A new study has found how schools that were shut around the world as a safety measure against the COVID-19 pandemic can reopen.
The study that was led by the Yale School of Public Health says to safely reopen institutions of learning, pupils and students need to be screened for the virus infection every two or three days.
The COVID-19 pandemic has however led to severe financial stress for both hospitals and physician practices, raising serious concerns that many may either close or be purchased by larger organisations.
Such consolidation is well-recognised to lead to higher prices. Whether it will lead to better quality of care is less clear.
A new study published in the August Issue of Health Affairs, based on the first comprehensive national survey of physician practices, hospitals and health systems, found that larger, more integrated systems do not generally deliver better quality.
“We looked at a broad range of quality measures and compared independent hospitals and practices with those owned by different kinds of health systems”, says Elliott Fisher, MD, MPH, lead author and professor of medicine and health policy at Dartmouth. “In no case was ownership by larger, more complex health systems associated with better quality.”
Another key finding from the study was the remarkable degree of variation in quality scores across hospitals and physician practices, regardless of whether they were independent or owned by larger systems.
“This degree of variation points to tremendous opportunities to improve the quality of care in both hospitals and practices”, says Stephen Shortell, Ph.D., Professor of the Graduate School, University of California, Berkeley. “We must continue to put in place the incentives and programs needed to drive improvement.”
The research team assessed the degree to which hospitals and physician practices under several different ownership structures—including financial independence and financial integration with larger health systems—adopted care delivery and payment reforms intended to improve quality.
They analysed data from the National Survey of Healthcare Organizations and Systems, which included responses from 2,190 physician practices and 739 hospitals that were collected between June 2017 and August 2018.
The surveys included questions about care for complex, high-need patients; participation in quality-focused payment programs; screening for clinical conditions and social needs; and use of registries and evidence-based guidelines.
“The policy implications of this research are clear”, says Carrie Colla, Ph.D., professor of health policy and clinical practice at Dartmouth, who worked as a policy advisor in Congress during a recent sabbatical.
“With COVID-19 wreaking financial havoc on smaller healthcare organizations, policy makers—both at the federal and state levels—should ensure that purchases of practices and hospitals adhere to current antitrust law. They should also consider financial support for those most threatened by the pandemic.”
In the mean time, the research on how schools can reopen, published in JAMA Open Network, comes as universities across the United States are grappling with whether and how to reopen for the fall 2020 semester.
Residential campuses—with their communal living and dining spaces, crowded classrooms, and populations of young adults eager to socialize—pose a particular challenge.
For many US colleges, COVID-19 represents an existential dilemma: Either they open their doors to students in September or they face severe financial consequences.
Investigators led by Professor A. David Paltiel used epidemic modeling and cost-effectiveness analysis to assemble data on SARS-CoV-2 screening performance—including frequency, diagnostic accuracy, turnaround time, and cost—to design a monitoring program that would minimise cumulative infections and reduce strain on colleges’ isolation and quarantine capacities at a justifiable cost.
With this new testing programme, researchers found, most colleges would be able to prevent significant outbreaks of the disease.
“It is possible to reopen US residential colleges safely in the fall”, said Paltiel, “but it will require high-cadence screening in addition to strict adherence to masking, social distancing, and other preventive practices.”
Researchers from Massachusetts General Hospital and the Harvard Medical School co-authored the study.
Two findings surprised the investigators. First, it is possible to screen too frequently. “Too much screening overwhelms isolation facilities with false positive results, generating unnecessary expenditures, fueling anxiety, and undermining confidence in the ability of the university to keep its students safe”, said senior study author Rochelle P. Walensky, chief of the Massachusetts General Hospital’s Division of Infectious Diseases and professor at Harvard Medical School.
Second, the frequency of screening is much more important than the accuracy of the test. Testing every two days, even with a low-quality test (e.g., one the has a 70% chance of correctly detecting the presence of infection and a 98% chance of correctly detecting the absence of infection) will avert more infections than weekly testing with a higher-quality alternative (e.g., one that has a 90% chance of correctly detecting the presence of infection and a 99.8% chance of correctly detecting the absence of infection).
Due to the limitations on regulating student behavior on campus, it will not be sufficient for colleges to simply monitor students for the symptoms of COVID-19 and use signs of illness to trigger isolation and contact tracing, the researchers said.
“You cannot move swiftly enough to contain an outbreak if you wait until you see symptoms before you respond”, said co-author Amy Zheng of Harvard Medical School. “This virus is too readily transmitted by highly infectious, asymptomatic, ‘silent spreaders,’ especially if there might be sporadic parties that lead to outbreaks.”
The researchers acknowledge that the findings of their study set a high bar—logistically, financially, and behaviorally—that may be beyond the capacity of many universities and the students in their care. Paltiel concedes that the analysis’ recommended protocols may not, in fact, be feasible.
But, he adds, the adverse consequences of an outbreak will be disproportionately visited upon the non-student members of a college community—its staff, faculty, and the more vulnerable members of the surrounding community.
“Any school that cannot meet these minimum screening standards or maintain uncompromising control over good prevention practices has to ask itself if it has any business reopening,” Paltiel said.