Early this week, I had a big story published in The Missouri Independent, as part of the Documenting COVID-19 project’s ongoing collaboration with that nonprofit newsroom. This piece goes in-depth on the Missouri health department’s contract with SLSCO, a Texas-based construction company that expanded to provide healthcare support during the pandemic.
While this was a local story, to me, the piece provides important insights about the type of support that is actually needed in U.S. hospitals right now: not temporary assistance, but long-term, structural change.
The Missouri agency hired SLSCO to provide two services, with a total contract of $30 million:
Provide staffing support (nurses, technicians, etc.) to hospitals across the state struggling in the wake of the Delta surge.
Set up, staff, and operate six monoclonal antibody infusion sites where Missourians infected with the coronavirus could easily access the treatment.
SLSCO made lofty promises to the Missouri health department, citing its ability to quickly send hundreds of workers to facilities that required assistance. But in fact, the hospital staffing assistance was marred by delays, no-shows, and high rates.
Here are a few paragraphs from the story:
Fewer hospitals signed on to receive staff than the Department of Health and Senior Services anticipated. Within the first few weeks, some hospitals faced no-shows, while the company’s hourly rates — up to $215 an hour for some nurses and $550 an hour for doctors — were too high for other hospitals to afford after state funds ran out, according to emails obtained by The Independent and the Documenting COVID-19 project through records requests. (Copies of SLS’ contract and emails between state agencies can be found here.)
“153 staff requested and only 10 deployed,” wrote Alex Tuttle, the governor’s legislative budget director, after receiving a staffing report early in the contract period. “Am I reading that right?”
From mid-August through November, just 206 staff were ultimately sent to 53 hospitals, said Lisa Cox, a spokeswoman for DHSS. The healthcare support had left by the time omicron hit in the winter.
The monoclonal antibody infusion sites were more successful; in fact, the Missouri health department ended up redirecting funding from the staffing support to the infusion sites. The six sites served a total of 3,688 patients over a two-month period.
However, the sites could have served a lot more patients: these clinics could have treated up to 136 patients each day but peaked at about 90, with numbers often much lower, according to my analysis of data from the health department. Due to these low numbers, the state of Missouri ended up spending more than $5,600 for each patient. One monoclonal antibody expert I talked to for the piece called this an “exorbitant” cost.
Now, I don’t mean to hate on monoclonal antibody treatments here—these drugs are truly a great way to boost the immune systems of COVID-19 patients who may be at higher risk for severe symptoms. Maggie Schaffer, a case management nurse who helped set up one of the infusion sites, told me that people who had this treatment typically are “feeling like a whole new person” within a day or two.
However, the treatments are very expensive and inefficient; one patient’s infusion appointment can take hours. The drugs themselves cost around $2,100 per dose, about 100 times as much as one vaccine. Health departments and facilities that offer monoclonal antibodies need to focus on getting the word out to patients so that these expensive supplies aren’t wasted.
At the same time, temporary healthcare staff can be great to help a facility out a surge—but they are not a long-term solution. In particular, nurses at a hospital may be frustrated by watching new staff come in from out of town and receive much higher pay rates; the “traveling nurse phenomenon,” as this is called, may contribute to burnout and staff leaving to go become traveling workers themselves.
What do hospitals actually need to do to address their staffing crisis? Here are a few ideas from Tener Veenema, a nursing expert focused on health systems a professor of nursing who researches health systems and emergency preparedness at Johns Hopkins’ Bloomberg School of Public Health:
Higher pay and assistance with education bills.
Regulations on things like work hours, the number of patients one nurse can be responsible for at once.
Mental health assistance that nurses are actually given time and space to access.
I’ll end the post with this quote from Veenema, which is also the last line of the story:
“If we don’t fix the toxic work environment, this issue of mandatory overtime, inadequate staffing levels, lack of time to access mental health resources,” Veenema said, “then you’re simply shooting more new nurses out of the cannon, but into the lake where they’re going to drown.”
