COVID-19

Systemic lupus erythematosus (SLE), or lupus, is a rare autoimmune disease estimated to occur in about 5.1 cases per 100,000 person-years in the United States in 2018.¹ The disease predominantly affects females, with an incidence of 8.7 cases per 100,000 person-years vs 1.2 cases per 100,000 person-years in males, and is most common in patients aged 15 to 44 years.^1,2

Lupus presents with a constellation of clinical signs and symptoms that evolve, along with hallmark laboratory findings indicative of immune dysregulation and polyclonal B-cell activation. Consequently, a wide array of autoantibodies may be produced, although the combination of epitope specificity can vary from patient to patient.3 Nevertheless, > 98% of individuals diagnosed with lupus produce antinuclear antibodies (ANA), making ANA positivity a near-universal serologic feature at the time of diagnosis.

The pathogenesis of lupus is complex. Research from the past 5 decades supports the role of certain viral infections—such as Epstein-Barr virus (EBV) and cytomegalovirus—as potential triggers.⁴ These viruses are thought to initiate disease through mechanisms including activation of interferon pathways, exposure of cryptic intracellular antigens, molecular mimicry, and epitope spreading. Subsequent clonal expansion and autoantibody production occur to varying degrees, influenced by viral load and host susceptibility factors.

During the COVID-19 pandemic, it became evident that SARS-CoV-2 exerts profound effects on immune regulation, influencing infection outcomes through mechanisms such as hyperactivation of innate immunity, especially in the lungs, leading to acute respiratory distress syndrome. Additionally, SARS-CoV-2 has been associated with polyclonal B-cell activation and the generation of autoantibodies. This association gained attention after Bastard et al identified anti–type I interferon antibodies in patients with severe COVID-19, predominantly among males with a genetic predisposition. These autoantibodies were shown to impair antiviral defenses and contribute to life-threatening pneumonia.⁵

Subsequent studies demonstrated the production of a wide spectrum of functional autoantibodies, including ANA, in patients with COVID-19.^6,7 These findings were attributed to the acute expansion of autoreactive clones among naïve-derived immunoglobulin G1 antibody-secreting cells during the early stages of infection, with the degree of expansion correlating with disease severity.^8,9 Although longitudinal data up to 15 months postinfection suggest this serologic abnormality resolves in more than two-thirds of patients, the number of individuals infected globally has raised serious public health concerns regarding the potential long-term sequelae, including the onset of lupus or other autoimmune diseases in COVID-19 survivors.^6-9 A limited number of case reports describing the onset of lupus following SARS-CoV-2 infection support this hypothesis.¹⁰

This surveillance analysis investigates lupus incidence among patients within the Military Health System (MHS), encompassing all TRICARE beneficiaries, from January 2018 to December 2022. The objective of this analysis was to examine lupus incidence trends throughout the COVID-19 pandemic, stratified by sex, age, and active-duty status.

Methods

The MHS provides health care services to about 9.5 million US Department of Defense (DoD) beneficiaries. Outpatient health records and laboratory results for individuals receiving care at military treatment facilities (MTFs) between January 1, 2018, and December 31, 2022, were obtained from the Comprehensive Ambulatory/ Professional Encounter Record and MHS GENESIS. For beneficiaries receiving care in the private sector, data were sourced from the TRICARE Encounter Data—Non-Institutional database.

Laboratory test results, including ANA testing, were available only for individuals receiving care at MTFs. These laboratory data were extracted from the Composite Health Care System Chemistry database and MHS GENESIS laboratory systems for the same time frame. Inpatient data were not included in this analysis. Data from 2017 were used solely as a look-back (or washout) period to identify and exclude prevalent lupus cases diagnosed before 2018 and were not included in the final results.

Lupus cases were identified by the presence of a positive ANA test and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. A positive ANA result was defined as either a qualitative result marked positive or a titer ≥ 1:80. The ICD-10-CM codes considered indicative of lupus included variations of M32, L93, or H01.12.

M32, L93, or H01.12. For cases with a positive ANA test, a lupus diagnosis required the presence of ≥ 2 lupus related ICD-10-CM codes. In the absence of ANA test results, a stricter criterion was applied: ≥ 4 lupus ICD-10-CM diagnosis codes recorded on separate days were required for inclusion.

Beneficiaries were excluded if they had a negative ANA result, only 1 lupus ICD- 10-CM diagnosis code, 1 positive ANA with only 1 corresponding ICD-10-CM code, or if their diagnosis occurred outside the defined study period. Patients and members of the public were not involved in the design, conduct, reporting, or dissemination of this study.

Results

Between January 1, 2017, and December 31, 2022, 99,946 TRICARE beneficiaries had some indication of lupus testing or diagnosis in their health records (Figure 1). Of these beneficiaries, 5335 had a positive ANA result and ≥ 2 ICD-10-CM lupus diagnosis codes. An additional 28,275 beneficiaries had ≥ 4 ICD-10-CM lupus diagnosis codes but no ANA test results. From these groups, the final sample included 10,760 beneficiaries who met the incident case definitions for SLE during the study period (2018 through 2022).

Most cases (85.1%, n = 9157) were diagnosed through TRICARE claims, while 1205 (11.2%) were diagnosed within the MHS. Another 398 (3.7%) had documentation of care both within and outside the MHS. Incident SLE cases declined by an average of 16% annually during the study period (Figure 2). This trend amounted to an overall reduction of 48.2%, from 2866 cases in 2018 to 1399 cases in 2022. This decline occurred despite total medical encounters among DoD beneficiaries remaining relatively stable during the pandemic years, with only a 3.5% change between 2018 and 2022.

The disease was more prevalent among female beneficiaries, with a female to- male ratio of 7:1 (Table 1). Among women, the number of new cases declined from 2519 in 2018 to 1223 in 2022, while the number of cases among men remained consistently < 350 annually. Similar trends were observed across other strata. Incident SLE cases were more common among nonactive-duty beneficiaries than active-duty service members, with a ratio of 18:1. New cases among active-duty members remained < 155 per year. Age-stratified data revealed that SLE was diagnosed predominantly in individuals aged ≥ 18 years, with a ratio of 37:1 compared with individuals aged < 18 years. Among children, the number of new cases remained < 75 per year throughout the study period.

A mean 56,850 ANA tests were conducted annually in centralized laboratories using standardized protocols (Table 2). The mean ANA positivity rate was 17.3%, which remained relatively stable from 2018 through 2022.

Discussion

This study examined the annual incidence of newly diagnosed SLE cases among all TRICARE beneficiaries from January 1, 2018, through December 31, 2022, covering both before and during the peak years of the COVID-19 pandemic. This analysis revealed a steady decline in SLE cases during this period. The reliability of these findings is reinforced by the comprehensiveness of the MHS, one of the largest US health care delivery systems, which maintains near-complete medical data capture for about 9.5 million DoD TRICARE beneficiaries across domestic and international settings.

SLE is a rare autoimmune disorder that presents a diagnostic challenge due to its wide range of nonspecific symptoms, many of which resemble other conditions. To reduce the likelihood of false-positive results and ensure diagnostic accuracy, this study adopted a stringent case definition. Incident cases were identified by the presence of ANA testing in conjunction with lupus-specific ICD-10-CM codes and required ≥ 4 lupus related diagnostic entries. This criterion was necessary due to the absence of ANA test results in data from private sector care settings. Our case definition aligns with established literature. For example, a Vanderbilt University chart review study demonstrated that combining ANA positivity with ≥ 4 lupus related ICD-10-CM codes achieves a positive predictive value of 100%, albeit with a sensitivity of 45%.¹¹ Other studies similarly affirm the diagnostic validity of using recurrent ICD-10-CM codes to improve specificity in identifying lupus cases.^12,13

The primary objective of this study was to examine the temporal trend in newly diagnosed lupus cases, rather than derive precise incidence rates. Although the TRICARE system includes about 9.5 million beneficiaries, this number represents a dynamic population with continual inflow and outflow. Accurate incidence rate calculation would require access to detailed denominator data, which were not readily available. In comparison with our findings, a study limited to active-duty service members reported fewer lupus cases. This discrepancy likely reflects differences in case definitions—specifically, the absence of laboratory data, the restricted range of diagnostic codes, and the requirement that diagnoses be rendered by specialists.¹⁴ Despite these differences, demographic patterns were consistent, with higher incidence observed in females and individuals aged ≥ 20 years.

A Centers for Disease Control and Prevention (CDC) study of lupus incidence in the general population also reported lower case counts.¹ However, the CDC estimates were based on 5 state-level registries, which rely on clinician-reported cases and therefore may underestimate true disease burden. Moreover, the DoD beneficiary population differs markedly from the general population: it includes a large cohort of retirees, ensuring an older demographic; all members have comprehensive health care access; and active-duty personnel are subject to pre-enlistment medical screening. Taken together, these factors suggest this study may offer a more complete and systematically captured profile of lupus incidence.

We observed a marked decline of newly diagnosed SLE cases during the study period, which coincided with the widespread circulation of COVID-19. This decrease is unlikely to be attributable to reduced access to care during the pandemic. The MHS operates under a single-payer model, and the total number of patient encounters remained relatively stable throughout the pandemic.

To our knowledge, this is the only study to monitor lupus incidence in a large US population over the 5-year period encompassing before and during the COVID-19 pandemic. To date, only 4 large-scale surveillance studies have addressed similar questions. ^14-17 Our findings are consistent with the most recent of these reports: an analysis limited to active-duty members of the US Armed Forces identified 1127 patients with newly diagnosed lupus between 2000 and 2022 and reported stable incidence trends throughout the pandemic.¹⁴ The other 3 studies adopted a different approach, comparing the emergence of autoimmune diseases, including lupus, between individuals with confirmed SARS-CoV-2 infection and those without. Each of these trials concluded that COVID-19 increases the risk of various autoimmune conditions, although the findings specific to lupus were inconsistent.^15-17

Chang et al reported a significant increase in new lupus diagnoses (n = 2,926,016), with an adjusted hazard ratio (aHR) of 2.99 (95% CI, 2.68-3.34), spanning all ages and both sexes. The highest incidence was observed in individuals of Asian descent.¹⁵ Using German routine health care data from 2020, Tesch et al identified a heightened risk of autoimmune diseases, including lupus, among patients with a history of SARS-CoV-2 infection (n = 641,407; 9.4% children, 57.3% female, 6.4% hospitalized), compared with matched infection-naïve controls (n = 1,560,357).¹⁶ Both studies excluded vaccinated individuals.

These 2 studies diverged in their assessment of the relationship between COVID-19 severity and subsequent autoimmune risk. Chang et al found a higher incidence among nonhospitalized ambulatory patients, while Tesch et al reported that increased risk was associated with patients requiring intensive care unit admission.^15,16

In contrast, based on a cohort of 4,197,188 individuals, Peng et al found no significant difference in lupus incidence among patients with SARS-CoV-2 infection (aHR, 1.05; 95% CI, 0.79-1.39).¹⁷ Notably, within the infected group, the incidence of SLE was significantly lower among vaccinated individuals compared with the unvaccinated group (aHR, 0.29; 95% CI, 0.18-0.47). Similar protective associations were observed for other antibody-mediated autoimmune disorders, including pemphigoid, Graves’ disease, and antiphospholipid antibody syndrome.

Limitations

Due to fundamental differences in study design, we were unable to directly reconcile our findings with those reported in the literature. This study lacked access to reliable documentation of COVID-19 infection status, primarily due to the widespread use of home testing among TRICARE beneficiaries. Additionally, the dataset did not include inpatient records and therefore did not permit evaluation of disease severity. Despite these constraints, it is plausible that the overall burden of COVID-19 infection within the study population was lower than that observed in the general US population.

As of December 2022, the DoD had reported about 750,000 confirmed COVID-19 cases among military personnel, civilian employees, dependents, and DoD contractors.¹⁸ Given that TRICARE beneficiaries represent about 2.8% of the total US population—and that > 90 million US individuals were infected between 2020 and 2022—the implied infection rate in our cohort appears to be about one-third of what might be expected.¹⁹ This discrepancy may be due to higher adherence to mitigation measures, such as social distancing and mask usage, among DoD-affiliated populations. COVID-19 vaccination was mandated for all active-duty service members, who constitute 5.4% of the study population. The remaining TRICARE beneficiaries also had access to guaranteed health care and vaccination coverage, likely contributing to high overall vaccination rates.

Because > 80% of the study population was composed of individuals from diverse civilian backgrounds, we expect the distribution of infection severity within the DoD beneficiary population to approximate that of the general US population.

Future Directions

The findings of this study offer circumstantial yet real-time evidence of the complexity underlying immune dysregulation at the intersection of host susceptibility and environmental exposures. The stability in ANA positivity rates during the study period mitigates concerns regarding undiagnosed subclinical lupus and may suggest that, overall, immune homeostasis was preserved among DoD beneficiaries.

