key: cord-0292172-ys3qwq7c
authors: Priem, Jennifer S.; Krinner, Lisa M.; Constantine, S. Tyler; McCurdy, Lewis
title: Diversification of COVID-19 Testing Resources to Decrease Racial/Ethnic Disparities: Comparative Use of Adaptive Approaches to Community Testing Across an Integrated Healthcare System
date: 2022-05-27
journal: nan
DOI: 10.1016/j.dialog.2022.100017
sha: 45b1781356ad3a1524d44b89c99959076348f30f
doc_id: 292172
cord_uid: ys3qwq7c

Background: Access to SARS-CoV-2 testing is a crucial component of early identification and disease containment. Racial and ethnic health disparities exist related to testing utilization. To optimize testing with limited resources, Atrium Health developed free-standing and roving testing centers outside of the traditional clinical settings in hopes of meeting the needs of a diverse urban community. The objective of this study is to evaluate differences in testing site utilization based on demographic factors, particularly race/ethnicity. Methods: A cohort study of patients tested for COVID-19 between March 10 and October 26, 2020, within the Atrium Health system. Results: 128,258 persons under investigation (PUIs) were tested across our health system, including 25,434 patients at our Mobile Integrated Health (previously called Community Paramedicine) drive-thru testing sites and community roving testing units. PUIs were on average 47 years old (SD = 17.7); approximately half were female and White/Caucasian. Drive-thru testing sites were utilized proportionally more by non-Hispanic Whites and African Americans, and less by Hispanic PUIs. Roving testing units were used significantly more by younger PUIs, Hispanics, and PUIs of other races/ethnicities. Conclusions: Diversification in testing site locations optimized testing resources, allowed for significant reduction in the burden of patient volumes, and avoided alteration of workflow in our urgent care facilities and Emergency Departments. Additionally, roving testing units may help to decrease racial/ethnic disparities in access to COVID-19 testing. Our results highlight the importance of offering a variety of testing modalities to reach different populations.

strategies to decrease racial/ethnic health disparities related to COVID-19 testing, treatment, and mortality. 12 In addition to increasing equitable deployment of resources, strategies need to address how to continue to meet the needs of non-COVID-19 patients and address a large influx of patients in EDs related to COVID-19, while augmenting containment strategies to reduce the likelihood of disease transmission.

In response to the increased need for improved hospital resource utilization and safety of both healthcare workers and patients who access care, Atrium Health (AH) established a process for virtual COVID-19 community screening, combined with drive-thru testing centers outside of the traditional clinical settings supported by our Mobile Integrated Health Program (MIH, previous called Community Paramedicine), and roving testing units deployed to communitybased sites located in COVID-19 hotspots and vulnerable communities.

In this paper, we evaluate the utilization of diversified testing sites comparing COVID-19 specific testing sites to traditional care facilities for individuals with COVID-related symptoms (henceforth labeled as persons under investigation (PUIs)). Our primary objective was to determine if there are testing site selection differences based on patient demographics, specifically evaluating age, sex, and race/ethnicity. Understanding differences in testing site utilization may inform strategies for improved implementation and access to virtual screening and free-standing testing sites. Insights gained will be useful for decision-making about offering increasing to meet testing demand). This initial site was established central to the footprint in Charlotte, NC. Over the following three weeks, additional clinics were set up at five other geographically distinct areas (see Figure 1 for locations). COVID-19 testing was conducted using in-house testing with a WHO assay specific for the RdRP gene of SARS-CoV-2 (starting on March 9 th ), and subsequently, on March 17. Additional testing with a Roche Cobas® nasopharyngeal PCR for SARS-CoV-2 began (Roche Diagnostics, Indianapolis, IN).

AH system data indicated that residents in the most vulnerable areas were suffering disproportionate COVID-19 disease burdens while having lower testing rates. Starting in May 2020, AH deployed roving testing units in addition to drive-thru testing sites. The roving COVID-19 testing units began with two buses that drove to target communities and provided walk-up testing, and later vaccination. Locations were strategically chosen based on the ongoing evaluation of COVID-19 hotspots. Testing schedules for the communities were posted online. The program was designed to overcome as many of the barriers to access and uptake as possible. Community members did not need to make an appointment or show identification. In addition, insurance was not required, and testing/vaccination services were free for uninsured residents. These measures helped increase utilization in hesitant residents who did not have health insurance or a primary care provider. The roving unit team included Spanish speaking staff to facilitate communication and connection. As part of the marketing for the program, community members were told that immigration status will never be shared, and undocumented patients will not be reported. Upon arrival, community members were screened for COVID-19 symptoms and those who screened positive were tested on the spot. Test results were delivered via text or phone call with follow-up instructions for care when needed.