Screenshot from the California SMARTER plan. This week, California became the first state to officially shift to an endemic strategy for dealing with COVID-19.
Last week, I discussed the recent trend in states ending mask requirements in public schools, businesses, and other settings, by providing readers with some suggestions for encouraging safety during this push to “open everything” (that wasn’t already open). This week, more states are dropping safety measures; for example, Washington governor Jay Inslee announced that the state’s indoor mask mandate will end on March 21, though this change is also contingent on a low level of COVID-19 hospital admissions.
At the same time, some states are also making major shifts in the ways they collect and report COVID-19 data. State public health departments are essentially moving to monitor COVID-19 more like the way they monitor the flu: as a disease that can pose a serious public health threat and deserves some attention, but does not entirely dictate how people live their lives.
You may have seen this shift discussed as a movement to treat COVID-19 as “endemic.” An endemic disease, from an epidemiologist’s standpoint, is one that’s controlled at an acceptable level—it hasn’t been completely eradicated, but the levels of cases, hospitalizations, and deaths are generally deemed as levels that can continue without major public health measures. For more on the topic, I recommend this post from epidemiologist Ellie Murray (whom I’ve quoted on this topic before).
We can argue—and many COVID-19 experts on Twitter are arguing—about whether this is the appropriate time to shift into endemic mode. Still, regardless of individual opinions, state public health departments are starting to make this shift, and I think it’s worthwhile to discuss how they’re doing it, particularly when it comes to data.
Here’s a brief roundup of four states that are shifting their COVID-19 data collection and reporting.
California
California made headlines this week for being the first state to officially shift into “endemic” policy for dealing with COVID-19. State officials have drafted a plan called “SMARTER”—which stands for Shots, Masks, Awareness, Readiness, Testing, Education, and Rx (treatment). I took a look at the plan, which reporters from NBC Bay Area kindly shared publicly on DocumentCloud.
Here are a few data-related highlights:
State officials will “focus on hospital numbers” to gauge how California should react to potential new variants that may be more infectious or more capable of causing severe disease.
Unlike some other states, California is maintaining testing capacity going forward, including an expansion of community testing sites and ongoing procurement of at-home antigen tests for public schools, long-term care facilities, and other institutions.
Throughout the pandemic, California has invested in genomic sequencing for COVID-19 cases, as well as a statewide modeling tool that compiles several different forecasts. These surveillance tools will be further expanded to respond to COVID-19 and other infectious disease outbreaks.
California also intends to “build a robust, regionally based wastewater surveillance and genome sequencing network” that can provide early warnings about new outbreaks.
The plan includes a focus on equity: California leaders will monitor testing, cases, and other metrics in minority communities so that resources can be provided to address disparities if needed.
Missouri
Missouri started its shift to “endemic” in December, as the governor declared an end to the state’s public health emergency around COVID-19—even though cases were at their highest-ever level in the state. Now, the Missouri health department is preparing to change its data reporting accordingly, my colleague Derek Kravitz and I reported in the Missouri Independent this week. (The Independent, a nonprofit newsroom focused on Missouri’s state government, is a long-time collaborator of the Documenting COVID-19 project, where I work part-time.)
Here are the planned data changes highlighted in our story:
Case investigations and contact tracing, where local health departments’ staffers reach out to people exposed to the virus in workplace or other public settings, will cease, unless a new, more transmissive or deadly variant emerges;
Daily reports on COVID-19 cases and deaths by the state health department will be replaced by aggregate weekly reports. In some cases, metro health departments, including those in St. Louis and Springfield, will likely continue collecting and disseminating daily reports but the state will stop its reporting;
Positivity rates will be phased out, as they are already difficult to interpret, with many Americans having switched from PCR tests to at-home antigen tests. Most people don’t report their results to local health departments. Missouri officials in January said they were prepared to be a “trend setter” in eliminating positivity rate reporting.
