Black patients hospitalized at disproportionately higher rates. What does this mean?

A new article published in The New England Journal of Medicine compares hospitalization and mortality rates among Black and non-Hispanic White patients in Louisiana. Previous data has shown that Black individuals account for a disproportionately high number of cases and deaths in places like the Bronx in New York, Georgia, and others. This study assessed the characteristics of 3,626 patients at the time of hospital admission and followed their courses between March 1st and April 11th. Black persons comprise 31 percent of the patient population served by Ochsner Health, the integrated-delivery health system where the study occurred. However, 77 percent of hospitalized patients and 71 percent of the patients who died were Black. Once hospitalized, Black race was not independently associated with an increased risk of death, suggesting that other factors were responsible for the high percentages in comparison to their representation in the population. For example, Black patients were more likely to present to the hospital having already developed signs of severe illness, including new evidence of kidney and/or liver dysfunction, and elevated markers of inflammation. While a metric of existing medical problems found that the fraction of patients with pre-existing medical conditions among Black and non-Black patients was similar, in reality that metric may not have been adequate; the "Charlson Comorbidity Index" is designed to predict 1-year mortality based on 17 conditions. Even amongst patients with many chronic medical problems, 1-year survival is usually quite high and so only extreme differences would show a "statistically significant" effect. Indeed, out of 12 chronic medical illnesses listed, 10 were more common in Black patients, including high blood pressure, diabetes, and obesity. All of these have been reported to increase risk of severe illness and death from covid-19. Also in this study, Black patients were more likely to require intensive care (36 percent versus 30 percent), mechanical ventilation (28 percent versus 21 percent). Of interest, in this cohort of patients, female sex was associated with higher rates of admission. This comes in contrast to many prior studies that have shown disproportionately high rates of male patients experiencing more severe SARS-CoV-2 infections.

Remdesivir update: a trial without a placebo somehow fails

The New England Journal of Medicine has elected to publish a study describing results from a phase three trial assessing remdesivir which did not use a placebo. The study compared outcomes of patients with covid-19 with initial oxygen levels of 94% of less, but who had not yet begun to use supplemental oxygen.  While the lack of placebo renders conclusions regarding the effectiveness of the drug in the treatment of covid-19 impossible, it is noteworthy that the study—which compared 5-day courses to 10-day courses of the trial drug—showed no major differences. The most notable findings reported were frequent trends towards worse outcomes in the patients who received the drug for longer. Sixty-five percent of the patients who received the drug for 5 days showed signs of improvement by day 14, compared to 54 percent among patients given the drug for 10 days, though some differences between the groups were already apparent by day 5, suggesting it was the baseline characteristics of the patients, and not the drug that was responsible for worse outcomes in the longer treatment group. Preliminary data recently published on the randomized controlled trial of remdesivir (covered in Brief19) showed that hospitalized patients who received the drug (and who did not require oxygen prior to the study) recovered several days sooner than those receiving placebo. No statistical mortality difference was detected in that trial, but that will be reassessed when more data is released.


Changes to military movements

Shortly after the national emergency was declared in response to covid-19, the Pentagon issued a stop-movement order for active duty personnel.  This affected travel of many kinds, including transferring to new duty stations, called permanent change of station (PCS) moves, and it restricted the distance that individuals could travel away from their homes.  Initially slated to last through June 30, the Pentagon has now released updated guidance. Per the instruction, military bases will be allowed to resume PCS activity once both the White House and Centers for Disease Control and Prevention (CDC) threshold recommendations have been met.  A five-phase program for re-opening has been delineated. Pentagon officials are relying on local conditions to make decisions. Conditions necessary for approval include the ability of an individual base to test for coronavirus as well as its capacity to maintain essential services.  Officials emphasized that there is no timeline attached to the plan and the progress will rely exclusively on the above attributes.  Further, in an effort to address an anticipated flood of government-coordinated moving requests, members who relocate themselves will temporarily be reimbursed at the government rate instead of the normal 95 percent. This policy will remain active through December 31st at least.

Working safely in an unsafe era

The Occupational Safety and Health Administration (OSHA) has released a document entitled "Guidance on Preparing Workplaces for COVID-19." The document outlines some expectations for managers, including the anticipation of absenteeism related to inadequate sick leave. In addition to encouraging employers to foster a culture of safety and hygiene, including recommending increased access to hand sanitizers in situations in which increased access to soap and sinks is not possible, employers are encouraged to tell employees not to come to work if they are sick, encouraging "respiratory etiquette" (i.e. covering coughs and sneezes), and reminding co-workers not to share phones and desks. Providing face masks, when possible, is advised. In addition, OSHA is advising that employers have sick leave policies that are "flexible and consistent with public health guidance," including provisions for workers who need to stay home to take care of other members of their household. Also included is a recommendation not to require employees obtain "work notes" from healthcare providers in order to gain permission either to miss work, nor to return to work, as stretched resources may limit access. However, the recommendations of this document are non-binding. OSHA could turn this document into a regulatory requirement, which would mean that employers would be bound by its policies. So far, that does not appear likely.