A blog covering the health/care ecosystem and people.

The most effective, engaging, and enchanting digital health innovations speak to patients beyond their role as health consumers and caregivers: digital health is at its best when it addresses peoples’ health citizenship. I had the great experience brainstorming the convergence of digital health, wearable tech, user-centered (UX) design, and health citizenship with João Bocas, @WearablesExpert, in a on his podcast. And if those topics weren’t enough, I wove in the role of LEGO for our well-being, “playing well,” and inspiring STEM- and science-thinking. João and I started our chat first defining health citizenship, which is a phrase I first learned from

“Americans remain in limbo between lives once lived and whatever the post-pandemic future holds,” the American Psychological Association observes in their latest read into Stress in America 2021, with this phase of the perennial study focused on Stress and Decision-Making During the Pandemic. The top-line: people face a daily web of risk assessment, up-ended routines, and endless news about the coronavirus locally and globally. While most people in the U.S. believe that “everything will work out” after the pandemic ends, the mental, emotional, and logistical daily distance between “now” and “then” brings uncertainty and indeed, prolonged stress. More Millennials, who

In the U.S., peoples’ expectations of their health care experience is melding with their best retail experience — and that’s taken a turn toward their digital and ecommerce life-flows. The American Customer Satisfaction Index Insurance and Health Care Study 2020-2021 published today, recognizing consumers’ value for the quality of health insurance companies’ mobile apps and reliability of those apps. Those digital health expectations surpass peoples’ benchmarks for accessing primary care doctors and specialty care doctors and hospitals, based on ACSI’s survey conducted among 12,274 customers via email. The study was fielded between October 2020 and September 2021. Year on year,

Most U.S. adults across political parties favor allowing the Federal government authority to negotiate for drug prices — even after hearing the arguments against the health policy. Drug price negotiation, say by the Medicare program, is a unifying public policy in the current era of political schisms in America, based on the findings in a special Kaiser Family Foundation (KFF) Health Tracking Poll conducted in late September-early October 2021. Overall, 4 in 5 Americans favor allowing the Federal government negotiating power for prescription drug prices, shown in the first chart from the KFF report. By party, nearly all Democrats agree

Before the coronavirus emerged, the top causes of death in developed countries were heart disease, cancers, diabetes, and accidents. Then COVID-19 joined the top-10 list of killers in the U.S. and the issue of pandemic preparedness for the next “Disease X” became part of global public health planning. But the biggest health threat to human life is climate change, according to a new report from the World Health Organization titled The Health Argument for Climate Action. It’s WHO’s special report on climate change and health, dedicated to the memory of Ella Kissi-Debrah — a child who died succumbing to impacts

A new look into Americans’ views on health privacy from Morning Consult provides a current snapshot on citizens’ concerned embrace of technology — worried pragmatism, let’s call it. This ambivalence will flavor how health citizens will adopt and adapt to the growing digitization of health care, and challenge the healthcare ecosystem’s assumption that patients and caregivers will universally, uniformly engage with medical tools and apps and technologies. More Boomers are concerned with health data app privacy than Gen Z consumers, as the chart illustrates. 46% of U.S. adults said that health monitoring apps were not an invasion of privacy; 32%

Years before we knew how to spell “coronavirus,” I gained Italian citizenship while retaining my U.S. citizenship. My family’s plan was to, soon thereafter, split time for work and life between the U.S. and the E.U. Then, COVID-19 emerged as a pandemic the world over, and the move to Brussels in January 2020 was quite short-lived. Now, the plan is in play and I’m writing this post from our home in Brussels, Belgium. Why Brussels? Among many smart reasons, the city is welcoming, our farm-to-table food style is doable, the walkability is brilliant, and the transportation options are accessible to

In 2020, Genentech launched its first study into health inequities. The company spelled out their rationale to undertake this research very clearly: “Through our work pursuing groundbreaking science and developing medicines for people with life-threatening diseases, we consistently witness an underrepresentation of non-white patients in clinical research. We have understood inequities and disproportionate enrollment in clinical trials existed, but nowhere could we find if patients of color had been directly asked: ‘why?’ So, we undertook a landmark study to elevate the perspectives of these medically disenfranchised individuals and reveal how this long-standing inequity impacts their relationships with the healthcare system