Hospitalization data will become even more important, with state health officials hoping to make reporting more timely;
Wastewater surveillance will become a more relied-on data point for public health officials, as a way to spot COVID-19 early in its life cycle and identify potential hot spots. Missouri is a leader in wastewater surveillance, as the state has the highest number of collection sites reported on a new CDC dashboard.
Iowa
A couple of weeks ago, I called out the state of Iowa for decommissioning its two COVID-19 dashboards, one dedicated to vaccination data and one for other major metrics. (I’m still bummed out about this, to be honest! Iowa had one of my favorite/most chaotic dashboards to check as a COVID Tracking Project data entry volunteer.)
Rather than reporting daily COVID-19 case numbers, vaccinations, and other data, Iowa is now providing weekly updates. The new, pared-down dashboard includes positive tests and death numbers over time, case and vaccination rates by county, and some demographic data.
For more frequent COVID-19 reporting, the Iowa dashboard now directs residents to federal data sources. Iowa is still reporting daily to the federal government, as all states are required to do.
The state health department “will continue to review and analyze COVID-19 and other public health data daily,” Governor Kim Reynolds said. But some teams focused on the COVID-19 response will return to pre-pandemic responsibilities.
This reporting change is intended to align with “existing reporting standards for other respiratory viruses,” Gov. Reynolds said.
Iowa is focusing on at-home tests with a program called “Test Iowa at Home,” in which residents can request to have a test kit sent to their homes for free. (It was unclear to me, from browsing the website, whether these are rapid antigen tests or PCR tests.) The state health department processes these tests and collects data from the program.
South Carolina
A Tweet from South Carolina data expert Philip Nelson alerted me to this one: not only is South Carolina shifting from daily to weekly data reports, the state is essentially ending all reporting of COVID-19 cases. This is paired with a gradual shutdown of testing sites in the state.
South Carolina’s health department will stop reporting daily COVID-19 case counts on March 15.
The agency will continue to report COVID-19 hospitalizations and deaths as important indicators of disease severity, but these will switch to a weekly update schedule rather than daily.
The shift away from case reporting aligns with a greater focus on rapid at-home tests, which South Carolina’s health department says are “not reportable.” (While it’s true that the vast majority of rapid at-home test results are not reported, some jurisdictions, like D.C., allow residents to self-report their results!)
South Carolina’s health department is planning to gradually shut down almost all public PCR testing sites in the state throughout the month of March. According to the department, these sites have seen “a significant decrease in demand” due to increased availability for rapid tests.
The department is also discouraging regular testing for asymptomatic South Carolina residents, saying that individuals who are currently symptomatic or have a close contact who tested positive should be prioritized.
More news on this topic
The CDC continues adding wastewater collection sites to its new dashboard. Two weeks ago, I wrote that only ten states had ten or more sites included on the dashboard; since then, three additional states have crossed that threshold: Illinois, Washington, and West Virginia. But the dashboard is still empty for the majority of states, indicating a lack of this important surveillance tool in much of the country.
For an upcoming story, I recently interviewed Lauren Ancel Meyers, a modeling expert at the University of Texas at Austin and lead author on this fascinating paper about using hospital admissions and mobility data for pandemic surveillance. Meyers has considered cases to be a messy indicator throughout the pandemic, she told me. She finds hospital admissions to be more useful, as this metric will directly show how many people are seeking healthcare due to their COVID-19 symptoms.
Another interesting paper, published in Nature this week, describes the use of machine learning models to drive COVID-19 testing at a university. The models could “predict which students were at elevated risk and should be tested,” the researchers write; students tested because of the models tended to be tested more quickly and were more likely to test positive than those identified through manual contact tracing or general surveillance. Such modeling could be used to augment the type of random sampling that Natalie Dean described in a recent article, shared in last week’s issue.
Are there any other states shifting their data reporting for an endemic COVID-19 state that I’ve missed? Email me or comment below and let me know!
COVID-19 Data Dispatch 