J o u r n a l P r e -p r o o f

The study cohort includes PUIs tested for COVID-19 at EDs, urgent care facilities, drivethru testing sites, and roving testing units within the AH system between March 10 and October 26, 2020. All patients tested for SARS-CoV-2 were tracked in a prospective registry linked with the health system's electronic medical record (EMR), which was IRB approved for research use and included a waiver of informed consent. Because the focus of the study was on utilization of testing sites, patients who did not have a choice in testing location, including those tested in rehabilitation or skilled nursing facilities, patients who were tested after being admitted for an inpatient stay, and AH employees were excluded from analyses.

All COVID-19 test orders, date and time of test order and admission, and patient demographics were collected from the EMR. Patient comorbidities were identified in a 3-year EMR look-back for diagnosis codes related to the target comorbidities; conditions were chosen based on their relevance to COVID-19 risk. We compared testing site utilization for the drivethru testing sites and roving testing units to utilization of urgent care facilities and EDs within the AH system. To compare average age among testing sites, we used One-way Analysis of Variance with Games-Howell post-hoc tests. Distributions of sex, race/ethnicity, and SARS-CoV-2 test results by testing site were analyzed using separate Chi-Square Fishers Exact tests; the p-values reported are for the overall Fishers test. Proportional differences within each testing site were tested using z-tests with Bonferroni p-value adjustments. Data were analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, N.Y., USA).

A total of 128,258 COVID-19 tests were conducted at all four testing sites between March 10 and October 26, 2020.

To assess the potential of drive-thru and roving testing sites in reducing the number of COVID-19 related ED visits, we examined the proportion of SARS-CoV-2 tests at each testing location using Chi-squared Fisher's Exact tests. Comparing the different testing sites, 46% of tests were conducted at the free-standing drive-thru testing sites and 20% at roving testing units.

Of the remaining tests, 14% were conducted at an ED and 20% were at urgent care facilities (see Table 1 ). Of the 128,258 tests conducted, 10.3% were positive. The proportion of positive tests was highest when PUIs were tested in the ED, and lowest when PUIs were tested at drive-thru testing sites compared to other testing sites (see Table 1 ).

PUIs demographic characteristics by testing site are shown in Table 2 . PUIs were on average 47 years old (SD = 17.6). Approximately half of the PUIs were female (55.5%). Most PUIs were White/Caucasian (55%) or Black/African American (23%). The age of PUIs differed significantly by testing site with older PUIs presenting to drive-thru testing sites (average 51 years), and younger individuals using mobile testing sites (average 42 years). Females did not preferentially use drive-thru testing sites compared to EDs (56% vs. 55%) or roving testing units (56% vs. 53%), while significantly more males used roving testing units compared to all other testing sites (p < .001; Table 2 ). Table 2 also presents common comorbidities among the PUIs. Almost one-third of the PUIs had hypertension and 15% had diabetes. PUIs with asthma and pregnant PUIs were more likely to be tested at the ED, whereas PUIs with cancer, chronic heart failure, chronic kidney disease, diabetes, and hypertension were significantly more likely to use drive-thru testing sites.

PUIs with comorbidities were generally less likely to use roving units for testing.

Since the early identification of the SARS-CoV-2 virus, testing has been emphasized as paramount to the identification of infected persons and the control of viral spread. One of the challenges has been the ability to test large populations with increased disease prevalence, and secondly, to assure safe and easy accessibility to rapid testing. At our institution, we were successful in deploying free-standing drive-thru testing sites supported by MIH. These sites are physically distinct from any existing medical facility and allow for direct scheduling of PUIs to these sites instead of to traditional care sites. In addition, roving testing units provided a similar external option, but without the need to schedule an appointment or provide proof of insurance.

Whereas the drive-thru testing sites were identified early in the pandemic in a fixed location, the roving testing units moved throughout the community based on COVID-19 hotspots and social vulnerability of communities 10 Redirecting these patients allowed for a significant reduction in the burden of patient volumes and avoided alteration of workflow in our urgent care facilities and EDs. Our study is the first to compare testing site utilization and demographic differences in testing site utilization from COVID-19 specific drive-thru and roving testing sites across a large integrated healthcare system with a large geographic footprint.

Our process to utilize directed testing via virtual screening at free-standing testing sites provided an effective testing mechanism for PUIs. The proportion of test positivity was lowest at our drive-thru testing sites (2.6%) compared to the EDs (15.3%). This suggests that the screening process for drive-thru testing sites was successful at identifying patients' COVID-19 symptoms and allowed optimization of testing resources in a safe and efficient process. Overall, by diversifying testing options, patients could be tested in the most appropriate place for their specific needs and without over-burdening urgent cares and EDs.

