes, PhD, academic affiliation non-partnership track employee -Substantially contributed to the conception and design of the study -Substantially contributed to the revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Hughes reports grants from Harvey L. Neiman Health Policy Institute, outside the submitted work. Pina C. Sanelli, MD, MPH, FACR, academic affiliation non-partnership track employee, Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell -Substantially contributed to the conception and design of the study -Substantially contributed to the data curation and organization -Substantially contributed to the statistical analyses -Substantially contributed to the writing and revision of the manuscript -Approved the final version of the manuscript -Accountable for the manuscript's contents Disclosure statement: Dr. Sanelli reports grants from Harvey L. Neiman Health Policy Institute, during the conduct of the study; grants and non-financial support from Siemens Healthineers, Inc, outside the submitted work. Statement of Data Access and Integrity: The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. The COVID-19 pandemic continues to take a significant toll on the health of the population with over 7 million people affected in the U.S. resulting in over 200,000 deaths, as of September 21, 2020 [1] . The devastating impact from the pandemic highlights the long-standing socioeconomic health disparities and inequities in the U.S. healthcare system. Preventive measures intended to contain the spread of the SARS-CoV-2 virus, such as stay-at-home orders and social distancing efforts, have been challenging to effectively implement in low socioeconomic and underserved communities [2] . Crowded living conditions and employment in public-facing occupations, such as services and transportation, impair effective social distancing [3] . As a consequence, healthcare policy and the social determinants of health disproportionately affected the welfare of the minority, older, lower income and Medicaid/uninsured population. The most pervasive health disparities have been observed among African American and Latino individuals suffering both higher rates of COVID-19 infection and disease-related mortality [3] . The underlying socioeconomic factors that contribute to health disparities are complex and multifactorial, including age, sex, race, ethnicity, insurance status, education and income level. In the U.S., racial and ethnic variation in the access and utilization of medical resources has been well established. There is a growing body of literature reporting socioeconomic health disparities in diagnostic imaging and interventional radiology [4, 5] . There is a concern that these health disparities may be exacerbated when medical resources are limited, as seen during the COVID-19 pandemic. At the onset, healthcare institutions reallocated resources and limited some routine care, including imaging, in J o u r n a l P r e -p r o o f preparation for the rapid influx of patients requiring medical attention. Radiology practices developed imaging recommendations for the judicious use of cross-sectional imaging, ultrasound and interventional radiology in order to prevent spread of COVID-19 disease to patients and healthcare providers [6, 7] . Much has been written about the impact of COVID-19 on imaging volumes. Overall imaging volume declined, with the largest decline in the outpatient setting [6] . Inpatient imaging volume initially declined in preparation and subsequently rose with the influx of COVID-19 positive patients [7] . The rebound in inpatient imaging volume revealed a significant shift away from cross-sectional and advanced imaging modalities (CT, MRI, nuclear medicine, interventional procedures) toward radiography during the pandemic [7] . However, detailed analyses of the specific CPT-coded groups revealed that the individual imaging exams of CTA Chest, Radiography Chest and Ultrasound Venous Duplex had significantly increased imaging volumes in the late post-COVID-19 period, shedding light on the specific types of imaging exams needed to appropriately care for COVID-19 patients [7] . Although much is now known about imaging volumes during the pandemic, there is a relative paucity of data regarding the impact of COVID-19 on imaging utilization by different socioeconomic groups. Understanding the impact of social determinants on imaging utilization may assist healthcare leaders in allocating appropriate imaging resources during and after the COVID-19 pandemic. The purpose of this study was to evaluate socioeconomic factors related to imaging utilization during the COVID-19 pandemic. We analyzed patient-level imaging data to assess socioeconomic factors stratified by the patient service location (inpatient, J o u r n a l P r e -p r o o f emergency department, outpatient) during the COVID-19 pandemic in a large healthcare system. We performed a retrospective review of the Radiology invoices in the charge master from January 1, 2019 -May 31, 2020 to evaluate socioeconomic factors related to imaging utilization during the COVID-19 pandemic in a large integrated healthcare system. All consecutive billing invoices were obtained according to the date of service across all patient locations (inpatient, emergency department, outpatient). Patient level data was obtained from the radiology professional billing system containing patients' contact information (residential address and zip code), payor billing information (insurance type), and demographic data (birthdate, sex, race). At the time of scheduling and registration, staff either obtain this data on new patients or reconfirm this data on existing patients in our healthcare system. Institutional Review Board (IRB) approval and waiver of informed consent was obtained for this retrospective analysis. Our healthcare system is located in the New York metropolitan area serving a highly diverse population. In New York City, the first confirmed COVID-19 patient was The data variables were categorized as age (<18, 18-39, 40-59, 60-79, ≥80 years old), sex (male, female), race (white, black, Asian, other/multiracial, unknown), and insurance status (commercial, Medicare, Medicaid, uninsured). Self-pay status was included in the