Druss, B. G.

Ku, B. S.

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Hofstra Northwell Academic Works (Hofstra Northwell School of Medicine)

Journal Articles 2020 Associations Between Primary Care Provider Shortage Areas and County-Level COVID-19 Infection and Mortality Rates in the USA B. S. Ku Zucker School of Medicine at Hofstra/Northwell B. G. Druss Follow this and additional works at: https://academicworks.medicine.hofstra.edu/articles Recommended Citation Ku BS, Druss BG. Associations Between Primary Care Provider Shortage Areas and County-Level COVID-19 Infection and Mortality Rates in the USA. . 2020 Jan 01; ():Article 6601 [ p.]. Available from: https://academicworks.medicine.hofstra.edu/articles/6601. Free full text article. This Article is brought to you for free and open access by Donald and Barbara Zucker School of Medicine Academic Works. It has been accepted for inclusion in Journal Articles by an authorized administrator of Donald and Barbara Zucker School of Medicine Academic Works. For more information, please contact academicworks@hofstra.edu. Associations Between Primary Care Provider ShortageAreas and County-Level COVID-19 Infection and MortalityRates in the USAJ Gen Intern MedDOI: 10.1007/s11606-020-06130-4© Society of General Internal Medicine 2020INTRODUCTIONAs COVID-19 disproportionately impacts certain regionsacross the USA, there have been speculations on variousfactors that may contribute to this disparity.1 Primary careHealth Professional Shortage Areas (HPSAs) are regions witha lack of primary care providers based on need for care. Theseareas have been associated with greater poverty, larger pro-portions of racial minorities,2 low-wage essential workers, andcongregate settings, including homeless shelters and prisons,all of whom could be at increased risk of contracting thevirus.1 Shortage areas may also have limited availability oftesting and treatment, which may contribute to higherCOVID-19 mortality.1 However, it is not known whethershortage areas are associated with higher COVID-19 infectionor mortality rates. This study investigates the hypothesis thatprimary care HPSAs are associated with higher rates ofCOVID-19 infection and mortality.METHODSCounty-level COVID-19 daily new cases and deaths fromMarch 22, 2020, to May 16, 2020, in the USA were extractedfrom https://coronavirus.1point3acres.com/en and COVID-19Data Repository by the Johns Hopkins University Center forSystems Science and Engineering population-based datasetson May 18, 2020. Cases and deaths were aggregated bycounty into weeks and only counties with reported COVID-19 cases and deaths during all 8 weeks were included so thatall counties were proportionately represented. 10,328 county-weeks were linked to county-level characteristics including2019 population estimates from the US Census Bureau.3Socioeconomic variables including poverty, unemployment,low educational attainment, population ages 65 and older,male gender, and non-Hispanic white race/ethnicitywere derived from the 2017 American Community Survey5-year estimates.3 The 2013 rural-urban continuum codes usedto classify rurality and whole county primary care HPSAswere separately derived from the 2018 Area Health ResourceFile.4 Primary care HPSAs were based on ratios of primarycare specialties (general or family practice, general internalmedicine, pediatrics, and obstetrics and gynecology) to resi-dents depending on needs for primary care services in specificgeographic areas.4Because most counties still do not have COVID-19 testingavailable, counties without any reported infections may lackcases due to a lack of local testing capacity.5 Therefore, wefocused on infection rates for the 10,328 county-weeks withreported COVID-19 infections as a proxy for infection burden.Generalized linear mixed models with negative binomial dis-tribution were used to test the associations of primary careHPSAs and COVID-19 rates, controlling for time, rurality,population, and six county-level socioeconomic variables.RESULTSDuring this study period, 1,381,197 individuals were diag-nosed with COVID-19 in the USA, and 85,097 died from thiscondition. There were 170 (13.2%) whole county primary careHPSAs and 1121 (86.8%) areas that were not wholecounty primary care HPSAs.COVID-19 infection and death rates were higher in wholecounty primary care HPSAs compared with non-wholecounty primary care HPSAs (overall median: 30.9 vs 18.0per 10,000 residents and 1.1 vs 0.7 per 10,000 residents,respectively). In models adjusting for county-level factorsand sociodemographic characteristics shown in Table 1, pri-mary care HPSAs were significantly associated with COVID-19 infection rate (adjusted IRR: 1.41 [95% CI, 1.19–1.66]; p <0.001) and COVID-19 mortality rate (adjusted IRR: 1.54[95% CI, 1.17–2.02]; p = 