It is noteworthy that during the COVID-19 pandemic, the incidence of several common infections—such as influenza and EBV—declined markedly, likely as a result of widespread social distancing and other public health interventions.²⁰ Mitigation strategies implemented within the military may have conferred protection not only against COVID-19 but also against other community-acquired pathogens.

In light of these observations, we hypothesize that for COVID-19 to act as a trigger for SLE, a prolonged or repeated disruption of immune equilibrium may be required—potentially mediated by recurrent infections or sustained inflammatory states. The association between viral infections and autoimmunity is well established. Immune dysregulation leading to autoantibody production has been observed not only in the context of SARS-CoV-2 but also following infections with EBV, cytomegalovirus, enteroviruses, hepatitis B and C viruses, HIV, and parvovirus B19.²¹

This dysregulation is often transient, accompanied by compensatory immune regulatory responses. However, in individuals subjected to successive or overlapping infections, these regulatory mechanisms may become compromised or overwhelmed, due to emergent patterns of immune interference of varying severity. In such cases, a transient immune perturbation may progress into a bona fide autoimmune disease, contingent upon individual risk factors such as genetic predisposition, preexisting immune memory, and regenerative capacity.²¹

Therefore, we believe the significance of this study is 2-fold. First, lupus is known to develop gradually and may require 3 to 5 years to clinically manifest after the initial break in immunological tolerance.³ Continued public health surveillance represents a more pragmatic strategy than retrospective cohort construction, especially as histories of COVID-19 infection become increasingly complete and definitive. Our findings provide a valuable baseline reference point for future longitudinal studies.

The interpretation of surveillance outcomes—whether indicating an upward trend, a stable baseline, or a downward trend—offers distinct analytical value. Within this study population, we observed neither an upward trajectory that might suggest a direct causal link, nor a flat trend that would imply absence of association between COVID-19 and lupus pathogenesis. Instead, the observation of a downward trend invites consideration of nonlinear or protective influences. From this perspective, we recommend that future investigations adopt a holistic framework when assessing environmental contributions to immune dysregulation—particularly when evaluating the long-term immunopathological consequences of the COVID-19 pandemic on lupus and related autoimmune conditions.

Conclusions

This study identified a declining trend in incident lupus cases during the COVID-19 pandemic among the DoD beneficiary population. Further investigation is warranted to elucidate the underlying factors contributing to this decline. Conducting longitudinal epidemiologic studies and applying multivariable regression analyses will be essential to determine whether incidence rates revert to prepandemic baselines and how these trends may be influenced by evolving environmental factors within the general population.

Systemic lupus erythematosus (SLE), or lupus, is a rare autoimmune disease estimated to occur in about 5.1 cases per 100,000 person-years in the United States in 2018.¹ The disease predominantly affects females, with an incidence of 8.7 cases per 100,000 person-years vs 1.2 cases per 100,000 person-years in males, and is most common in patients aged 15 to 44 years.^1,2

Lupus presents with a constellation of clinical signs and symptoms that evolve, along with hallmark laboratory findings indicative of immune dysregulation and polyclonal B-cell activation. Consequently, a wide array of autoantibodies may be produced, although the combination of epitope specificity can vary from patient to patient.3 Nevertheless, > 98% of individuals diagnosed with lupus produce antinuclear antibodies (ANA), making ANA positivity a near-universal serologic feature at the time of diagnosis.

The pathogenesis of lupus is complex. Research from the past 5 decades supports the role of certain viral infections—such as Epstein-Barr virus (EBV) and cytomegalovirus—as potential triggers.⁴ These viruses are thought to initiate disease through mechanisms including activation of interferon pathways, exposure of cryptic intracellular antigens, molecular mimicry, and epitope spreading. Subsequent clonal expansion and autoantibody production occur to varying degrees, influenced by viral load and host susceptibility factors.

During the COVID-19 pandemic, it became evident that SARS-CoV-2 exerts profound effects on immune regulation, influencing infection outcomes through mechanisms such as hyperactivation of innate immunity, especially in the lungs, leading to acute respiratory distress syndrome. Additionally, SARS-CoV-2 has been associated with polyclonal B-cell activation and the generation of autoantibodies. This association gained attention after Bastard et al identified anti–type I interferon antibodies in patients with severe COVID-19, predominantly among males with a genetic predisposition. These autoantibodies were shown to impair antiviral defenses and contribute to life-threatening pneumonia.⁵

Subsequent studies demonstrated the production of a wide spectrum of functional autoantibodies, including ANA, in patients with COVID-19.^6,7 These findings were attributed to the acute expansion of autoreactive clones among naïve-derived immunoglobulin G1 antibody-secreting cells during the early stages of infection, with the degree of expansion correlating with disease severity.^8,9 Although longitudinal data up to 15 months postinfection suggest this serologic abnormality resolves in more than two-thirds of patients, the number of individuals infected globally has raised serious public health concerns regarding the potential long-term sequelae, including the onset of lupus or other autoimmune diseases in COVID-19 survivors.^6-9 A limited number of case reports describing the onset of lupus following SARS-CoV-2 infection support this hypothesis.¹⁰

This surveillance analysis investigates lupus incidence among patients within the Military Health System (MHS), encompassing all TRICARE beneficiaries, from January 2018 to December 2022. The objective of this analysis was to examine lupus incidence trends throughout the COVID-19 pandemic, stratified by sex, age, and active-duty status.

Methods

The MHS provides health care services to about 9.5 million US Department of Defense (DoD) beneficiaries. Outpatient health records and laboratory results for individuals receiving care at military treatment facilities (MTFs) between January 1, 2018, and December 31, 2022, were obtained from the Comprehensive Ambulatory/ Professional Encounter Record and MHS GENESIS. For beneficiaries receiving care in the private sector, data were sourced from the TRICARE Encounter Data—Non-Institutional database.

Laboratory test results, including ANA testing, were available only for individuals receiving care at MTFs. These laboratory data were extracted from the Composite Health Care System Chemistry database and MHS GENESIS laboratory systems for the same time frame. Inpatient data were not included in this analysis. Data from 2017 were used solely as a look-back (or washout) period to identify and exclude prevalent lupus cases diagnosed before 2018 and were not included in the final results.

Lupus cases were identified by the presence of a positive ANA test and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. A positive ANA result was defined as either a qualitative result marked positive or a titer ≥ 1:80. The ICD-10-CM codes considered indicative of lupus included variations of M32, L93, or H01.12.

M32, L93, or H01.12. For cases with a positive ANA test, a lupus diagnosis required the presence of ≥ 2 lupus related ICD-10-CM codes. In the absence of ANA test results, a stricter criterion was applied: ≥ 4 lupus ICD-10-CM diagnosis codes recorded on separate days were required for inclusion.

Beneficiaries were excluded if they had a negative ANA result, only 1 lupus ICD- 10-CM diagnosis code, 1 positive ANA with only 1 corresponding ICD-10-CM code, or if their diagnosis occurred outside the defined study period. Patients and members of the public were not involved in the design, conduct, reporting, or dissemination of this study.

Results

Between January 1, 2017, and December 31, 2022, 99,946 TRICARE beneficiaries had some indication of lupus testing or diagnosis in their health records (Figure 1). Of these beneficiaries, 5335 had a positive ANA result and ≥ 2 ICD-10-CM lupus diagnosis codes. An additional 28,275 beneficiaries had ≥ 4 ICD-10-CM lupus diagnosis codes but no ANA test results. From these groups, the final sample included 10,760 beneficiaries who met the incident case definitions for SLE during the study period (2018 through 2022).

Most cases (85.1%, n = 9157) were diagnosed through TRICARE claims, while 1205 (11.2%) were diagnosed within the MHS. Another 398 (3.7%) had documentation of care both within and outside the MHS. Incident SLE cases declined by an average of 16% annually during the study period (Figure 2). This trend amounted to an overall reduction of 48.2%, from 2866 cases in 2018 to 1399 cases in 2022. This decline occurred despite total medical encounters among DoD beneficiaries remaining relatively stable during the pandemic years, with only a 3.5% change between 2018 and 2022.

The disease was more prevalent among female beneficiaries, with a female to- male ratio of 7:1 (Table 1). Among women, the number of new cases declined from 2519 in 2018 to 1223 in 2022, while the number of cases among men remained consistently < 350 annually. Similar trends were observed across other strata. Incident SLE cases were more common among nonactive-duty beneficiaries than active-duty service members, with a ratio of 18:1. New cases among active-duty members remained < 155 per year. Age-stratified data revealed that SLE was diagnosed predominantly in individuals aged ≥ 18 years, with a ratio of 37:1 compared with individuals aged < 18 years. Among children, the number of new cases remained < 75 per year throughout the study period.

A mean 56,850 ANA tests were conducted annually in centralized laboratories using standardized protocols (Table 2). The mean ANA positivity rate was 17.3%, which remained relatively stable from 2018 through 2022.

Discussion

This study examined the annual incidence of newly diagnosed SLE cases among all TRICARE beneficiaries from January 1, 2018, through December 31, 2022, covering both before and during the peak years of the COVID-19 pandemic. This analysis revealed a steady decline in SLE cases during this period. The reliability of these findings is reinforced by the comprehensiveness of the MHS, one of the largest US health care delivery systems, which maintains near-complete medical data capture for about 9.5 million DoD TRICARE beneficiaries across domestic and international settings.

SLE is a rare autoimmune disorder that presents a diagnostic challenge due to its wide range of nonspecific symptoms, many of which resemble other conditions. To reduce the likelihood of false-positive results and ensure diagnostic accuracy, this study adopted a stringent case definition. Incident cases were identified by the presence of ANA testing in conjunction with lupus-specific ICD-10-CM codes and required ≥ 4 lupus related diagnostic entries. This criterion was necessary due to the absence of ANA test results in data from private sector care settings. Our case definition aligns with established literature. For example, a Vanderbilt University chart review study demonstrated that combining ANA positivity with ≥ 4 lupus related ICD-10-CM codes achieves a positive predictive value of 100%, albeit with a sensitivity of 45%.¹¹ Other studies similarly affirm the diagnostic validity of using recurrent ICD-10-CM codes to improve specificity in identifying lupus cases.^12,13

The primary objective of this study was to examine the temporal trend in newly diagnosed lupus cases, rather than derive precise incidence rates. Although the TRICARE system includes about 9.5 million beneficiaries, this number represents a dynamic population with continual inflow and outflow. Accurate incidence rate calculation would require access to detailed denominator data, which were not readily available. In comparison with our findings, a study limited to active-duty service members reported fewer lupus cases. This discrepancy likely reflects differences in case definitions—specifically, the absence of laboratory data, the restricted range of diagnostic codes, and the requirement that diagnoses be rendered by specialists.¹⁴ Despite these differences, demographic patterns were consistent, with higher incidence observed in females and individuals aged ≥ 20 years.

A Centers for Disease Control and Prevention (CDC) study of lupus incidence in the general population also reported lower case counts.¹ However, the CDC estimates were based on 5 state-level registries, which rely on clinician-reported cases and therefore may underestimate true disease burden. Moreover, the DoD beneficiary population differs markedly from the general population: it includes a large cohort of retirees, ensuring an older demographic; all members have comprehensive health care access; and active-duty personnel are subject to pre-enlistment medical screening. Taken together, these factors suggest this study may offer a more complete and systematically captured profile of lupus incidence.

We observed a marked decline of newly diagnosed SLE cases during the study period, which coincided with the widespread circulation of COVID-19. This decrease is unlikely to be attributable to reduced access to care during the pandemic. The MHS operates under a single-payer model, and the total number of patient encounters remained relatively stable throughout the pandemic.

To our knowledge, this is the only study to monitor lupus incidence in a large US population over the 5-year period encompassing before and during the COVID-19 pandemic. To date, only 4 large-scale surveillance studies have addressed similar questions. ^14-17 Our findings are consistent with the most recent of these reports: an analysis limited to active-duty members of the US Armed Forces identified 1127 patients with newly diagnosed lupus between 2000 and 2022 and reported stable incidence trends throughout the pandemic.¹⁴ The other 3 studies adopted a different approach, comparing the emergence of autoimmune diseases, including lupus, between individuals with confirmed SARS-CoV-2 infection and those without. Each of these trials concluded that COVID-19 increases the risk of various autoimmune conditions, although the findings specific to lupus were inconsistent.^15-17

Chang et al reported a significant increase in new lupus diagnoses (n = 2,926,016), with an adjusted hazard ratio (aHR) of 2.99 (95% CI, 2.68-3.34), spanning all ages and both sexes. The highest incidence was observed in individuals of Asian descent.¹⁵ Using German routine health care data from 2020, Tesch et al identified a heightened risk of autoimmune diseases, including lupus, among patients with a history of SARS-CoV-2 infection (n = 641,407; 9.4% children, 57.3% female, 6.4% hospitalized), compared with matched infection-naïve controls (n = 1,560,357).¹⁶ Both studies excluded vaccinated individuals.