In the fourth quarter of 2021, U.S. hospital margins will still be lower than before the COVID-19 pandemic, Kaufman, Hall & Associates project in their latest read on hospital finances. Kaufman Hall has been monitoring hospitals’ financial health in the coronavirus era since March 2020, month-by-month. This new report looks into the Financial Effects of COVID-19: Hospital Outlook for the Remainder of 2021. This report was conducted on behalf of the American Hospital Association (AHA), who succinctly summarized the forecast saying, “COVID-19 [is] expected to drive continued hospital losses throughout 2021.” That projection is further couched in the concern that

When Dignity Health, the Catholic health care system, launched the “Hello humankindness” PR campaign in June 2013, well, they had me at “Hello.” When the project went live, Dignity Health’s President/CEO Lloyd Dean provided the rationale for the program, saying: “What’s missing in the public discourse about health care is the fact that while medicine has the power to cure, it’s humanity that holds the power to heal.” Dean pointed to two drivers shaping U.S. culture and the nation’s health care industry: The institutionalization of health care, and, The decline of civility in society. That was 2013. #HelloHumankindness sought to

The COVID-19 pandemic exacerbated food insecurity in the U.S., a situation that was already challenging for millions of American families before the public health crisis emerged. While several Congressional and administrative actions were implemented in 2020 and the first half of 2021, the issue of food insecurity — defined as being unable to acquire enough food due to insufficient money or resources — remains a tragic aspect of daily living for many Americans — and especially for children who live in households where jobs have been lost and incomes reduced. Nutrition security has also been a health risk where people

The Catholic Health Association (CHA) is urging Americans to “love thy neighbor” by getting the COVID-19 vaccine, Sister Mary Haddad wrote in an editorial published in Modern Healthcare, published on September 3, 2021. Sister Mary is CEO and President of CHA. “Some may suggest that there are moral and religious concerns to receiving the COVID-19 vaccine,” Sister Mary observed. “We strongly affirm the position of the leaders of the Catholic Church: the vaccines are morally acceptable and getting vaccinated is “an act of love.” she asserted. CHA launched a portal on the act of love, featuring lots of science-based articles

“CVS wants to be your therapist, too,” the Wall Street Journal reported on 31st August, discussing the plans of retail stores, Big Box and pharmacies, adding mental health services to their growing health/care portfolios. The coronavirus spawned an epidemic inside and beyond the pandemic throughout the U.S.: very clear and widespread mental and behavioral health impacts that have become a new and transparent normal in America. Enter CVS Health, joining retail health competitors such as Walgreens and Walmart, both of which have been growing services to help consumers access help to deal with anxiety, depression, and stress. The first chart

Financial Experience (let’s call it FX) is the next big thing in the world of patient experience and health care. Patients, as health consumers, have taken on more of the financial risk for health care payments. The growth of high-deductible health plans as well as people paying more out-of-pocket exposes patients’ wallets in ways that implore the health care industry to serve up a better retail experience for patients. But that just isn’t happening. One of the challenges has been price transparency, which is the central premise of this weekend’s New York Times research-rich article by reporters Sarah Kliff and

There is one health care public policy issue that unites U.S. voters across political party: that is the consumer-facing costs of prescription drugs. With the price of medicines in politicians’ and health citizens’ cross-hairs, the pharmaceutical and biotech industries have responded in many ways to the Rx pricing critiques from consumers (via, for example, Consumer Reports/Consumers Union and AARP), hospitals (through the American Hospital Association), and insurance companies (from AHIP, America’s Health Insurance Plans). The latest poll from the University of Chicago/Harris Public Policy and the Associate Press-NORC Center for Public Affairs Research quantifies the issue cross-party, finding that 74%

As connected devices proliferate within health care enterprises and across the health care ecosystem, cybersecurity risks abound. During the first year of the COVID-19 pandemic, the health care sector was profoundly affected by cyber-attacks on connected devices, we learn in the report, Rise of the Machines 2021: State of Connected Devices – IT, IoT, IoMT and OT from Ordr. For this annual report, Ordr analyzed security risks across over 500 deployments in healthcare, life sciences, retail, and manufacturing sectors for the 12 months June 2020 through June 2021. In health care, outdated operating systems present some of the greatest risks:

