key: cord-1005271-npa4mp3p authors: Abrams, Elissa M.; Singer, Alexander G.; Shaker, Marcus; Greenhawt, Matthew title: What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care date: 2020-11-27 journal: J Allergy Clin Immunol Pract DOI: 10.1016/j.jaip.2020.11.033 sha: 57a7bac1df28530e98e77b749b776c44469c3951 doc_id: 1005271 cord_uid: npa4mp3p The Coronavirus disease 2019 (COVID-19) pandemic has forever changed how we view healthcare service delivery. While there are undoubtedly some unintended consequences that will result from current healthcare service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. In order to determine what is “routine”, what is “essential”, and what is “exceptional” it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement (IHI) definition of the dimensions of quality based on whether the care is safe, effective, patient-centred, timely, efficient and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the COVID-19 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-COVID health care system. The Coronavirus disease 2019 (COVID-19) pandemic has undoubtedly changed health care in 65 ways that may have seemed unimaginable months ago. The rapid adoption of technologies 66 that support virtual care have demonstrated health care providers' capacity to pivot in 67 imaginative ways to support ongoing patient care, while complying with physical distancing 68 restrictions and healthcare resource reallocation. At the same time, large proportions of in-69 person care provision have simply ceased because they have been deemed "non-essential", or 70 we have adapted to endure without certain services. As we strive to return to elements of shift previously abstract ideas about risks into imminent threats. The pandemic has forced us to 82 re-examine whether some of the care we have traditionally provided was due to clinical inertia 83 J o u r n a l P r e -p r o o f and presents a valuable opportunity to critically assess healthcare delivery patterns to refine 84 practices and enhance value. 85 Several studies have shown significant reductions in care delivery have occurred during the 86 COVID-19 pandemic, leaving much of what was previously routine care to be either restricted 87 (due to mandated service rationing) or delayed. The Centers for Disease Control and Prevention 88 (CDC) have noted a decline in child vaccination coverage to less than 50% during the COVID-19 89 pandemic.(4) CDC data also demonstrate a reduction in Emergency Department visits for acute 90 life threatening emergencies including heart attacks, strokes and hyperglycemic crises.(5) Some 91 direct or indirect harm will likely result from restricted face-to-face encounters for some 92 patients, and there will likely be unintended consequences of health care service reduction. 93 However, the balance of reducing the risk of transmitting COVID-19 to individuals and 94 populations, decreased rate of overdiagnosis and overtreatment, and cost-reductions of non-95 essential care may balance any potential harms, and has the potential to result in greater ability 96 to deliver cost-effective care in many circumstances.(6-8) 97 Dimensions of Quality 98 The incorporation of virtual care has forced clinicians to adopt new, leaner habits of healthcare 99 delivery.(9,10) In the context of lessons learned, moving forward some of what was previously patient-centred, timely, efficient and equitable (Table 1) .(11) This type of stewardship has been 105 applied to many interventions already deemed unnecessary by organizations such as the 106 Choosing Wisely initiative, but the COVID-19 pandemic provides a lens from which to consider 107 other aspects of care. The following will provide examples from Allergy/Immunology that 108 outline how we can reconsider what quality means in the post-COVID health care system. The COVID-19 pandemic has taken almost a million lives and will change health care delivery 240 forever. But it will cost countless more if we do not learn the lessons this experience has taught 241 us and use them to improve the care we deliver now and in the coming months and years. With 242 deliberate effort, these experiences can be used not only to inform our preparedness for future 243 pandemics and national emergencies but can also be used to accelerate the evolution of care 244 we provide every day to maximize value in health. Determining Levers of Cost-effectiveness for Screening Infants 281 at High Risk for Peanut Sensitization Before Early Peanut Introduction Understanding the feasibility and implications of implementing early peanut introduction 285 for prevention of peanut allergy Timing of introduction of allergenic solids for 287 infants at high risk Pros and cons of 289 38. Shaker M, Abrams EM, Greenhawt M. Clinician Adoption of US Peanut Introduction Guidelines-A Case for Conditional Recommendations and Contextual Considerations to 352 Empower Shared Decision-Making A review of shared decision-making: A call to 354 arms for health care professionals How fair is our service? 356 Evaluating access to specialist paediatric care Allergen 358 immunotherapy: a practice parameter third update Evaluation and Management of Penicillin 361 Allergy: A Review Should testing be initiated prior to amoxicillin challenge in 363 children? Prevalence of beta-365 lactam allergy: A retrospective chart review of drug allergy assessment in a 366 predominantly pediatric population The Importance of Delabeling Lactam Allergy in Children Self-Reported Penicillin Allergy: A Systematic Review The impact of 373 penicillin skin testing on clinical practice and antimicrobial stewardship Delabeling penicillin allergy: Is skin testing required at all? 376 Management 378 of allergy to penicillins and other beta-lactams Assessing the 380 diagnostic properties of a graded oral provocation challenge for the diagnosis of 381 immediate and nonimmediate reactions to amoxicillin in children CPS Practice Point: Beta-lactam allergy in the paediatric population Update on penicillin allergy delabeling GRADE 387 equity guidelines 1: considering health equity in GRADE guideline development: 388 introduction and rationale The Impact of Social Determinants of 390 Health on Children with Asthma Urban minority 392 children with asthma: substantial morbidity, compromised quality and access to 393 specialists, and the importance of poverty and specialty care Racial and ethnic disparities in medical and dental health, 396 access to care, and use of services in US children COVID-19 and the impact of social determinants of health COVID-19 and African Americans