These 2 studies diverged in their assessment of the relationship between COVID-19 severity and subsequent autoimmune risk. Chang et al found a higher incidence among nonhospitalized ambulatory patients, while Tesch et al reported that increased risk was associated with patients requiring intensive care unit admission.^15,16

In contrast, based on a cohort of 4,197,188 individuals, Peng et al found no significant difference in lupus incidence among patients with SARS-CoV-2 infection (aHR, 1.05; 95% CI, 0.79-1.39).¹⁷ Notably, within the infected group, the incidence of SLE was significantly lower among vaccinated individuals compared with the unvaccinated group (aHR, 0.29; 95% CI, 0.18-0.47). Similar protective associations were observed for other antibody-mediated autoimmune disorders, including pemphigoid, Graves’ disease, and antiphospholipid antibody syndrome.

Limitations

Due to fundamental differences in study design, we were unable to directly reconcile our findings with those reported in the literature. This study lacked access to reliable documentation of COVID-19 infection status, primarily due to the widespread use of home testing among TRICARE beneficiaries. Additionally, the dataset did not include inpatient records and therefore did not permit evaluation of disease severity. Despite these constraints, it is plausible that the overall burden of COVID-19 infection within the study population was lower than that observed in the general US population.

As of December 2022, the DoD had reported about 750,000 confirmed COVID-19 cases among military personnel, civilian employees, dependents, and DoD contractors.¹⁸ Given that TRICARE beneficiaries represent about 2.8% of the total US population—and that > 90 million US individuals were infected between 2020 and 2022—the implied infection rate in our cohort appears to be about one-third of what might be expected.¹⁹ This discrepancy may be due to higher adherence to mitigation measures, such as social distancing and mask usage, among DoD-affiliated populations. COVID-19 vaccination was mandated for all active-duty service members, who constitute 5.4% of the study population. The remaining TRICARE beneficiaries also had access to guaranteed health care and vaccination coverage, likely contributing to high overall vaccination rates.

Because > 80% of the study population was composed of individuals from diverse civilian backgrounds, we expect the distribution of infection severity within the DoD beneficiary population to approximate that of the general US population.

Future Directions

The findings of this study offer circumstantial yet real-time evidence of the complexity underlying immune dysregulation at the intersection of host susceptibility and environmental exposures. The stability in ANA positivity rates during the study period mitigates concerns regarding undiagnosed subclinical lupus and may suggest that, overall, immune homeostasis was preserved among DoD beneficiaries.

It is noteworthy that during the COVID-19 pandemic, the incidence of several common infections—such as influenza and EBV—declined markedly, likely as a result of widespread social distancing and other public health interventions.²⁰ Mitigation strategies implemented within the military may have conferred protection not only against COVID-19 but also against other community-acquired pathogens.

In light of these observations, we hypothesize that for COVID-19 to act as a trigger for SLE, a prolonged or repeated disruption of immune equilibrium may be required—potentially mediated by recurrent infections or sustained inflammatory states. The association between viral infections and autoimmunity is well established. Immune dysregulation leading to autoantibody production has been observed not only in the context of SARS-CoV-2 but also following infections with EBV, cytomegalovirus, enteroviruses, hepatitis B and C viruses, HIV, and parvovirus B19.²¹

This dysregulation is often transient, accompanied by compensatory immune regulatory responses. However, in individuals subjected to successive or overlapping infections, these regulatory mechanisms may become compromised or overwhelmed, due to emergent patterns of immune interference of varying severity. In such cases, a transient immune perturbation may progress into a bona fide autoimmune disease, contingent upon individual risk factors such as genetic predisposition, preexisting immune memory, and regenerative capacity.²¹

Therefore, we believe the significance of this study is 2-fold. First, lupus is known to develop gradually and may require 3 to 5 years to clinically manifest after the initial break in immunological tolerance.³ Continued public health surveillance represents a more pragmatic strategy than retrospective cohort construction, especially as histories of COVID-19 infection become increasingly complete and definitive. Our findings provide a valuable baseline reference point for future longitudinal studies.

The interpretation of surveillance outcomes—whether indicating an upward trend, a stable baseline, or a downward trend—offers distinct analytical value. Within this study population, we observed neither an upward trajectory that might suggest a direct causal link, nor a flat trend that would imply absence of association between COVID-19 and lupus pathogenesis. Instead, the observation of a downward trend invites consideration of nonlinear or protective influences. From this perspective, we recommend that future investigations adopt a holistic framework when assessing environmental contributions to immune dysregulation—particularly when evaluating the long-term immunopathological consequences of the COVID-19 pandemic on lupus and related autoimmune conditions.

Conclusions

This study identified a declining trend in incident lupus cases during the COVID-19 pandemic among the DoD beneficiary population. Further investigation is warranted to elucidate the underlying factors contributing to this decline. Conducting longitudinal epidemiologic studies and applying multivariable regression analyses will be essential to determine whether incidence rates revert to prepandemic baselines and how these trends may be influenced by evolving environmental factors within the general population.

Systemic lupus erythematosus (SLE), or lupus, is a rare autoimmune disease estimated to occur in about 5.1 cases per 100,000 person-years in the United States in 2018.¹ The disease predominantly affects females, with an incidence of 8.7 cases per 100,000 person-years vs 1.2 cases per 100,000 person-years in males, and is most common in patients aged 15 to 44 years.^1,2

Lupus presents with a constellation of clinical signs and symptoms that evolve, along with hallmark laboratory findings indicative of immune dysregulation and polyclonal B-cell activation. Consequently, a wide array of autoantibodies may be produced, although the combination of epitope specificity can vary from patient to patient.3 Nevertheless, > 98% of individuals diagnosed with lupus produce antinuclear antibodies (ANA), making ANA positivity a near-universal serologic feature at the time of diagnosis.

The pathogenesis of lupus is complex. Research from the past 5 decades supports the role of certain viral infections—such as Epstein-Barr virus (EBV) and cytomegalovirus—as potential triggers.⁴ These viruses are thought to initiate disease through mechanisms including activation of interferon pathways, exposure of cryptic intracellular antigens, molecular mimicry, and epitope spreading. Subsequent clonal expansion and autoantibody production occur to varying degrees, influenced by viral load and host susceptibility factors.

During the COVID-19 pandemic, it became evident that SARS-CoV-2 exerts profound effects on immune regulation, influencing infection outcomes through mechanisms such as hyperactivation of innate immunity, especially in the lungs, leading to acute respiratory distress syndrome. Additionally, SARS-CoV-2 has been associated with polyclonal B-cell activation and the generation of autoantibodies. This association gained attention after Bastard et al identified anti–type I interferon antibodies in patients with severe COVID-19, predominantly among males with a genetic predisposition. These autoantibodies were shown to impair antiviral defenses and contribute to life-threatening pneumonia.⁵

Subsequent studies demonstrated the production of a wide spectrum of functional autoantibodies, including ANA, in patients with COVID-19.^6,7 These findings were attributed to the acute expansion of autoreactive clones among naïve-derived immunoglobulin G1 antibody-secreting cells during the early stages of infection, with the degree of expansion correlating with disease severity.^8,9 Although longitudinal data up to 15 months postinfection suggest this serologic abnormality resolves in more than two-thirds of patients, the number of individuals infected globally has raised serious public health concerns regarding the potential long-term sequelae, including the onset of lupus or other autoimmune diseases in COVID-19 survivors.^6-9 A limited number of case reports describing the onset of lupus following SARS-CoV-2 infection support this hypothesis.¹⁰

This surveillance analysis investigates lupus incidence among patients within the Military Health System (MHS), encompassing all TRICARE beneficiaries, from January 2018 to December 2022. The objective of this analysis was to examine lupus incidence trends throughout the COVID-19 pandemic, stratified by sex, age, and active-duty status.

Methods

The MHS provides health care services to about 9.5 million US Department of Defense (DoD) beneficiaries. Outpatient health records and laboratory results for individuals receiving care at military treatment facilities (MTFs) between January 1, 2018, and December 31, 2022, were obtained from the Comprehensive Ambulatory/ Professional Encounter Record and MHS GENESIS. For beneficiaries receiving care in the private sector, data were sourced from the TRICARE Encounter Data—Non-Institutional database.

Laboratory test results, including ANA testing, were available only for individuals receiving care at MTFs. These laboratory data were extracted from the Composite Health Care System Chemistry database and MHS GENESIS laboratory systems for the same time frame. Inpatient data were not included in this analysis. Data from 2017 were used solely as a look-back (or washout) period to identify and exclude prevalent lupus cases diagnosed before 2018 and were not included in the final results.

Lupus cases were identified by the presence of a positive ANA test and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. A positive ANA result was defined as either a qualitative result marked positive or a titer ≥ 1:80. The ICD-10-CM codes considered indicative of lupus included variations of M32, L93, or H01.12.

M32, L93, or H01.12. For cases with a positive ANA test, a lupus diagnosis required the presence of ≥ 2 lupus related ICD-10-CM codes. In the absence of ANA test results, a stricter criterion was applied: ≥ 4 lupus ICD-10-CM diagnosis codes recorded on separate days were required for inclusion.

Beneficiaries were excluded if they had a negative ANA result, only 1 lupus ICD- 10-CM diagnosis code, 1 positive ANA with only 1 corresponding ICD-10-CM code, or if their diagnosis occurred outside the defined study period. Patients and members of the public were not involved in the design, conduct, reporting, or dissemination of this study.

Results

Between January 1, 2017, and December 31, 2022, 99,946 TRICARE beneficiaries had some indication of lupus testing or diagnosis in their health records (Figure 1). Of these beneficiaries, 5335 had a positive ANA result and ≥ 2 ICD-10-CM lupus diagnosis codes. An additional 28,275 beneficiaries had ≥ 4 ICD-10-CM lupus diagnosis codes but no ANA test results. From these groups, the final sample included 10,760 beneficiaries who met the incident case definitions for SLE during the study period (2018 through 2022).

Most cases (85.1%, n = 9157) were diagnosed through TRICARE claims, while 1205 (11.2%) were diagnosed within the MHS. Another 398 (3.7%) had documentation of care both within and outside the MHS. Incident SLE cases declined by an average of 16% annually during the study period (Figure 2). This trend amounted to an overall reduction of 48.2%, from 2866 cases in 2018 to 1399 cases in 2022. This decline occurred despite total medical encounters among DoD beneficiaries remaining relatively stable during the pandemic years, with only a 3.5% change between 2018 and 2022.

The disease was more prevalent among female beneficiaries, with a female to- male ratio of 7:1 (Table 1). Among women, the number of new cases declined from 2519 in 2018 to 1223 in 2022, while the number of cases among men remained consistently < 350 annually. Similar trends were observed across other strata. Incident SLE cases were more common among nonactive-duty beneficiaries than active-duty service members, with a ratio of 18:1. New cases among active-duty members remained < 155 per year. Age-stratified data revealed that SLE was diagnosed predominantly in individuals aged ≥ 18 years, with a ratio of 37:1 compared with individuals aged < 18 years. Among children, the number of new cases remained < 75 per year throughout the study period.

A mean 56,850 ANA tests were conducted annually in centralized laboratories using standardized protocols (Table 2). The mean ANA positivity rate was 17.3%, which remained relatively stable from 2018 through 2022.

Discussion

This study examined the annual incidence of newly diagnosed SLE cases among all TRICARE beneficiaries from January 1, 2018, through December 31, 2022, covering both before and during the peak years of the COVID-19 pandemic. This analysis revealed a steady decline in SLE cases during this period. The reliability of these findings is reinforced by the comprehensiveness of the MHS, one of the largest US health care delivery systems, which maintains near-complete medical data capture for about 9.5 million DoD TRICARE beneficiaries across domestic and international settings.

SLE is a rare autoimmune disorder that presents a diagnostic challenge due to its wide range of nonspecific symptoms, many of which resemble other conditions. To reduce the likelihood of false-positive results and ensure diagnostic accuracy, this study adopted a stringent case definition. Incident cases were identified by the presence of ANA testing in conjunction with lupus-specific ICD-10-CM codes and required ≥ 4 lupus related diagnostic entries. This criterion was necessary due to the absence of ANA test results in data from private sector care settings. Our case definition aligns with established literature. For example, a Vanderbilt University chart review study demonstrated that combining ANA positivity with ≥ 4 lupus related ICD-10-CM codes achieves a positive predictive value of 100%, albeit with a sensitivity of 45%.¹¹ Other studies similarly affirm the diagnostic validity of using recurrent ICD-10-CM codes to improve specificity in identifying lupus cases.^12,13

The primary objective of this study was to examine the temporal trend in newly diagnosed lupus cases, rather than derive precise incidence rates. Although the TRICARE system includes about 9.5 million beneficiaries, this number represents a dynamic population with continual inflow and outflow. Accurate incidence rate calculation would require access to detailed denominator data, which were not readily available. In comparison with our findings, a study limited to active-duty service members reported fewer lupus cases. This discrepancy likely reflects differences in case definitions—specifically, the absence of laboratory data, the restricted range of diagnostic codes, and the requirement that diagnoses be rendered by specialists.¹⁴ Despite these differences, demographic patterns were consistent, with higher incidence observed in females and individuals aged ≥ 20 years.