The COVID-19 pandemic digitally transformed most people living in the U.S., re-shaping consumers to work from home when possible, go to school there, and buy all manners of goods and services via ecommerce. In March 2021, Zoom conducted research into the question, “how virtual do we want our future to be?” posing that to thousands of citizens living in 10 countries including the U.S. As the first chart from the study illustrates, most people in America expect hybrid lifestyles, from fitness and retail to entertainment and education. And 7 in 10 U.S. health citizens want their health care to be

Simply put, is the equation, “Spend more, get less” a sustainable business model? Of course not. But that’s the simple math on U.S. health care spending and what comes from it, according to Mirror, Mirror 2021: Reflecting Poorly, a perennial report from The Commonwealth Fund that compares health system performance across eleven developed countries. The first table details the metrics that the Fund compares across the eleven peer nations, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The metrics compared were access to care, care process, administrative efficiency, equity,

“You can trust us to help you find the right Medicare coverage for you and your lifestyle,” the tagline reads. What kind of organization would be behind this campaign: a healthcare navigator company, an insurance company, or a social services agency? In fact, it’s a grocery store called Hy-Vee, which launched the “Medicare Aisle” to help consumers living in the eight states in which the chain’s 240+ stores operate to sort through the daunting labyrinth of Medicare choices. “Hy-Vee is a trusted leader in the health and wellness space, and as a retail and specialty pharmacy provider, we are deeply

When we say the word “pharmacy,” we might picture the Main Street brick-and-mortar chain drugstore that dispenses medicines from behind the counter in the far back of the building, and sweet and salty snacks at the front by the cashier. In fact, “pharmacy” is the jumping off point for the expanding and increasingly beloved retail health ecosystem, J.D. Power found in the company’s latest 2021 U.S. Pharmacy Study. Each year, J.D. Power assesses consumers’ perceptions of pharmacies by category, including those retail chains along with supermarket operated, mass merchants, and mail order channels. This is the 13th year of the

There is no doubt that the COVID-19 pandemic motivated health care providers, payers, and patients to adopt digital tools and contact-less services, allowing people to deliver and receive medical care. Still, 18 months into the pandemic, now endemic and in its fourth wave of cases spiking around the world and in many parts of the U.S., some aspects of “digital transformation” seem not to have fully transformed American healthcare, we learn in HIMSS’s annual 2021 State of Healthcare Report. HIMSS collaborated with the organizations Trust  Accenture, The Chartix Group, and ZS on this year’s research. Nine in ten clinicians have recommended

The level of medical debt in America exceeded debt of other types in 2020. Furthermore, the flow of medical debt was greater among health citizens living in states that did not expand Medicaid as part of the Affordable Care Act, compared with patients who reside in Medicaid expansion states, according to an original research essay, Medical Debt in the US, 2009-2020 published in JAMA on 20 July 2021. The first line chart illustrates the trends in medical debt in collections by state expansion of Medicaid, with the bottom darkest line representing debt in collections in Medicaid expansion states from the

Cain Brothers is a 100+ year old financial services firm with a strong health care experience, now part of KeyBanc. A recent “House Calls” memo and podcast from two company analysts detailed the state of Medicaid, Motherhood and America’s Future: Giving Birth to Better Maternity Outcomes. Christian Pesci and David Johnson’s in-depth discussion detailed their bottom-line that, “maternity care in the U.S. is in crisis but poised for rapid evolution…(recognizing) that an uncoordinated system with misaligned incentives harms too many individuals, families, and communities.” They lay out the crisis as follows: Medicaid funds nearly one-half of births in the U.S.

“Self-care” took on new meaning and personal work-flows for people living in and through the coronavirus pandemic in the U.S. Acosta, the retail market research pro’s, updated our understanding consumers evolving as COVID-19 Has Elevated the Health and Wellness Trends of the Recent Years, results of a survey conducted among in May 2021. In the U.S., consumers’ take on self-care has most to do with healthy eating and nutrition (for 1 in 2 people), getting regular medical checkups (for 42%), taking exercise, relaxing, using vitamins and supplements, and getting good sleep. Healthy relationships are an integral part of self-care for