uninsured group. The residential zip code was linked to the median annual household income level (<$60,000, $60,000-79,999, $80,000-119,999, $120,000-149,999 and ≥$150,000) reported by the U.S. Census Bureau [8] . The weekly total imaging volumes in 2020 and 2019 were analyzed from January remained consistent across all patient service locations. The greatest effect was observed for the inpatient location with males having 33% higher odds compared to females. In contrast, the white race variable had the strongest negative association with imaging utilization during the pandemic across all patient service locations. The greatest effect was also seen for the inpatient location with 29% lower odds of whites compared to non-whites (blacks, Asian, other, unknown). Insurance status and income level was variable depending on the patient service location. In the emergency department J o u r n a l P r e -p r o o f location, commercial insurance and higher income level (≥$80,000) had significant negative associations with imaging utilization. In contrast, the outpatient location showed that higher income level (≥$80,000) had significant positive association with imaging utilization while commercial insurance was not statistically associated. The COVID-19 pandemic has highlighted long-standing health disparities in the U.S. and has had a disproportionate impact on the health and well-being of individuals of lower socioeconomic status, thus compounding the pre-existing inequities in the U.S. Furthermore, some differences were observed when the socioeconomic factors were stratified by patient service location (inpatient, emergency department, outpatient). In the emergency department and inpatient locations, the socioeconomic factors that were related to statistically increased imaging utilization followed the same pattern of patient demographics that were most impacted by the pandemic (older, males, nonwhite and lower income) because these patients experienced a higher prevalence of COVID and were likely seeking care in the emergency department and subsequently admitted to the hospital. Additionally, the multivariable regression model revealed that the male sex variable had the strongest positive association and the white race variable had the strongest negative association with imaging utilization during the COVID-19 pandemic across all patient service locations, with the greatest effect observed in the inpatient setting. In contrast, the patients that had significantly decreased proportions of imaging utilization in the outpatient location during the 2020 post-COVID-19 period were females, younger patients (<18 and 40-59 years old), white, lower income (<$60,000) and higher income (≥$120,000) levels. One possible explanation for this decline in the use of outpatient imaging services is that these patient groups were delaying their care during the COVID-19 pandemic as a consequence of the Centers for Medicare & Medicaid Services recommendation to limit nonessential and nonurgent medical care (9) . This mandate particularly affected the performance of routine outpatient imaging, such as breast cancer screening, which would disproportionately affect the younger, female population. Additionally, the economic downturn caused by the pandemic resulted in high rates of unemployment and loss of medical insurance(10), J o u r n a l P r e -p r o o f which may have disproportionately impacted those patients with prior commercial insurance and lower income households. However, we also consider the possibility that these findings can be explained by the pre-existing disparities related to imaging services reported in the literature (11) , in particular to cancer screening and follow-up imaging (12, 13) . If this is indeed the case, this delayed care may lead to potential adverse health consequences for these populations. Understanding the impact of the decline in the utilization of imaging services for specific patient groups is important to better guide health policy during and after the pandemic to ensure imaging needs are met. If this issue is not addressed proactively, it may potentially result in widening of existing disparities in radiology in the post pandemic era that includes access to outpatient imaging services, especially cancer screening programs. The main limitation of this study is the retrospective design using aggregated volume data, thus limiting our ability to perform more detailed regression analyses evaluating the key socioeconomic factors driving specific types of imaging utilization by CPT-coded groups during the COVID-19 pandemic. Another limitation is that our healthcare institution experienced an extremely high volume of COVID-19 patients during the pandemic potentially limiting the generalizability of these results to less J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f -Identifying socioeconomic health disparities related to imaging utilization is an initial step towards understanding the need for imaging resources in specific patient groups during the COVID-19 pandemic and subsequent recovery. -In a time of a healthcare crisis, it is important to understand socioeconomic factors related to imaging utilization to direct imaging resources in order to ensure adequate access and availability. United States COVID-19 and African Americans COVID-19 and Racial/Ethnic Disparities An Introduction to health disparities for the practicing radiologist Racial and ethnic differences in diagnostic imaging utilization during adult emergency department visits in the United States Impact of the COVID-19 pandemic on imaging case volumes Coronavirus disease 2019 (COVID-19) pandemic shifts inpatient imaging utilization American Community Survey 5-Year Estimates. Available at: ftp.census.gov Elective Medical Services, and Treatment Recommendations 2020 Recover Wisely From COVID-19: Responsible Resumption of Nonurgent Radiology Services Racial and Ethnic Disparities in Radiology: A Call to Action Improving Lung Cancer Screening Access for Individuals With Serious Mental Illness Factors Associated With Optimal Follow-up in Women With BI-RADS 3 Breast Findings Sources of support: Funding support received from the Harvey L. Neiman Health Policy Institute through a research partnership.