A Centers for Disease Control and Prevention (CDC) study of lupus incidence in the general population also reported lower case counts.¹ However, the CDC estimates were based on 5 state-level registries, which rely on clinician-reported cases and therefore may underestimate true disease burden. Moreover, the DoD beneficiary population differs markedly from the general population: it includes a large cohort of retirees, ensuring an older demographic; all members have comprehensive health care access; and active-duty personnel are subject to pre-enlistment medical screening. Taken together, these factors suggest this study may offer a more complete and systematically captured profile of lupus incidence.

We observed a marked decline of newly diagnosed SLE cases during the study period, which coincided with the widespread circulation of COVID-19. This decrease is unlikely to be attributable to reduced access to care during the pandemic. The MHS operates under a single-payer model, and the total number of patient encounters remained relatively stable throughout the pandemic.

To our knowledge, this is the only study to monitor lupus incidence in a large US population over the 5-year period encompassing before and during the COVID-19 pandemic. To date, only 4 large-scale surveillance studies have addressed similar questions. ^14-17 Our findings are consistent with the most recent of these reports: an analysis limited to active-duty members of the US Armed Forces identified 1127 patients with newly diagnosed lupus between 2000 and 2022 and reported stable incidence trends throughout the pandemic.¹⁴ The other 3 studies adopted a different approach, comparing the emergence of autoimmune diseases, including lupus, between individuals with confirmed SARS-CoV-2 infection and those without. Each of these trials concluded that COVID-19 increases the risk of various autoimmune conditions, although the findings specific to lupus were inconsistent.^15-17

Chang et al reported a significant increase in new lupus diagnoses (n = 2,926,016), with an adjusted hazard ratio (aHR) of 2.99 (95% CI, 2.68-3.34), spanning all ages and both sexes. The highest incidence was observed in individuals of Asian descent.¹⁵ Using German routine health care data from 2020, Tesch et al identified a heightened risk of autoimmune diseases, including lupus, among patients with a history of SARS-CoV-2 infection (n = 641,407; 9.4% children, 57.3% female, 6.4% hospitalized), compared with matched infection-naïve controls (n = 1,560,357).¹⁶ Both studies excluded vaccinated individuals.

These 2 studies diverged in their assessment of the relationship between COVID-19 severity and subsequent autoimmune risk. Chang et al found a higher incidence among nonhospitalized ambulatory patients, while Tesch et al reported that increased risk was associated with patients requiring intensive care unit admission.^15,16

In contrast, based on a cohort of 4,197,188 individuals, Peng et al found no significant difference in lupus incidence among patients with SARS-CoV-2 infection (aHR, 1.05; 95% CI, 0.79-1.39).¹⁷ Notably, within the infected group, the incidence of SLE was significantly lower among vaccinated individuals compared with the unvaccinated group (aHR, 0.29; 95% CI, 0.18-0.47). Similar protective associations were observed for other antibody-mediated autoimmune disorders, including pemphigoid, Graves’ disease, and antiphospholipid antibody syndrome.

Limitations

Due to fundamental differences in study design, we were unable to directly reconcile our findings with those reported in the literature. This study lacked access to reliable documentation of COVID-19 infection status, primarily due to the widespread use of home testing among TRICARE beneficiaries. Additionally, the dataset did not include inpatient records and therefore did not permit evaluation of disease severity. Despite these constraints, it is plausible that the overall burden of COVID-19 infection within the study population was lower than that observed in the general US population.

As of December 2022, the DoD had reported about 750,000 confirmed COVID-19 cases among military personnel, civilian employees, dependents, and DoD contractors.¹⁸ Given that TRICARE beneficiaries represent about 2.8% of the total US population—and that > 90 million US individuals were infected between 2020 and 2022—the implied infection rate in our cohort appears to be about one-third of what might be expected.¹⁹ This discrepancy may be due to higher adherence to mitigation measures, such as social distancing and mask usage, among DoD-affiliated populations. COVID-19 vaccination was mandated for all active-duty service members, who constitute 5.4% of the study population. The remaining TRICARE beneficiaries also had access to guaranteed health care and vaccination coverage, likely contributing to high overall vaccination rates.

Because > 80% of the study population was composed of individuals from diverse civilian backgrounds, we expect the distribution of infection severity within the DoD beneficiary population to approximate that of the general US population.

Future Directions

The findings of this study offer circumstantial yet real-time evidence of the complexity underlying immune dysregulation at the intersection of host susceptibility and environmental exposures. The stability in ANA positivity rates during the study period mitigates concerns regarding undiagnosed subclinical lupus and may suggest that, overall, immune homeostasis was preserved among DoD beneficiaries.

It is noteworthy that during the COVID-19 pandemic, the incidence of several common infections—such as influenza and EBV—declined markedly, likely as a result of widespread social distancing and other public health interventions.²⁰ Mitigation strategies implemented within the military may have conferred protection not only against COVID-19 but also against other community-acquired pathogens.

In light of these observations, we hypothesize that for COVID-19 to act as a trigger for SLE, a prolonged or repeated disruption of immune equilibrium may be required—potentially mediated by recurrent infections or sustained inflammatory states. The association between viral infections and autoimmunity is well established. Immune dysregulation leading to autoantibody production has been observed not only in the context of SARS-CoV-2 but also following infections with EBV, cytomegalovirus, enteroviruses, hepatitis B and C viruses, HIV, and parvovirus B19.²¹

This dysregulation is often transient, accompanied by compensatory immune regulatory responses. However, in individuals subjected to successive or overlapping infections, these regulatory mechanisms may become compromised or overwhelmed, due to emergent patterns of immune interference of varying severity. In such cases, a transient immune perturbation may progress into a bona fide autoimmune disease, contingent upon individual risk factors such as genetic predisposition, preexisting immune memory, and regenerative capacity.²¹

Therefore, we believe the significance of this study is 2-fold. First, lupus is known to develop gradually and may require 3 to 5 years to clinically manifest after the initial break in immunological tolerance.³ Continued public health surveillance represents a more pragmatic strategy than retrospective cohort construction, especially as histories of COVID-19 infection become increasingly complete and definitive. Our findings provide a valuable baseline reference point for future longitudinal studies.

The interpretation of surveillance outcomes—whether indicating an upward trend, a stable baseline, or a downward trend—offers distinct analytical value. Within this study population, we observed neither an upward trajectory that might suggest a direct causal link, nor a flat trend that would imply absence of association between COVID-19 and lupus pathogenesis. Instead, the observation of a downward trend invites consideration of nonlinear or protective influences. From this perspective, we recommend that future investigations adopt a holistic framework when assessing environmental contributions to immune dysregulation—particularly when evaluating the long-term immunopathological consequences of the COVID-19 pandemic on lupus and related autoimmune conditions.

Conclusions

This study identified a declining trend in incident lupus cases during the COVID-19 pandemic among the DoD beneficiary population. Further investigation is warranted to elucidate the underlying factors contributing to this decline. Conducting longitudinal epidemiologic studies and applying multivariable regression analyses will be essential to determine whether incidence rates revert to prepandemic baselines and how these trends may be influenced by evolving environmental factors within the general population.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

Primary care physicians who served marginalized communities had the highest proportion of patients who were unvaccinated against COVID-19, Canadian data suggested.

A study of more than 9000 family physicians in Ontario also found that the physicians with the largest proportion of unvaccinated patients were more likely to be male, to have trained outside Canada, to be older, and to work in an enhanced fee-for-service model than their counterparts who had lower proportions of unvaccinated patients.

“The family physicians with the most unvaccinated patients were also more likely to be solo practitioners and less likely to practice in team-based models, meaning they may have fewer support staff in their clinics,” lead author Jennifer Shuldiner, PhD, a scientist at Women’s College Hospital in Toronto, Ontario, Canada, told this news organization.

The findings were published in CMAJ.
 

Need vs Resources

Dr. Shuldiner and her team had been working on a project to provide additional support to family physicians with large numbers of patients who had not received their COVID-19 vaccinations. Their goal was to encourage family physicians to support these patients in getting vaccinated.

“As we were designing this project, we wondered how these physicians and their patients might differ. What characteristics might they have that would enable us to design and implement an intervention with high uptake and impact?” she said.

The researchers conducted a cross-sectional, population-based cohort study using linked administrative datasets in Ontario. They calculated the percentage of patients unvaccinated against SARS-CoV-2 who were enrolled with each comprehensive care family physician, ranked physicians according to the proportion of unvaccinated patients, and identified 906 physicians in the top 10% of unvaccinated patients. These physicians were compared with the remaining 90% of family physicians.

The physicians with the highest proportion of unvaccinated patients cared for 259,130 unvaccinated patients as of November 1, 2021. The proportion of patients who received two or more doses of the SARS-CoV-2 vaccine in this group was 74.2%. In comparison, the proportion of patients who received two or more doses of the vaccine was 87.0% in the remaining 90% of physicians.

Physicians with the largest proportion of unvaccinated patients were more likely to be male (64.6% vs 48.1%), to have trained outside Canada (46.9% vs 29.3%), to be older (mean age, 56 years vs 49 years), and to work in an enhanced fee-for-service model (49% vs 28%).

The study also found that patients enrolled with physicians in the most unvaccinated group tended to live in places with more ethnic diversity, higher material deprivation, and lower incomes. The proportion of recent immigrants was higher in this group.

“Clinics or practices with a large number of unvaccinated patients could be viable targets for efforts to coordinate public health and primary care,” said Dr. Shuldiner.

The findings indicate “the ongoing inverse relationship between the need for care and its accessibility and utilization. In other words, the practices with the highest need receive the fewest resources,” she noted.

“We know that relationships with trusted family physicians can positively influence patients’ decisions. Our study highlights the need to create equitable systems and processes that create opportunities for primary care teams to play a crucial role in influencing general and COVID-19-specific vaccine-related decision-making.”
 

Helping Primary Care Physicians

Commenting on the study for this news organization, Sabrina Wong, RN, PhD, professor of nursing at the University of British Columbia in Vancouver, British Columbia, Canada, said, “They did quite a nice analysis to show this using administrative data, and I think the information they’ve uncovered will be helpful in trying to fill the gaps and provide these practitioners with more support.”

Dr. Wong did not participate in the study. “The information they provide will be useful in helping us to move forward working with underserved, underresourced communities and also hopefully provide the clinicians, family physicians, and nurse practitioners working in these areas with more resources,” she said.

“The authors also point out that there needs to be more collaboration between public health and primary care to support these communities in their efforts to get the vaccines to the people in these communities who need them.”

The study was supported by a Canadian Institutes of Health Research grant. Dr. Shuldiner and Dr. Wong reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Primary care physicians who served marginalized communities had the highest proportion of patients who were unvaccinated against COVID-19, Canadian data suggested.

A study of more than 9000 family physicians in Ontario also found that the physicians with the largest proportion of unvaccinated patients were more likely to be male, to have trained outside Canada, to be older, and to work in an enhanced fee-for-service model than their counterparts who had lower proportions of unvaccinated patients.

“The family physicians with the most unvaccinated patients were also more likely to be solo practitioners and less likely to practice in team-based models, meaning they may have fewer support staff in their clinics,” lead author Jennifer Shuldiner, PhD, a scientist at Women’s College Hospital in Toronto, Ontario, Canada, told this news organization.

The findings were published in CMAJ.
 

Need vs Resources

Dr. Shuldiner and her team had been working on a project to provide additional support to family physicians with large numbers of patients who had not received their COVID-19 vaccinations. Their goal was to encourage family physicians to support these patients in getting vaccinated.

“As we were designing this project, we wondered how these physicians and their patients might differ. What characteristics might they have that would enable us to design and implement an intervention with high uptake and impact?” she said.

The researchers conducted a cross-sectional, population-based cohort study using linked administrative datasets in Ontario. They calculated the percentage of patients unvaccinated against SARS-CoV-2 who were enrolled with each comprehensive care family physician, ranked physicians according to the proportion of unvaccinated patients, and identified 906 physicians in the top 10% of unvaccinated patients. These physicians were compared with the remaining 90% of family physicians.

The physicians with the highest proportion of unvaccinated patients cared for 259,130 unvaccinated patients as of November 1, 2021. The proportion of patients who received two or more doses of the SARS-CoV-2 vaccine in this group was 74.2%. In comparison, the proportion of patients who received two or more doses of the vaccine was 87.0% in the remaining 90% of physicians.