The ultimate health and wellbeing of an adult depends on the factors that shape us when we are children. A new, deep report from the OECD, Measuring What Matters for Child Well-being and Policies, spells out the many domains of experience that, together, bolster our whole health as we grow from child to adult. The first chart presents the OECD’s framework for measuring child well-being, calling out the nature of being “aspirational.” This re-look at children’s health data is aspirational because it is laying out how to best measure child well-being to set the bar higher for doing so. It addresses

The FDA’s approval of the first therapy to treat Alzheimer’s Disease in over twenty years brought attention to a not-yet-convened debate of U.S. health care costs and spending, innovation, and return-on-the-investment (as well as “for whom” do the returns accrue). In my latest post for Medecision, I explore different angles on the Aduhelm and Alzheimer’s discussion, covering: The macro- and micro-economics of Alzheimer’s and the $56,000 list price for the drug The FDA regulatory process and aftermath U.S. consumers’ bipartisan support for drug price regulation through Medicare negotiation and private/commercial sector adoption Congressional legislation addressing the price of medicines in

COVID-19 reshaped people around the world, one-half of whom are re-defining their personal purpose and life-goals. This sense of purpose extends to peoples’ willingness to buy or patronize companies who do not meet their needs for health, safety, sustainability and trust. For example, two in three of these people would switch travel brands if they felt health and safety weren’t up to par, discovered in Life Reimagined – Mapping the motivations that matter for today’s consumers, from Accenture’s Voices of Change series. In May 2021, Accenture polled over 25,000 consumers globally, in 22 countries, and found that one-half of people

Getting totally rid of the coronavirus isn’t likely, so we humans must accept the fact that SARS-CoV-2 will be endemic. The economic and healthcare system impacts of this were explored in the Post-Covid Healthcare Landscape, delivered by Fitch Solutions’ Jamie Davies and Beau Noafshar, leaders in the Pharmaceuticals, Healthcare, and Medical Devices groups. I welcomed the opportunity to learn from this team’s approach in weaving together the dynamic issues that help us to plan for the long-tail of COVID-19 and its impact on the economy and prospects for the health care industry and health citizens. The first graph illustrates the

One in two people in the U.S. with employer-sponsored health insurance worry that a major health event in their household could lead to bankruptcy, according to research gathered by West Health and Gallup in Business Speaks: The Future of Employer-Sponsored Insurance. Gallup and West Health presented their study in a webinar earlier this week; in today’s post, I feature a few key data points that particularly resonate as I celebrate/appreciate yesterday’s U.S. Supreme Court’s ruling on the Affordable Care Act (i.e., California v. Texas) combined with a new study published in JAMA Network Open, discussed below the digital fold in

Wherever you live in the world touched by the coronavirus pandemic, you felt (and were) stress-tested. Both you were, and your home was as well. In this year’s 2021 annual report by Deloitte into Connectivity & Mobile Trends, their report details How the pandemic has stress-tested the crowded digital home. This analysis was done, as it is every year, by the Deloitte Center for Technology, Media & Telecommunications. Deloitte’s Center commissioned an online survey among 2,009 U.S. consumers to gauge five generations of peoples’ perspectives on connected life in the context of COVID. The report covers the various life-flows of

The pandemic ushered in millions of peoples’ first digital health experiences, many of which will persist according to the 23rd Annual U.S. Consumer Technology Ownership & Market Potential Study, published by the Consumer Technology Association. CTA conducted an online survey among 2,409 U.S. adult 18 and over in April 2021 to gather data for this annual report. To ensure a fair sample, CTA drew three datasets for the general population along with an Hispanic oversample and an oversample for people 65 years of age and older. The study looked at 83 consumer technology products and sub-categories, including many directly related

Two studies published in May 2021 illustrate the value and importance of telehealth to patients in 2020, and a disconnect among many C-level executives working in hospitals, academic medical centers, and other care provider organizations. Together, the two reports from J.D. Power and BDO illustrate some mis-alignment between the demand and supply side of telehealth. On the consumer demand side, patients’ growing use of telehealth in the COVID-19 pandemic along with more frequent digital contacts with health plans bolstered member satisfaction, discovered by the J.D. Power 2021 U.S. Commercial Member Health Plan Study. J.D. Power has conducted the U.S. Commercial