0.002).DISCUSSIONOur findings suggest that primary care provider shortage areaswith reported COVID-19 cases face a higher burden ofCOVID-19 infections and death even after adjusting for so-cioeconomic and other county-level factors. While it is notpossible to assess causal pathways using these cross-sectional,Received July 1, 2020Accepted August 10, 2020observational data, it is possible that reduced access to primarycare in provider shortage areas could lead to higher burden ofCOVID-19 disease and death rates due to delays in diagnosisand resource shortages. It is also possible that these areas faceother, unmeasured medical, economic, and social makers ofvulnerability.2 Further research should track these findingsover time and seek to disaggregate the possible underlyingmechanisms. Regardless of the causal pathway, the findingssuggest that many communities are likely to face simultaneouschallenges of high burden of coronavirus, social and economicdisadvantage, and limited access to primary medical care.Benson S. Ku, M.D.1Benjamin G. Druss, M.D., M.P.H.21Department of Psychiatry and Behavioral Sciences,Emory University School of Medicine,Atlanta, GA, USA2Department of Health Policy and Management,Rollins School of Public Health, Emory University,Atlanta, GA, USACorresponding Author: Benson S. Ku, M.D.; Department of Psychi-atry and Behavioral Sciences, Emory University School of Medicine,Atlanta, GA, USA (e-mail: bsku@emory.edu).Compliance with Ethical Standards:Conflict of Interest: The authors declare that they do not have aconflict of interest.REFERENCES1. Bibbins-Domingo K. This time must be different: disparities during theCOVID-19 pandemic. Ann Intern Med. April 2020. https://doi.org/10.7326/M20-22472. Streeter RA, Snyder JE, Kepley H, Stahl AL, Li T, Washko MM. Thegeographic alignment of primary care Health Professional Shortage Areaswith markers for social determinants of health. PLoS One. 2020;15(4).https://doi.org/10.1371/journal.pone.02314433. US Census Bureau. Census.gov. Accessed 30 Mar 2020.4. Health Resources and Services. Area Health Resources Files. https://data.hrsa.gov/topics/health-workforce/ahrf. Accessed 30 March 2020.5. Castlight. Location, location, location. https://www.castlighthealth.com/wp-content/uploads/2020/05/Retail-Clinics-COVID19-Report.pdf.Accessed 22 May 2020.Publisher’s Note: Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.Table 1 Relationships Between Population Characteristics and COVID-19 Infection and Mortality RatesModel A1 Model B2 Model C3 Model D4PopulationcharacteristicUnadjusted IRR(95% CI)p Adjusted IRR(95% CI)p Unadjusted IRR(95% CI)p Adjusted IRR(95% CI)pPrimary care HPSA 1.59 (1.35–1.87) < 0.001 1.41 (1.19–1.66) < 0.001 1.61 (1.25–2.08) < 0.001 1.54 (1.17–2.02) 0.002RUCC 1.01 (0.99–1.04) 0.363 1.02 (0.98–1.05) 0.342 1.00 (0.96–1.04) 0.847 0.98 (0.93–1.04) 0.555Low EducationalAttainment (%)1.03 (1.02–1.04) < 0.001 1.01 (1.02–0.99) 0.220 1.03 (1.01–1.05) < 0.001 0.99 (0.97–1.01) 0.426Unemployment (%) 1.15 (1.10–1.21) < 0.001 1.04 (0.98–1.09) 0.216 1.23 (1.15–1.32) < 0.001 1.08 (0.99–1.18) 0.078Poverty (%) 1.03 (1.02–1.04) < 0.001 0.99 (0.97–1.00) 0.141 1.04 (1.02–1.06) < 0.001 1.00 (0.97–1.03) 0.914Male gender (%) 0.97 (0.94–1.01) 0.099 0.98 (0.95–1.01) 0.232 0.89 (0.85–0.94) < 0.001 0.94 (0.89–1.00) 0.039Population ages65 and older (%)0.97 (0.96–0.99) < 0.001 0.99 (0.97–1.00) 0.179 1.01 (0.99–1.03) 0.513 1.04 (1.01–1.06) 0.003Non-Hispanic whitepopulation (%)0.99 (0.98–0.99) < 0.001 0.99 (0.98–0.99) < 0.001 0.98 (0.98–0.99) < 0.001 0.99 (0.98–0.99) < 0.0011Model A individually assessed the association between each characteristic and COVID-19 confirmed case rates2Model B mutually adjusted for all population characteristics and COVID-19 confirmed case rates3Model C individually assessed the association between each characteristic and COVID-19 mortality rates4Model D mutually adjusted for all population characteristics and confirmed COVID-19 mortality ratesHPSAs, Health Professional Shortage Areas; IRR, incidence rate ratio; RUCC, rural-urban continuum codes; Low Educational Attainment (%), thepercentage with less than high school educational attainment among the population ages 25 and older; Unemployment (%), percentage ofunemployment among civilian labor force population 16 years and over; Poverty (%), percentage of families and people whose income in the past 12months is below the poverty levelKu and Druss: PCP Shortage and COVID-19 JGIM

Associations Between Primary Care Provider Shortage Areas and County-Level COVID-19 Infection and Mortality Rates in the USA

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Associations Between Primary Care Provider Shortage Areas and County-Level COVID-19 Infection and Mortality Rates in the USA

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