Physicians with the largest proportion of unvaccinated patients were more likely to be male (64.6% vs 48.1%), to have trained outside Canada (46.9% vs 29.3%), to be older (mean age, 56 years vs 49 years), and to work in an enhanced fee-for-service model (49% vs 28%).

The study also found that patients enrolled with physicians in the most unvaccinated group tended to live in places with more ethnic diversity, higher material deprivation, and lower incomes. The proportion of recent immigrants was higher in this group.

“Clinics or practices with a large number of unvaccinated patients could be viable targets for efforts to coordinate public health and primary care,” said Dr. Shuldiner.

The findings indicate “the ongoing inverse relationship between the need for care and its accessibility and utilization. In other words, the practices with the highest need receive the fewest resources,” she noted.

“We know that relationships with trusted family physicians can positively influence patients’ decisions. Our study highlights the need to create equitable systems and processes that create opportunities for primary care teams to play a crucial role in influencing general and COVID-19-specific vaccine-related decision-making.”
 

Helping Primary Care Physicians

Commenting on the study for this news organization, Sabrina Wong, RN, PhD, professor of nursing at the University of British Columbia in Vancouver, British Columbia, Canada, said, “They did quite a nice analysis to show this using administrative data, and I think the information they’ve uncovered will be helpful in trying to fill the gaps and provide these practitioners with more support.”

Dr. Wong did not participate in the study. “The information they provide will be useful in helping us to move forward working with underserved, underresourced communities and also hopefully provide the clinicians, family physicians, and nurse practitioners working in these areas with more resources,” she said.

“The authors also point out that there needs to be more collaboration between public health and primary care to support these communities in their efforts to get the vaccines to the people in these communities who need them.”

The study was supported by a Canadian Institutes of Health Research grant. Dr. Shuldiner and Dr. Wong reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Primary care physicians who served marginalized communities had the highest proportion of patients who were unvaccinated against COVID-19, Canadian data suggested.

A study of more than 9000 family physicians in Ontario also found that the physicians with the largest proportion of unvaccinated patients were more likely to be male, to have trained outside Canada, to be older, and to work in an enhanced fee-for-service model than their counterparts who had lower proportions of unvaccinated patients.

“The family physicians with the most unvaccinated patients were also more likely to be solo practitioners and less likely to practice in team-based models, meaning they may have fewer support staff in their clinics,” lead author Jennifer Shuldiner, PhD, a scientist at Women’s College Hospital in Toronto, Ontario, Canada, told this news organization.

The findings were published in CMAJ.
 

Need vs Resources

Dr. Shuldiner and her team had been working on a project to provide additional support to family physicians with large numbers of patients who had not received their COVID-19 vaccinations. Their goal was to encourage family physicians to support these patients in getting vaccinated.

“As we were designing this project, we wondered how these physicians and their patients might differ. What characteristics might they have that would enable us to design and implement an intervention with high uptake and impact?” she said.

The researchers conducted a cross-sectional, population-based cohort study using linked administrative datasets in Ontario. They calculated the percentage of patients unvaccinated against SARS-CoV-2 who were enrolled with each comprehensive care family physician, ranked physicians according to the proportion of unvaccinated patients, and identified 906 physicians in the top 10% of unvaccinated patients. These physicians were compared with the remaining 90% of family physicians.

The physicians with the highest proportion of unvaccinated patients cared for 259,130 unvaccinated patients as of November 1, 2021. The proportion of patients who received two or more doses of the SARS-CoV-2 vaccine in this group was 74.2%. In comparison, the proportion of patients who received two or more doses of the vaccine was 87.0% in the remaining 90% of physicians.

Physicians with the largest proportion of unvaccinated patients were more likely to be male (64.6% vs 48.1%), to have trained outside Canada (46.9% vs 29.3%), to be older (mean age, 56 years vs 49 years), and to work in an enhanced fee-for-service model (49% vs 28%).

The study also found that patients enrolled with physicians in the most unvaccinated group tended to live in places with more ethnic diversity, higher material deprivation, and lower incomes. The proportion of recent immigrants was higher in this group.

“Clinics or practices with a large number of unvaccinated patients could be viable targets for efforts to coordinate public health and primary care,” said Dr. Shuldiner.

The findings indicate “the ongoing inverse relationship between the need for care and its accessibility and utilization. In other words, the practices with the highest need receive the fewest resources,” she noted.

“We know that relationships with trusted family physicians can positively influence patients’ decisions. Our study highlights the need to create equitable systems and processes that create opportunities for primary care teams to play a crucial role in influencing general and COVID-19-specific vaccine-related decision-making.”
 

Helping Primary Care Physicians

Commenting on the study for this news organization, Sabrina Wong, RN, PhD, professor of nursing at the University of British Columbia in Vancouver, British Columbia, Canada, said, “They did quite a nice analysis to show this using administrative data, and I think the information they’ve uncovered will be helpful in trying to fill the gaps and provide these practitioners with more support.”

Dr. Wong did not participate in the study. “The information they provide will be useful in helping us to move forward working with underserved, underresourced communities and also hopefully provide the clinicians, family physicians, and nurse practitioners working in these areas with more resources,” she said.

“The authors also point out that there needs to be more collaboration between public health and primary care to support these communities in their efforts to get the vaccines to the people in these communities who need them.”

The study was supported by a Canadian Institutes of Health Research grant. Dr. Shuldiner and Dr. Wong reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

TOPLINE: 

There were few cases of SARS-CoV-2 infections among emergency department (ED) healthcare personnel and no substantial changes in the delivery of emergency medical care during the initial phase of the COVID-19 pandemic.

METHODOLOGY:

• This multicenter prospective cohort study of US ED healthcare personnel called Project COVERED was conducted from May to December 2020 to evaluate the following outcomes:
• The possibility of infected ED personnel reporting to work
• The burden of COVID-19 symptoms on an ED personnel’s work status
• The association between SARS-CoV-2 infection levels and ED staffing
• Project COVERED enrolled 1673 ED healthcare personnel with 29,825 person weeks of observational data from 25 geographically diverse EDs.
• The presence of any SARS-CoV-2 infection was determined using reverse transcription polymerase chain reaction or IgG antibody testing at baseline, week 2, week 4, and every four subsequent weeks through week 20.
• Investigators also collected weekly data on ED staffing and the incidence of SARS-CoV-2 infections in healthcare facilities.

TAKEAWAY:

• Despite the absence of widespread natural immunity or COVID-19 vaccine availability during the time of this study, only 4.5% of ED healthcare personnel tested positive for SARS-CoV-2 infections, with more than half (57.3%) not experiencing any symptoms.
• Most personnel (83%) who experienced symptoms associated with COVID-19 reported working at least one shift in the ED and nearly all of them continued to work until they received laboratory confirmation of their infection.
• The working time lost as a result of COVID-19 and related concerns was minimal, as 89 healthcare personnel reported 90 person weeks of missed work (0.3% of all weeks).
• During this study, physician-staffing levels ranged from 98.7% to 102.0% of normal staffing, with similar values noted for nursing and nonclinical staffs. Reduced staffing was rare, even during COVID-19 surges.

IN PRACTICE:

“Our findings suggest that the cumulative interaction between infected healthcare personnel and others resulted in a negligible risk of transmission on the scale of public health emergencies,” the authors wrote.

SOURCE:

This study was led by Kurt D. Weber, MD, Department of Emergency Medicine, Orlando Health, Orlando, Florida, and published online in Annals of Emergency Medicine.

LIMITATIONS:

Data regarding the Delta variant surges that occurred toward the end of December and the ED status after the advent of the COVID-19 vaccine were not recorded. There may also have been a selection bias risk in this study because the volunteer participants may have exhibited behaviors like social distancing and use of protective equipment, which may have decreased their risk for infections.

DISCLOSURES:

This study was funded by a cooperative agreement from the Centers for Disease Control and Prevention and the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors declared no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE: 

There were few cases of SARS-CoV-2 infections among emergency department (ED) healthcare personnel and no substantial changes in the delivery of emergency medical care during the initial phase of the COVID-19 pandemic.

METHODOLOGY:

• This multicenter prospective cohort study of US ED healthcare personnel called Project COVERED was conducted from May to December 2020 to evaluate the following outcomes:
• The possibility of infected ED personnel reporting to work
• The burden of COVID-19 symptoms on an ED personnel’s work status
• The association between SARS-CoV-2 infection levels and ED staffing
• Project COVERED enrolled 1673 ED healthcare personnel with 29,825 person weeks of observational data from 25 geographically diverse EDs.
• The presence of any SARS-CoV-2 infection was determined using reverse transcription polymerase chain reaction or IgG antibody testing at baseline, week 2, week 4, and every four subsequent weeks through week 20.
• Investigators also collected weekly data on ED staffing and the incidence of SARS-CoV-2 infections in healthcare facilities.

TAKEAWAY:

• Despite the absence of widespread natural immunity or COVID-19 vaccine availability during the time of this study, only 4.5% of ED healthcare personnel tested positive for SARS-CoV-2 infections, with more than half (57.3%) not experiencing any symptoms.
• Most personnel (83%) who experienced symptoms associated with COVID-19 reported working at least one shift in the ED and nearly all of them continued to work until they received laboratory confirmation of their infection.
• The working time lost as a result of COVID-19 and related concerns was minimal, as 89 healthcare personnel reported 90 person weeks of missed work (0.3% of all weeks).
• During this study, physician-staffing levels ranged from 98.7% to 102.0% of normal staffing, with similar values noted for nursing and nonclinical staffs. Reduced staffing was rare, even during COVID-19 surges.

IN PRACTICE:

“Our findings suggest that the cumulative interaction between infected healthcare personnel and others resulted in a negligible risk of transmission on the scale of public health emergencies,” the authors wrote.

SOURCE:

This study was led by Kurt D. Weber, MD, Department of Emergency Medicine, Orlando Health, Orlando, Florida, and published online in Annals of Emergency Medicine.

LIMITATIONS:

Data regarding the Delta variant surges that occurred toward the end of December and the ED status after the advent of the COVID-19 vaccine were not recorded. There may also have been a selection bias risk in this study because the volunteer participants may have exhibited behaviors like social distancing and use of protective equipment, which may have decreased their risk for infections.

DISCLOSURES:

This study was funded by a cooperative agreement from the Centers for Disease Control and Prevention and the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors declared no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE: 

There were few cases of SARS-CoV-2 infections among emergency department (ED) healthcare personnel and no substantial changes in the delivery of emergency medical care during the initial phase of the COVID-19 pandemic.

METHODOLOGY:

• This multicenter prospective cohort study of US ED healthcare personnel called Project COVERED was conducted from May to December 2020 to evaluate the following outcomes:
• The possibility of infected ED personnel reporting to work
• The burden of COVID-19 symptoms on an ED personnel’s work status
• The association between SARS-CoV-2 infection levels and ED staffing
• Project COVERED enrolled 1673 ED healthcare personnel with 29,825 person weeks of observational data from 25 geographically diverse EDs.
• The presence of any SARS-CoV-2 infection was determined using reverse transcription polymerase chain reaction or IgG antibody testing at baseline, week 2, week 4, and every four subsequent weeks through week 20.
• Investigators also collected weekly data on ED staffing and the incidence of SARS-CoV-2 infections in healthcare facilities.

TAKEAWAY:

• Despite the absence of widespread natural immunity or COVID-19 vaccine availability during the time of this study, only 4.5% of ED healthcare personnel tested positive for SARS-CoV-2 infections, with more than half (57.3%) not experiencing any symptoms.
• Most personnel (83%) who experienced symptoms associated with COVID-19 reported working at least one shift in the ED and nearly all of them continued to work until they received laboratory confirmation of their infection.
• The working time lost as a result of COVID-19 and related concerns was minimal, as 89 healthcare personnel reported 90 person weeks of missed work (0.3% of all weeks).
• During this study, physician-staffing levels ranged from 98.7% to 102.0% of normal staffing, with similar values noted for nursing and nonclinical staffs. Reduced staffing was rare, even during COVID-19 surges.

IN PRACTICE:

“Our findings suggest that the cumulative interaction between infected healthcare personnel and others resulted in a negligible risk of transmission on the scale of public health emergencies,” the authors wrote.

SOURCE:

This study was led by Kurt D. Weber, MD, Department of Emergency Medicine, Orlando Health, Orlando, Florida, and published online in Annals of Emergency Medicine.

LIMITATIONS:

Data regarding the Delta variant surges that occurred toward the end of December and the ED status after the advent of the COVID-19 vaccine were not recorded. There may also have been a selection bias risk in this study because the volunteer participants may have exhibited behaviors like social distancing and use of protective equipment, which may have decreased their risk for infections.

DISCLOSURES:

This study was funded by a cooperative agreement from the Centers for Disease Control and Prevention and the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors declared no conflicts of interest.