The good news for health care costs for a family of four in America is that they fell, for the first time in like, ever, in 2020. But like a déjà vu all over again, annual health care costs for a family of four enrolled in a PPO will climb to over $28,000 in 2021, based on the latest 2021 Milliman Medical Index (MMI). The first chart shows how health care costs declined in our Year of COVID, 2020, by over $1,000 for that hypothetical U.S. family. But costs rise with a statistical vengeance this year, by nearly $2,200 per family–about

The emergence of the COVID-19 vaccine “infodemic” has slowed the ability for nations around the world to emerge out of the public health crisis. Growing cynicism among some health citizens facing the politicization of public health tactics like vaccines and facial masks is what we’re talking about. At the root is peoples’ lack of trust across a range of information providers, including government, media, business, and even peers. The 2021 Edelman Trust Barometer spotlighted the infodemic and eroding trust in the U.S. in the voices of public health, the public sector, and media. This is a global challenge as well,

You’re stressed, I’m stressed; most of us have felt stress in the COVID-19 era which began in the U.S. in the first quarter of 2020. Nearly eighteen months later, a 2021 Edelman Trust Barometer update finds that consumers’ trust in the health care industry is under stress, too — in the U.S. and around the world. The first chart from the Edelman health care update demonstrates that in most countries polled, health citizens’ trust in health care was buoyed in the first five months of 2020 (January through May): up 18 points in the U.S., 14 points in Canada and

The hearts and minds of nurses are fertile and inspirational sources and engines for health care innovation. This past weekend, and for the second time, I had the privilege and opportunity to be a panelist for the perennial hackathon meet-up of Nurse Hack 4 Health, sponsored by Microsoft, Johnson & Johnson, Sonsiel, and DevUp. This round, the hackathon attracted hundreds of nurses from at least 20 countries and 30 U.S. states. Even a few students attended, a growing trend as academia recognizes the shortage of workers trained to solve thorny problems of the world. In health care, right here, right

“Compare digital health to airlines, cruise lines, and other industries” and the sector looks quite privileged, opined Matthew Holt in a discussion on a study diving deeply into the State of Digital Health, conducted by Catalyst @ Health 2.0 and sponsored by WIPFLI.. The research was conducted among 335 respondents, which included 182 digital health companies polled between November 2020 and March 2021. Digital health companies represented 60% of the sample, the other 40% of which were consulting firms, subsidiaries of providers/payers/life science companies and tech corporations, and investors. As Matthew called out, the digital health sector has a relatively

To pay for health care expenses, the average nest-egg required for a couple retiring in the U.S. in 2021 will be $300,000 according to the 20th annual Fidelity Investments Retiree Health Care Cost Estimate. I’ve tracked this survey for over a decade here on Health Populi, and updated the annual chart shown here to reflect a $40,000 increase in retiree costs since 2016. While the rate of increase year-on-year since then has slowed, the $300,000 price-tag for retiree health care costs is a huge number few Americans have saved for. That $300K splits up unequally for an opposite-gender couple (in

The pandemic accelerated many Very Big Deals in digital health venture capital investment, mergers and acquisitions, and the re-emergence of SPACs in health care. A closer look at this activity points to a key trend that will persist post-pandemic: that telehealth and the broader theme of virtual care is re-shaping how health care is delivered. This graphic comes out of my current thinking about telehealth across the continuum of care. Before the pandemic, the dominant work-flow for telemedicine was for triage, primary care and pediatrics (think: your child registers a 105-degree fever on a Saturday night and the pediatrician’s office

Spending on medicines, globally, will rebound this year and rise above pre-pandemic levels through 2025. Between 2021 and 2025, the annual growth global growth rate for prescription drugs spending is expected to range from 3% to 6%, a $1.6 trillion bill for the worlds’s total Rx medicines market. That relatively low single-digit growth rate is tempered by savings from biosimilars and the loss of brand exclusivity (that is, more generics coming to market). On the faster-growth side, we can expect two big therapeutic areas to drive spending upward: oncology and immunology, projected to expand by 9% to 12% each year

In April 2020, the U.S. Centers for Disease Control issued a report featuring evidence that in the month of March 2020, the coronavirus pandemic was not an equal-opportunity killer. Within just a couple of months of COVID-19 emerging in America, it became clear that health disparities were evident in outcomes due to complications from the coronavirus. An update from that early look at differences in COVID-19 diagnoses and mortality rates was published in Health Disparities by Race and Ethnicity During the COVID-19 Pandemic: Current Evidence and Policy Approaches, In this report, the Assistant Secretary for Planning and Evaluation, part of