Drive-thru testing sites were set up in areas distinct from established healthcare facilities to better facilitate testing and improve access; however, we identified that more minorities were tested in the ED and urgent care settings compared to drive-thru testing sites. The racial and ethnic makeup of drive-thru testing sites was 65% non-Hispanic White, 21% African American, and 6% Hispanic, while the racial composition of tests conducted in the ED was 48% non-Hispanic White, 37% African American, and 11% Hispanic. The racial/ethnic makeup of the Charlotte area (based on the 2019 U.S. Census) 15 was 45% non-Hispanic white, 35% African American, and 13% Hispanic. The racial/ethnic testing site distribution in our sample suggests that while drive-thru testing sites are a benefit to offload testing in traditional healthcare settings, utilization was disproportionate in the minority communities and underutilized by the population with reported higher disease burden (data not shown in a table).

There may be several factors that impact this observation including the ability to contact the COVID-19 hotline and navigate the scheduling process. The hotline was publicly distributed but not widely advertised, and most accessed through referral from primary care or other institutional portals. It is possible those who sought testing preferentially in the ED lacked access to primary care or had insufficient information about drive-thru and roving testing sites. Since testing in the urgent care or ED did not require prior screening, presenting directly to a traditional care site may be preferred for these identified groups. In addition, individuals who were screened via the hotline or a primary care physician were directed to a drive-thru testing site based on symptom severity; it is possible that symptoms at the time of screening were greatest in the older population, males, and minorities, and therefore they were directed directly to the ED for more immediate clinical evaluation. Lastly, the location of testing sites relative to demographic densities and transportation insecurity may have played a role in testing site J o u r n a l P r e -p r o o f utilization. Similar to the rest of the U.S., 16 the majority of COVID-19 infections in our healthcare system are in the African American and other minority populations as well as the elderly, which were both underrepresented in our drive-thru testing sites. Consideration for optimal placement of free-standing drive-thru testing to better meet the demographics of the disease is necessary to optimize early access to testing and potentially improve overall outcomes.

In line with this, AH began deploying roving testing units to COVID-19 hotspots in areas of lower socioeconomic status to improve testing access. Consistent with previous research 9-10 , results for our roving testing sites suggest that units deployed directly into areas with a higher proportion of minority populations can specifically address racial/ethnic disparities, especially for Hispanic/Latinx populations and patients of other races/ethnicities. Roving health units can help underserved communities overcome common barriers to accessing healthcare, including time, geography, and trust. 17 By providing community-based access for hard-toreach populations, a mobile health strategy is integral to advancing health equity. This is especially relevant in the context of COVID-19 which has disproportionately impacted communities of color and lower socioeconomic status. 18 Taken together, our results further reinforce the need for a multi-faceted approach to testing equity, such as what was employed by AH, rather than a one-size-fits-all approach.

This study has a few caveats. We only had data for testing conducted within the AH system and can therefore not report or if other traditional testing sites were utilized by our patients. As research has shown, males and African Americans have been disproportionally impacted by COVID-19 with more detrimental outcomes including hospitalization, requiring an ICU stay or mechanical ventilation, and mortality. 19, 20 It is possible that African Americans were tested in the ED more often because they also suffered from more severe illness or J o u r n a l P r e -p r o o f comorbidities. 21 Future research should assess the clinical factors that may influence testing site choices, further define barriers to testing for racial/ethnic minorities and elderly patients, and the evaluate clinical outcomes for those testing positive based on utilization of each testing site.

We used a community COVID hotline to provide standardized screening across our wide health system footprint to target testing and optimize our testing resources to suit the needs of patients. Overall, our results show that the creation of drive-thru and roving testing sites was an effective strategy for offsetting the demand on EDs for COVID-19 testing. These testing sites provide alternative testing options for high-risk patients who do not require immediate care, and help in decreasing racial/ethnic disparities in access to COVID-19 testing. Our results highlight the importance of offering a variety of testing modalities to reach different populations. Although the testing sites varied in the makeup of PUIs that utilized them, both similarities and differences uncovered in this study may inform strategies for future outbreaks and help to employ the flexible and agile use of non-traditional staffing models and sites for screening and testing. Highlights  Diversifying testing site locations reduces patient volumes in Emergency Departments and Urgent Cares  46% of COVID-19 tests were conducted at the free-standing drive-thru testing sites and 20% at roving testing units.  Roving testing units can help to decrease racial disparities in COVID-19 testing  44.1% of Hispanics were tested via roving units, compared to other options  Patterns identified may inform strategies for future infectious disease outbreaks J o u r n a l P r e -p r o o f

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Table 1: Proportion of Positive COVID-19 Test Results by Testing Site

All authors made a significant contribution to the manuscript, reviewed, and approved the manuscript prior to submission. LM, JP, and LK drafted and revised the introduction, methods, and discussion; JP and LK drafted the results and conducted all statistical analyses; TC performed critical revision of the manuscript for important intellectual content. The manuscript is not under review and has not been submitted to any other journal.

The authors have no conflicts of interest to report and are not funded by any external grants. The study was conducted under IRB approved protocol for COVID-19 research that included all