A version of this article appeared on Medscape.com.

Amid the current wave of winter respiratory virus cases, influenza (types A and B) leads the way with the highest number of emergency room visits, followed closely by COVID-19, thanks to the JN.1 variant, and respiratory syncytial virus (RSV). With various similarities and differences in disease presentations, how challenging is it for physician’s to distinguish between, diagnose, and treat COVID-19 vs RSV and influenza? 

While these three respiratory viruses often have similar presentations, you may often find that patients with COVID-19 experience more fever, dry cough, and labored breathing, according to Cyrus Munguti, MD, assistant professor of medicine at KU Medical Center and hospitalist at Wesley Medical Center, Wichita, Kansas. 

“COVID-19 patients tend to have trouble breathing because the alveoli are affected and get inflammation and fluid accumulating in the lungs, and they end up having little to no oxygen,” said Dr. Munguti. “When we check their vital signs, patients with COVID tend to have hypoxemia [meaning saturations are less than 88% or 90% depending on the guidelines you follow].”

Patients with RSV and influenza tend to have more upper respiratory symptoms, like runny nose, sternutation — which later can progress to a cough in the upper airways, Dr. Munguti said. Unlike with COVID-19, patients with RSV and influenza — generally until they are very sick — often do not experience hypoxemia.

Inflammation in the airways can form as a result of all three viruses. Furthermore, bacteria that live in these airways could lead to a secondary bacterial infection in the upper respiratory and lower respiratory tracts — which could then cause pneumonia, Dr. Munguti said.

Another note: Changes in COVID-19 variants over the years have made it increasingly difficult to differentiate COVID-19 symptoms from those of RSV and influenza, according to Panagis Galiatsatos, MD, pulmonologist and associate professor at Johns Hopkins Medicine. “The Alpha through Delta variants really were a lot more lung tissue invading,” Dr. Galiatsatos said. “With the COVID-19 Omicron family — its capabilities are similar to what flu and RSV have done over the years. It’s more airway-invading.”

It’s critical to understand that diagnosing these diseases based on symptoms alone can be quite fickle, according to Dr. Galiatsatos. Objective tests, either at home or in a laboratory, are preferred. This is largely because disease presentation can depend on the host factor that the virus enters into, said Dr. Galiatsatos. For example, virus symptoms may look different for a patient with asthma and for someone with heart disease.

With children being among the most vulnerable for severe respiratory illness, testing and treatment are paramount and can be quite accurate in seasons where respiratory viruses thrive, according to Stan Spinner, MD, chief medical officer at Texas Children’s Pediatrics and Urgent Care. “When individuals are tested for either of these conditions when the prevalence in the community is low, we tend to see false positive results.” 

Texas Children’s Pediatrics and Urgent Care’s 12 sites offer COVID-19 and influenza antigen tests that have results ready in around 10 minutes. RSV testing, on the other hand, is limited to around half of the Texas Children’s Pediatrics and none of the urgent care locations, as the test can only be administered through a nasal swab conducted by a physician. As there is no specific treatment or therapy for RSV, the benefits of RSV testing can actually be quite low — often leading to frustrated parents regarding next steps after diagnosis.

“There are a number of respiratory viruses that may present with similar symptoms as RSV, and some of these viruses may even lead to much of the same adverse outcomes as the RSV virus,” Dr. Galiatsatos said. “Consequently, our physicians need to help parents understand this and give them guidance as to when to seek medical attention for worsening symptoms.”

There are two new RSV immunizations to treat certain demographics of patients, Dr. Spinner added. One is an RSV vaccine for infants under 8 months old, though there is limited supply. There is also an RSV vaccine available for pregnant women (between 32 and 36 weeks gestation) that has proved to be effective in fending off RSV infections in newborns up to 6 months old. 

Physicians should remain diligent in stressing to patients that vaccinations against COVID-19 and influenza play a key role in keeping their families safe during seasons of staggering respiratory infections.

“These vaccines are extremely safe, and while they may not always prevent infection, these vaccines are extremely effective in preventing more serious consequences, such as hospitalization or death,” Dr. Galiatsatos said.
 

A version of this article appeared on Medscape.com.

Amid the current wave of winter respiratory virus cases, influenza (types A and B) leads the way with the highest number of emergency room visits, followed closely by COVID-19, thanks to the JN.1 variant, and respiratory syncytial virus (RSV). With various similarities and differences in disease presentations, how challenging is it for physician’s to distinguish between, diagnose, and treat COVID-19 vs RSV and influenza? 

While these three respiratory viruses often have similar presentations, you may often find that patients with COVID-19 experience more fever, dry cough, and labored breathing, according to Cyrus Munguti, MD, assistant professor of medicine at KU Medical Center and hospitalist at Wesley Medical Center, Wichita, Kansas. 

“COVID-19 patients tend to have trouble breathing because the alveoli are affected and get inflammation and fluid accumulating in the lungs, and they end up having little to no oxygen,” said Dr. Munguti. “When we check their vital signs, patients with COVID tend to have hypoxemia [meaning saturations are less than 88% or 90% depending on the guidelines you follow].”

Patients with RSV and influenza tend to have more upper respiratory symptoms, like runny nose, sternutation — which later can progress to a cough in the upper airways, Dr. Munguti said. Unlike with COVID-19, patients with RSV and influenza — generally until they are very sick — often do not experience hypoxemia.

Inflammation in the airways can form as a result of all three viruses. Furthermore, bacteria that live in these airways could lead to a secondary bacterial infection in the upper respiratory and lower respiratory tracts — which could then cause pneumonia, Dr. Munguti said.

Another note: Changes in COVID-19 variants over the years have made it increasingly difficult to differentiate COVID-19 symptoms from those of RSV and influenza, according to Panagis Galiatsatos, MD, pulmonologist and associate professor at Johns Hopkins Medicine. “The Alpha through Delta variants really were a lot more lung tissue invading,” Dr. Galiatsatos said. “With the COVID-19 Omicron family — its capabilities are similar to what flu and RSV have done over the years. It’s more airway-invading.”

It’s critical to understand that diagnosing these diseases based on symptoms alone can be quite fickle, according to Dr. Galiatsatos. Objective tests, either at home or in a laboratory, are preferred. This is largely because disease presentation can depend on the host factor that the virus enters into, said Dr. Galiatsatos. For example, virus symptoms may look different for a patient with asthma and for someone with heart disease.

With children being among the most vulnerable for severe respiratory illness, testing and treatment are paramount and can be quite accurate in seasons where respiratory viruses thrive, according to Stan Spinner, MD, chief medical officer at Texas Children’s Pediatrics and Urgent Care. “When individuals are tested for either of these conditions when the prevalence in the community is low, we tend to see false positive results.” 

Texas Children’s Pediatrics and Urgent Care’s 12 sites offer COVID-19 and influenza antigen tests that have results ready in around 10 minutes. RSV testing, on the other hand, is limited to around half of the Texas Children’s Pediatrics and none of the urgent care locations, as the test can only be administered through a nasal swab conducted by a physician. As there is no specific treatment or therapy for RSV, the benefits of RSV testing can actually be quite low — often leading to frustrated parents regarding next steps after diagnosis.

“There are a number of respiratory viruses that may present with similar symptoms as RSV, and some of these viruses may even lead to much of the same adverse outcomes as the RSV virus,” Dr. Galiatsatos said. “Consequently, our physicians need to help parents understand this and give them guidance as to when to seek medical attention for worsening symptoms.”

There are two new RSV immunizations to treat certain demographics of patients, Dr. Spinner added. One is an RSV vaccine for infants under 8 months old, though there is limited supply. There is also an RSV vaccine available for pregnant women (between 32 and 36 weeks gestation) that has proved to be effective in fending off RSV infections in newborns up to 6 months old. 

Physicians should remain diligent in stressing to patients that vaccinations against COVID-19 and influenza play a key role in keeping their families safe during seasons of staggering respiratory infections.

“These vaccines are extremely safe, and while they may not always prevent infection, these vaccines are extremely effective in preventing more serious consequences, such as hospitalization or death,” Dr. Galiatsatos said.
 

A version of this article appeared on Medscape.com.

Amid the current wave of winter respiratory virus cases, influenza (types A and B) leads the way with the highest number of emergency room visits, followed closely by COVID-19, thanks to the JN.1 variant, and respiratory syncytial virus (RSV). With various similarities and differences in disease presentations, how challenging is it for physician’s to distinguish between, diagnose, and treat COVID-19 vs RSV and influenza? 

While these three respiratory viruses often have similar presentations, you may often find that patients with COVID-19 experience more fever, dry cough, and labored breathing, according to Cyrus Munguti, MD, assistant professor of medicine at KU Medical Center and hospitalist at Wesley Medical Center, Wichita, Kansas. 

“COVID-19 patients tend to have trouble breathing because the alveoli are affected and get inflammation and fluid accumulating in the lungs, and they end up having little to no oxygen,” said Dr. Munguti. “When we check their vital signs, patients with COVID tend to have hypoxemia [meaning saturations are less than 88% or 90% depending on the guidelines you follow].”

Patients with RSV and influenza tend to have more upper respiratory symptoms, like runny nose, sternutation — which later can progress to a cough in the upper airways, Dr. Munguti said. Unlike with COVID-19, patients with RSV and influenza — generally until they are very sick — often do not experience hypoxemia.

Inflammation in the airways can form as a result of all three viruses. Furthermore, bacteria that live in these airways could lead to a secondary bacterial infection in the upper respiratory and lower respiratory tracts — which could then cause pneumonia, Dr. Munguti said.

Another note: Changes in COVID-19 variants over the years have made it increasingly difficult to differentiate COVID-19 symptoms from those of RSV and influenza, according to Panagis Galiatsatos, MD, pulmonologist and associate professor at Johns Hopkins Medicine. “The Alpha through Delta variants really were a lot more lung tissue invading,” Dr. Galiatsatos said. “With the COVID-19 Omicron family — its capabilities are similar to what flu and RSV have done over the years. It’s more airway-invading.”

It’s critical to understand that diagnosing these diseases based on symptoms alone can be quite fickle, according to Dr. Galiatsatos. Objective tests, either at home or in a laboratory, are preferred. This is largely because disease presentation can depend on the host factor that the virus enters into, said Dr. Galiatsatos. For example, virus symptoms may look different for a patient with asthma and for someone with heart disease.

With children being among the most vulnerable for severe respiratory illness, testing and treatment are paramount and can be quite accurate in seasons where respiratory viruses thrive, according to Stan Spinner, MD, chief medical officer at Texas Children’s Pediatrics and Urgent Care. “When individuals are tested for either of these conditions when the prevalence in the community is low, we tend to see false positive results.” 

Texas Children’s Pediatrics and Urgent Care’s 12 sites offer COVID-19 and influenza antigen tests that have results ready in around 10 minutes. RSV testing, on the other hand, is limited to around half of the Texas Children’s Pediatrics and none of the urgent care locations, as the test can only be administered through a nasal swab conducted by a physician. As there is no specific treatment or therapy for RSV, the benefits of RSV testing can actually be quite low — often leading to frustrated parents regarding next steps after diagnosis.

“There are a number of respiratory viruses that may present with similar symptoms as RSV, and some of these viruses may even lead to much of the same adverse outcomes as the RSV virus,” Dr. Galiatsatos said. “Consequently, our physicians need to help parents understand this and give them guidance as to when to seek medical attention for worsening symptoms.”

There are two new RSV immunizations to treat certain demographics of patients, Dr. Spinner added. One is an RSV vaccine for infants under 8 months old, though there is limited supply. There is also an RSV vaccine available for pregnant women (between 32 and 36 weeks gestation) that has proved to be effective in fending off RSV infections in newborns up to 6 months old. 

Physicians should remain diligent in stressing to patients that vaccinations against COVID-19 and influenza play a key role in keeping their families safe during seasons of staggering respiratory infections.

“These vaccines are extremely safe, and while they may not always prevent infection, these vaccines are extremely effective in preventing more serious consequences, such as hospitalization or death,” Dr. Galiatsatos said.
 

A version of this article appeared on Medscape.com.

Question: What doubles every 2 months and takes more than a decade and a half to reach its ultimate destination?

Answer: Medical knowledge. 

In 2011, researchers projected that by 2020, medical knowledge would double every 73 days. Also in 2011, investigators estimated that clinical research takes 17 years to translate from bench to bedside. 

This “fast-slow” paradox became more relevant than ever in 2020, when the coronavirus pandemic brought the world to a near standstill. Stakeholders in undergraduate, postgraduate, and continuing medical education (CME) were suddenly faced with choices that had been discussed theoretically but not yet applied on a wide scale: How do we deliver education if in-person instruction is not an option? 

Organized medicine and the clinical community made choices based on groundwork that had been laid prior to the pandemic. The medical community acted quickly out of necessity, implementing novel learning methods that are now being utilized and that need to be assessed in an ongoing manner. 

