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“Mortality rates for Black people during the pandemic have been higher,” Wynia said. “What really got people’s concerns raised was you could have a perfect scoring system that was really accurate, and it would end up preferentially taking resources away from Black people.”
Both broad and narrow triage methods lead to similar outcomes: The oldest and sickest are first to see life-saving treatments halted and deaths among those demographics skyrocket, Wynia said. “We had very few places that ever acknowledged that they were making those kinds of triage decisions,” he said. “You can see it in the data, even if people won’t talk about it. You can see that during surges when ICUs were really crammed full, mortality rates for older people with COVID went way up.”
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Nursing shortages
Nursing represents the biggest workforce problem for most hospitals. The total number of registered nurses declined 2% and the number of nursing assistants fell 9% between 2020 and 2021, according to the Bureau of Labor Statistics.
In September, the American Nurses Association asked HHS Secretary Xavier Becerra to declare the shortage a national crisis because it jeopardizes patient care. As of this writing, he hasn’t. Some states had to mobilize the National Guard to fill out hospitals’ clinical teams, and approximately 95% of hospitals reported using nurse staffing agencies.
A robust body of research shows that having fewer nurses is linked to worse patient outcomes. Mortality and adverse health events rise, as do costs, when patients spend more time in hospitals and are more likely to be readmitted. This contributes to burnout and moral injury among clinicians, which can lead to declining patient satisfaction and lower Medicare reimbursements.
To mitigate patient volumes when there aren’t enough workers, hospitals halted or delayed care for lower-acuity patients. This freed up beds and specialists to care for COVID-19 patients and others with more severe illnesses, but it denied necessary care to many patients.
“You try and shed the things that are the lowest risk, like a knee surgery or coronary artery bypass graft,” Wynia said. “There are things you can defer, but you can’t defer them forever or they do start to become dangerous.”
Consider people who have kidney disease. End-stage renal disease patients are among those affected by deferred care because of staffing shortages and other reasons. The number of U.S. residents with kidney failure had more than quadrupled since 1990, only to fall in 2021 because 18,000 more of them died than projected, largely as a result of the pandemic, a ProPublica investigation found.
More than one-quarter of the kidney care visits projected for last year didn’t happen, lab surveillance of creatinine levels dropped 30%, and 8% fewer kidney failure-related prescriptions were filled during the pandemic. Those findings are based on an analysis of claims from January 2019 to August 2021 conducted by Duke University School of Medicine, OptumLabs, the National Kidney Foundation and the Icahn School of Medicine at Mount Sinai. Providers haven’t caught up, which means those patients are at higher risk of hospitalizations, advanced kidney treatments, uncontrolled diabetes and hypertension, the study found.
“The system wasn’t designed to make up for the deficit that has developed,” said Dr. David Cook, senior vice president at OptumLabs, who co-wrote the report.
The nephrologist shortage predates the pandemic, while the number of medical students choosing this specialty has steadily declined. Like other clinical disciplines, these kidney doctors face a care backlog at the same time there are fewer professionals to provide services.
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