As the COVID-19 expanded peoples’ consciousness about infectious disease and opportunities to keep a tricky virus at bay, consumers grew new muscles about public and individual wellness…now, “more invested in achieving it,” according to In Health We Trust, a survey report from Healthline Media. To gauge Americans changing perspectives on personal health, HealthLine conducted surveys among 1,533 U.S. consumers age 18 and over in February 2020 (just about the time the coronavirus pandemic was emerging in the U.S.) and 1,577 consumers in December 2020. One of the subtle shifts in health care consumerism concerns cost, which before the pandemic has

In the summer of 2020, four months into the pandemic, one-half of people living in the U.S. felt worry or stress related to the coronavirus that had a negative impact on their mental health. Over a year into the COVID-19 in America, nearly one-half of people still have negative mental health impacts due to the coronavirus, based on research from the Kaiser Family Foundation (KFF) published in their April 2021 update on the mental health impact of the COVID-19 pandemic. Note the line in the bar chart from the study has flat-lined and settled at just about 50% of U.S.

The United States has among the highest per capita incomes in the world. The U.S. also has sustained among the highest death rates per 100,000 people due to COVID-19, based on epidemiological data from the World Health Organization’s March 28, 2021, update. Higher incomes won’t prevent a person from death-by-coronavirus, but risks for the social determinants of health — exacerbated by income inequality — will and do. I have the good fortune of access to a study group paper shared by Paul Sheard, Research Fellow at the Mossaver-Rahmani Center for Business and Government at the Harvard Kennedy School. In reviewing

The coronavirus pandemic exposed weaknesses in the U.S. health care system that existed before the public health crisis. What lessons can be learned from the COVID-19 stress-test to build American health care back better? The National Academy of Medicine is publishing nine reports addressing health stakeholder segments impacted and re-shaped by COVID-19 — for public health, quality and safety, health care payers, clinicians, research, patients-families-communities, health product manufacturers, digital health, and care systems. The report on health care systems and providers was released this week:  COVID-19 Impact Assessment: Lessons Learned and Compelling Needs was authored by experts on the front-line

Investments in the digital health sector have fast-grown in the past decade, reaching $14bn in 2020 based on Rock Health’s latest read on the market. The COVID-19 pandemic accelerated the field across many industry segments. With such turbocharged growth on the supply side, Beazley, experts in specialty insurance, explores the risks of digital health and wellness in a new report, Digital health, telehealth and wellness: Attitudes to risk and insurance. With great potential for both innovation and reward comes great risks: Beazley points to the facts that, over two-thirds of digital health companies lack insurance coverage for medical malpractice for

COVID-19 ushered in the era of our homes as safe havens for work, shopping, education, fitness-awaking, bread-baking, and health-making. In my latest essay written for Medecision, I weave together new and important data and evidence supporting the basic social determinant of health — shelter, housing, home — and some innovations supporting housing-as-medicine from CVS Health, UnitedHealth Group, AHIP, Brookings Institution, the Urban Land Institute, and other stakeholders learning how housing underpins our health — physical, mental, financial. Read about a wonderful development from Communidad Partners, working with the Veritas Impact Partners group, channeling telehealth to housing programs serving residents with

Springtime is finally emerging on the east coast of the U.S. and my local CSA farm is on my mind. It’s timely, then, to re-visit a research paper on subsidizing fruits and vegetables from a March 2019 issue of PLOS as an introduction to a new initiative growing out of The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) on produce prescriptions. Timely, too, that Chef José Andrés has been called to President Biden’s White House to help address food security in America. First, let’s look at the research in PLOS: Cost-effectiveness of financial incentives for

In 2021, racial and ethnic disparities in healthcare are a top patient safety issue, according to ECRI’s annual list of major concerns facing healthcare consumers’ risks to adverse events that can harm them. ECRI has published their annual Top 10 list since 2018, when the list featured diagnostic errors, o behavioral health needs in acute care settings, and patient engagement and health literacy — all of which play into this year’s #1 issue, racial and ethnic disparities in health care. In fact, among the risks in this year’s Top Ten list, eight were accelerated and highlighted by the COVID-19 pandemic