The Backdrop

Medical education has long been dominated by an in-person, didactic model anchored in teacher-centered, classroom-based learning. This design has been firmly entrenched for more than 100 years, since the publication of the Flexner report in 1910, which established the standard of 4 years of medical education. Prior to 2020, many experts acknowledged that alternative practices and emerging technologies should play a role in medical education, but indecision abounded, perhaps because there was no real-world catalyst for reform. Thus, despite various attempts, the adoption of alternative forms of teaching moved slowly. 

Pre-pandemic efforts

In 2017, the American Medication Association issued a report calling for “one of the most complete curricular reforms since the Flexner Report.” It urged leaders to “rethink nearly every facet of physician training,” including “greater emphasis on new technology.” The report also suggested a 14-month pre-rotation program focused on the core medical knowledge necessary to practice in a hospital setting, along with work in a primary care setting once every other week. 

Before the pandemic, “blended learning” (digital and live) and “flipped classroom” approaches were assessed. A meta-analysis comparing a blended learning format to traditional classroom model programs found that blended learning resulted in better knowledge outcomes. In the flipped classroom approach, non-classroom individual or group activities replace in-class instruction after pre-class self-preparation with provided resources. A meta-analysis of 28 comparative studies showed that the flipped classroom approach resulted in improved learning compared to traditional methods. Additionally, bite-sized learning approaches have been implemented and evaluated, showing improvement in immediate knowledge recall. 

Barriers to widespread implementation

Despite the need to increase medical knowledge dissemination and implement approaches proven to do so effectively, barriers to adoption are well documented. Obstacles include time limitations, inadequate technical skills, insufficient infrastructure, and a wide variety in and range of expertise of both learners and institutional strategies. There are also differences in effective techniques for teaching various topics based on the content. Some topics require knowledge-based training, whereas others fall more easily into skills-based training. 

Additionally, when it comes to new evidence that needs to be translated to clinical evaluation and delivery, there is ongoing debate about the established peer-review process, which is rigorous but time-consuming vs the open-access publication process, which can disseminate information more quickly but is prone to error. 

Proposed solutions

Proposed solutions to these barriers include improving educator skills, offering incentives for innovative content development, cultivating better institutional strategies, and achieving buy-in from all stakeholders. Also important is thoughtful adaptation of content to various electronic formats, such as audiovisual presentation of educational material, social media content, and gamification of content, as well as ongoing assessment of both education delivery and consumption—followed by rapid pivoting when necessary. 

Despite these clearly identified challenges and thoughtful solutions, change was relatively slow until March 2020. 

The Trigger

With medical knowledge expanding so rapidly, imagine if medical education moved slowly or came to a complete halt when a worldwide pandemic was declared, the effects would have been catastrophic. COVID pushed organized medicine and the healthcare community to accelerate the adoption of novel technological approaches to keep the medical knowledge pipeline flowing at a relatively reasonable— if not ideal—rate. 

Challenges the pandemic produced, along with potential mitigation strategies, are outlined below.      

Economic consequences: The pandemic resulted in lost income for training programs and decreased funding for graduate medical education.

Possible solution: Creating budget allowances to adopt new technologies

Impact on diversity, equity, and inclusion: COVID-19 amplified existing implicit and explicit biases in society, particularly in the field of medicine. Women trainees and individuals from disadvantaged backgrounds were disproportionately impacted.

Possible solution: Creating programs that increase awareness of the subtle nature of implicit bias and the outsized impact it can have on certain segments of the population, and offering resources to mitigate stressors such as childcare and access to technology solutions

Impact on mental health and wellness: Working through the pandemic was challenging professionally, and the pandemic also exposed individuals to stigma, loneliness, and behavioral health issues (eg, mood and sleeping disorders), which created challenges in personal lives as well. These challenges lasted well over 2 years and have a clear ongoing impact.  

Possible solution: Providing accessible behavioral health resources, regularly assessing and addressing burnout, and regularly cycling trainees off of high-intensity rotations

Education delivery challenges: The sudden cancellation of in-person classes and training, from medical school lectures to rotations, created uncertainty. In-person rounds and bedside learning were significantly restricted. Moreover, as the need to perform clinical duties during the pandemic increased, time for teaching decreased. Some areas were more heavily impacted than others (eg, instruction around elective surgeries, outpatient medicine, and non-critical care training). 

Possible solution: Digitizing education delivery and developing other innovative methods to compensate for a lack of face-to-face instruction

Sudden need for rapid information dissemination: The limits of traditional peer review were tested during the pandemic. Managing individuals infected with the novel coronavirus created a situation where the clinical community needed scientific information quickly, increasing the risk of misinformation. 

Possible solution: Disseminating information as quickly as possible by leveraging public-private partnerships and government investment in high-quality science while maintaining peer review integrity to ensure rigorous evaluation

The Evidence

Early evidence is emerging about efforts undertaken during the pandemic to maintain adequate levels of preclinical learning, clinical training, and CME. 

Preclinical learning: Virtual formats are generally accepted, and interactive discussion is preferred. But be aware of potential stressors.

A cross-sectional study involving 173 histology and pathology students at European University Cyprus found that preclinical medical education is possible via virtual learning. The pandemic forced respondents to adapt immediately to emergency remote teaching. Survey results found the concept was generally well accepted, though some stressors (eg, poor internet connection) impacted perception. Most histology and pathology students (58% and 68%, respectively) said they would prefer blended learning in the future, compared with all-live (39% and 28%, respectively), or all-virtual (4% and 5%, respectively) classrooms. 

In a systematic review of 13 studies that compared digital learning with live classroom education for medical and nursing students, investigators from China found that standalone digital models are as effective as conventional modalities for improving knowledge and practice. Moreover, students preferred interactive discussion to a straight lecture format when participating online. 

Clinical training: Virtual clerkships work, but a blended approach seems preferable.

In a study involving 16 third-year medical students in the general surgery clerkship at Cleveland Clinic, respondents reported their experience before and after participating in a case-based virtual surgery clerkship program. Students were significantly more confident that they could independently assess a surgical consult after taking the course. Average scores of curriculum-based surgical knowledge increased as well. 

In an assessment of alternative approaches to clinical clerkships involving 42 students, investigators from China evaluated the impact of using simulated electronic health records (EHRs) for inpatient training and electronic problem-based learning and virtual interviews for outpatient training. Students using simulated EHRs felt it improved their ability to write in and summarize the record. Those who participated in electronic problem-based learning and virtual interviewing said their interviewing and counseling skills improved. However, students also noted traditional clinical clerkships are better for certain types of learning, suggesting that a blended approach is preferred. 

CME: Virtual CME is accepted and improves performance, but barriers remain, including a preference for face-to-face networking.

Researchers reviewed 2,007 post-activity responses from clinicians who participated in online CME at a South Korean hospital. Of the 1332 participants who reported their satisfaction level, 85% reported being satisfied with the format and content. Among all respondents, nearly 9 in 10 said that the content would influence the way they practice. Of the 611 participants who responded to a follow-up survey 3 months later, 78% said they made changes in their clinical practice based on what they learned. 

However, many clinicians prefer in-person CME. A Canadian-based memory clinic held 5 interprofessional education sessions and reported on participant experience; 3 of the sessions occurred live before March 2020 and 2 were held via videoconference once the pandemic was declared. Ratings of satisfaction, relevance, knowledge acquisition, and knowledge application were similar in both groups, but the virtual sessions were rated as less enjoyable and lacking in networking opportunities. In-person learning was preferred. 

Primary care clinicians in Portugal evaluated a CME digital platform and reported several barriers, including time constraints, perceived excessive work, lack of digital competence, lack of motivation, and emotional factors.      

The Future
Although challenges remain, changes due to the pandemic have been implemented in medical training and have shown preliminary success in certain domains. Medical education is rapidly evolving, and as we move further from the pandemic, diligent ongoing evaluation is needed to assess the best use of technology and various innovative teaching modalities. Keeping medical education learner-centered and instituting timely course correction if certain modalities of knowledge/skill delivery are found to be ineffective will be key to ensuring the robustness of training for future generations.   

Question: What doubles every 2 months and takes more than a decade and a half to reach its ultimate destination?

Answer: Medical knowledge. 

In 2011, researchers projected that by 2020, medical knowledge would double every 73 days. Also in 2011, investigators estimated that clinical research takes 17 years to translate from bench to bedside. 

This “fast-slow” paradox became more relevant than ever in 2020, when the coronavirus pandemic brought the world to a near standstill. Stakeholders in undergraduate, postgraduate, and continuing medical education (CME) were suddenly faced with choices that had been discussed theoretically but not yet applied on a wide scale: How do we deliver education if in-person instruction is not an option? 

Organized medicine and the clinical community made choices based on groundwork that had been laid prior to the pandemic. The medical community acted quickly out of necessity, implementing novel learning methods that are now being utilized and that need to be assessed in an ongoing manner. 

The Backdrop

Medical education has long been dominated by an in-person, didactic model anchored in teacher-centered, classroom-based learning. This design has been firmly entrenched for more than 100 years, since the publication of the Flexner report in 1910, which established the standard of 4 years of medical education. Prior to 2020, many experts acknowledged that alternative practices and emerging technologies should play a role in medical education, but indecision abounded, perhaps because there was no real-world catalyst for reform. Thus, despite various attempts, the adoption of alternative forms of teaching moved slowly. 

Pre-pandemic efforts

In 2017, the American Medication Association issued a report calling for “one of the most complete curricular reforms since the Flexner Report.” It urged leaders to “rethink nearly every facet of physician training,” including “greater emphasis on new technology.” The report also suggested a 14-month pre-rotation program focused on the core medical knowledge necessary to practice in a hospital setting, along with work in a primary care setting once every other week. 

Before the pandemic, “blended learning” (digital and live) and “flipped classroom” approaches were assessed. A meta-analysis comparing a blended learning format to traditional classroom model programs found that blended learning resulted in better knowledge outcomes. In the flipped classroom approach, non-classroom individual or group activities replace in-class instruction after pre-class self-preparation with provided resources. A meta-analysis of 28 comparative studies showed that the flipped classroom approach resulted in improved learning compared to traditional methods. Additionally, bite-sized learning approaches have been implemented and evaluated, showing improvement in immediate knowledge recall. 

Barriers to widespread implementation

Despite the need to increase medical knowledge dissemination and implement approaches proven to do so effectively, barriers to adoption are well documented. Obstacles include time limitations, inadequate technical skills, insufficient infrastructure, and a wide variety in and range of expertise of both learners and institutional strategies. There are also differences in effective techniques for teaching various topics based on the content. Some topics require knowledge-based training, whereas others fall more easily into skills-based training. 

Additionally, when it comes to new evidence that needs to be translated to clinical evaluation and delivery, there is ongoing debate about the established peer-review process, which is rigorous but time-consuming vs the open-access publication process, which can disseminate information more quickly but is prone to error. 

Proposed solutions

Proposed solutions to these barriers include improving educator skills, offering incentives for innovative content development, cultivating better institutional strategies, and achieving buy-in from all stakeholders. Also important is thoughtful adaptation of content to various electronic formats, such as audiovisual presentation of educational material, social media content, and gamification of content, as well as ongoing assessment of both education delivery and consumption—followed by rapid pivoting when necessary. 

Despite these clearly identified challenges and thoughtful solutions, change was relatively slow until March 2020. 

The Trigger

With medical knowledge expanding so rapidly, imagine if medical education moved slowly or came to a complete halt when a worldwide pandemic was declared, the effects would have been catastrophic. COVID pushed organized medicine and the healthcare community to accelerate the adoption of novel technological approaches to keep the medical knowledge pipeline flowing at a relatively reasonable— if not ideal—rate. 

Challenges the pandemic produced, along with potential mitigation strategies, are outlined below.      

Economic consequences: The pandemic resulted in lost income for training programs and decreased funding for graduate medical education.

Possible solution: Creating budget allowances to adopt new technologies

Impact on diversity, equity, and inclusion: COVID-19 amplified existing implicit and explicit biases in society, particularly in the field of medicine. Women trainees and individuals from disadvantaged backgrounds were disproportionately impacted.

Possible solution: Creating programs that increase awareness of the subtle nature of implicit bias and the outsized impact it can have on certain segments of the population, and offering resources to mitigate stressors such as childcare and access to technology solutions

Impact on mental health and wellness: Working through the pandemic was challenging professionally, and the pandemic also exposed individuals to stigma, loneliness, and behavioral health issues (eg, mood and sleeping disorders), which created challenges in personal lives as well. These challenges lasted well over 2 years and have a clear ongoing impact.  

Possible solution: Providing accessible behavioral health resources, regularly assessing and addressing burnout, and regularly cycling trainees off of high-intensity rotations

Education delivery challenges: The sudden cancellation of in-person classes and training, from medical school lectures to rotations, created uncertainty. In-person rounds and bedside learning were significantly restricted. Moreover, as the need to perform clinical duties during the pandemic increased, time for teaching decreased. Some areas were more heavily impacted than others (eg, instruction around elective surgeries, outpatient medicine, and non-critical care training). 

Possible solution: Digitizing education delivery and developing other innovative methods to compensate for a lack of face-to-face instruction

Sudden need for rapid information dissemination: The limits of traditional peer review were tested during the pandemic. Managing individuals infected with the novel coronavirus created a situation where the clinical community needed scientific information quickly, increasing the risk of misinformation. 

Possible solution: Disseminating information as quickly as possible by leveraging public-private partnerships and government investment in high-quality science while maintaining peer review integrity to ensure rigorous evaluation

The Evidence

Early evidence is emerging about efforts undertaken during the pandemic to maintain adequate levels of preclinical learning, clinical training, and CME. 

Preclinical learning: Virtual formats are generally accepted, and interactive discussion is preferred. But be aware of potential stressors.

A cross-sectional study involving 173 histology and pathology students at European University Cyprus found that preclinical medical education is possible via virtual learning. The pandemic forced respondents to adapt immediately to emergency remote teaching. Survey results found the concept was generally well accepted, though some stressors (eg, poor internet connection) impacted perception. Most histology and pathology students (58% and 68%, respectively) said they would prefer blended learning in the future, compared with all-live (39% and 28%, respectively), or all-virtual (4% and 5%, respectively) classrooms. 

In a systematic review of 13 studies that compared digital learning with live classroom education for medical and nursing students, investigators from China found that standalone digital models are as effective as conventional modalities for improving knowledge and practice. Moreover, students preferred interactive discussion to a straight lecture format when participating online. 

Clinical training: Virtual clerkships work, but a blended approach seems preferable.

In a study involving 16 third-year medical students in the general surgery clerkship at Cleveland Clinic, respondents reported their experience before and after participating in a case-based virtual surgery clerkship program. Students were significantly more confident that they could independently assess a surgical consult after taking the course. Average scores of curriculum-based surgical knowledge increased as well. 

In an assessment of alternative approaches to clinical clerkships involving 42 students, investigators from China evaluated the impact of using simulated electronic health records (EHRs) for inpatient training and electronic problem-based learning and virtual interviews for outpatient training. Students using simulated EHRs felt it improved their ability to write in and summarize the record. Those who participated in electronic problem-based learning and virtual interviewing said their interviewing and counseling skills improved. However, students also noted traditional clinical clerkships are better for certain types of learning, suggesting that a blended approach is preferred. 

CME: Virtual CME is accepted and improves performance, but barriers remain, including a preference for face-to-face networking.

Researchers reviewed 2,007 post-activity responses from clinicians who participated in online CME at a South Korean hospital. Of the 1332 participants who reported their satisfaction level, 85% reported being satisfied with the format and content. Among all respondents, nearly 9 in 10 said that the content would influence the way they practice. Of the 611 participants who responded to a follow-up survey 3 months later, 78% said they made changes in their clinical practice based on what they learned. 

However, many clinicians prefer in-person CME. A Canadian-based memory clinic held 5 interprofessional education sessions and reported on participant experience; 3 of the sessions occurred live before March 2020 and 2 were held via videoconference once the pandemic was declared. Ratings of satisfaction, relevance, knowledge acquisition, and knowledge application were similar in both groups, but the virtual sessions were rated as less enjoyable and lacking in networking opportunities. In-person learning was preferred. 

Primary care clinicians in Portugal evaluated a CME digital platform and reported several barriers, including time constraints, perceived excessive work, lack of digital competence, lack of motivation, and emotional factors.      

The Future
Although challenges remain, changes due to the pandemic have been implemented in medical training and have shown preliminary success in certain domains. Medical education is rapidly evolving, and as we move further from the pandemic, diligent ongoing evaluation is needed to assess the best use of technology and various innovative teaching modalities. Keeping medical education learner-centered and instituting timely course correction if certain modalities of knowledge/skill delivery are found to be ineffective will be key to ensuring the robustness of training for future generations.   

Question: What doubles every 2 months and takes more than a decade and a half to reach its ultimate destination?

Answer: Medical knowledge. 

In 2011, researchers projected that by 2020, medical knowledge would double every 73 days. Also in 2011, investigators estimated that clinical research takes 17 years to translate from bench to bedside. 

This “fast-slow” paradox became more relevant than ever in 2020, when the coronavirus pandemic brought the world to a near standstill. Stakeholders in undergraduate, postgraduate, and continuing medical education (CME) were suddenly faced with choices that had been discussed theoretically but not yet applied on a wide scale: How do we deliver education if in-person instruction is not an option? 

Organized medicine and the clinical community made choices based on groundwork that had been laid prior to the pandemic. The medical community acted quickly out of necessity, implementing novel learning methods that are now being utilized and that need to be assessed in an ongoing manner. 

The Backdrop

Medical education has long been dominated by an in-person, didactic model anchored in teacher-centered, classroom-based learning. This design has been firmly entrenched for more than 100 years, since the publication of the Flexner report in 1910, which established the standard of 4 years of medical education. Prior to 2020, many experts acknowledged that alternative practices and emerging technologies should play a role in medical education, but indecision abounded, perhaps because there was no real-world catalyst for reform. Thus, despite various attempts, the adoption of alternative forms of teaching moved slowly. 

Pre-pandemic efforts

In 2017, the American Medication Association issued a report calling for “one of the most complete curricular reforms since the Flexner Report.” It urged leaders to “rethink nearly every facet of physician training,” including “greater emphasis on new technology.” The report also suggested a 14-month pre-rotation program focused on the core medical knowledge necessary to practice in a hospital setting, along with work in a primary care setting once every other week. 

Before the pandemic, “blended learning” (digital and live) and “flipped classroom” approaches were assessed. A meta-analysis comparing a blended learning format to traditional classroom model programs found that blended learning resulted in better knowledge outcomes. In the flipped classroom approach, non-classroom individual or group activities replace in-class instruction after pre-class self-preparation with provided resources. A meta-analysis of 28 comparative studies showed that the flipped classroom approach resulted in improved learning compared to traditional methods. Additionally, bite-sized learning approaches have been implemented and evaluated, showing improvement in immediate knowledge recall. 

Barriers to widespread implementation

Despite the need to increase medical knowledge dissemination and implement approaches proven to do so effectively, barriers to adoption are well documented. Obstacles include time limitations, inadequate technical skills, insufficient infrastructure, and a wide variety in and range of expertise of both learners and institutional strategies. There are also differences in effective techniques for teaching various topics based on the content. Some topics require knowledge-based training, whereas others fall more easily into skills-based training. 

Additionally, when it comes to new evidence that needs to be translated to clinical evaluation and delivery, there is ongoing debate about the established peer-review process, which is rigorous but time-consuming vs the open-access publication process, which can disseminate information more quickly but is prone to error. 

Proposed solutions

Proposed solutions to these barriers include improving educator skills, offering incentives for innovative content development, cultivating better institutional strategies, and achieving buy-in from all stakeholders. Also important is thoughtful adaptation of content to various electronic formats, such as audiovisual presentation of educational material, social media content, and gamification of content, as well as ongoing assessment of both education delivery and consumption—followed by rapid pivoting when necessary. 

Despite these clearly identified challenges and thoughtful solutions, change was relatively slow until March 2020. 

The Trigger

With medical knowledge expanding so rapidly, imagine if medical education moved slowly or came to a complete halt when a worldwide pandemic was declared, the effects would have been catastrophic. COVID pushed organized medicine and the healthcare community to accelerate the adoption of novel technological approaches to keep the medical knowledge pipeline flowing at a relatively reasonable— if not ideal—rate. 

Challenges the pandemic produced, along with potential mitigation strategies, are outlined below.      

Economic consequences: The pandemic resulted in lost income for training programs and decreased funding for graduate medical education.

Possible solution: Creating budget allowances to adopt new technologies

Impact on diversity, equity, and inclusion: COVID-19 amplified existing implicit and explicit biases in society, particularly in the field of medicine. Women trainees and individuals from disadvantaged backgrounds were disproportionately impacted.

Possible solution: Creating programs that increase awareness of the subtle nature of implicit bias and the outsized impact it can have on certain segments of the population, and offering resources to mitigate stressors such as childcare and access to technology solutions

Impact on mental health and wellness: Working through the pandemic was challenging professionally, and the pandemic also exposed individuals to stigma, loneliness, and behavioral health issues (eg, mood and sleeping disorders), which created challenges in personal lives as well. These challenges lasted well over 2 years and have a clear ongoing impact.  

Possible solution: Providing accessible behavioral health resources, regularly assessing and addressing burnout, and regularly cycling trainees off of high-intensity rotations

Education delivery challenges: The sudden cancellation of in-person classes and training, from medical school lectures to rotations, created uncertainty. In-person rounds and bedside learning were significantly restricted. Moreover, as the need to perform clinical duties during the pandemic increased, time for teaching decreased. Some areas were more heavily impacted than others (eg, instruction around elective surgeries, outpatient medicine, and non-critical care training). 

Possible solution: Digitizing education delivery and developing other innovative methods to compensate for a lack of face-to-face instruction

Sudden need for rapid information dissemination: The limits of traditional peer review were tested during the pandemic. Managing individuals infected with the novel coronavirus created a situation where the clinical community needed scientific information quickly, increasing the risk of misinformation. 

Possible solution: Disseminating information as quickly as possible by leveraging public-private partnerships and government investment in high-quality science while maintaining peer review integrity to ensure rigorous evaluation

The Evidence

Early evidence is emerging about efforts undertaken during the pandemic to maintain adequate levels of preclinical learning, clinical training, and CME. 

Preclinical learning: Virtual formats are generally accepted, and interactive discussion is preferred. But be aware of potential stressors.

A cross-sectional study involving 173 histology and pathology students at European University Cyprus found that preclinical medical education is possible via virtual learning. The pandemic forced respondents to adapt immediately to emergency remote teaching. Survey results found the concept was generally well accepted, though some stressors (eg, poor internet connection) impacted perception. Most histology and pathology students (58% and 68%, respectively) said they would prefer blended learning in the future, compared with all-live (39% and 28%, respectively), or all-virtual (4% and 5%, respectively) classrooms. 

In a systematic review of 13 studies that compared digital learning with live classroom education for medical and nursing students, investigators from China found that standalone digital models are as effective as conventional modalities for improving knowledge and practice. Moreover, students preferred interactive discussion to a straight lecture format when participating online. 

Clinical training: Virtual clerkships work, but a blended approach seems preferable.

In a study involving 16 third-year medical students in the general surgery clerkship at Cleveland Clinic, respondents reported their experience before and after participating in a case-based virtual surgery clerkship program. Students were significantly more confident that they could independently assess a surgical consult after taking the course. Average scores of curriculum-based surgical knowledge increased as well. 

In an assessment of alternative approaches to clinical clerkships involving 42 students, investigators from China evaluated the impact of using simulated electronic health records (EHRs) for inpatient training and electronic problem-based learning and virtual interviews for outpatient training. Students using simulated EHRs felt it improved their ability to write in and summarize the record. Those who participated in electronic problem-based learning and virtual interviewing said their interviewing and counseling skills improved. However, students also noted traditional clinical clerkships are better for certain types of learning, suggesting that a blended approach is preferred. 

CME: Virtual CME is accepted and improves performance, but barriers remain, including a preference for face-to-face networking.

Researchers reviewed 2,007 post-activity responses from clinicians who participated in online CME at a South Korean hospital. Of the 1332 participants who reported their satisfaction level, 85% reported being satisfied with the format and content. Among all respondents, nearly 9 in 10 said that the content would influence the way they practice. Of the 611 participants who responded to a follow-up survey 3 months later, 78% said they made changes in their clinical practice based on what they learned. 

However, many clinicians prefer in-person CME. A Canadian-based memory clinic held 5 interprofessional education sessions and reported on participant experience; 3 of the sessions occurred live before March 2020 and 2 were held via videoconference once the pandemic was declared. Ratings of satisfaction, relevance, knowledge acquisition, and knowledge application were similar in both groups, but the virtual sessions were rated as less enjoyable and lacking in networking opportunities. In-person learning was preferred. 

Primary care clinicians in Portugal evaluated a CME digital platform and reported several barriers, including time constraints, perceived excessive work, lack of digital competence, lack of motivation, and emotional factors.      

The Future
Although challenges remain, changes due to the pandemic have been implemented in medical training and have shown preliminary success in certain domains. Medical education is rapidly evolving, and as we move further from the pandemic, diligent ongoing evaluation is needed to assess the best use of technology and various innovative teaching modalities. Keeping medical education learner-centered and instituting timely course correction if certain modalities of knowledge/skill delivery are found to be ineffective will be key to ensuring the robustness of training for future generations.