RESEARCH BRIEFING

Covid-19, race, and hospital mortality. A large study provides insight

There is a disproportionate incidence of covid-19 cases in minority populations. Covid-19 mortality has also been revealed to be higher in these populations. However, available national-level data for covid-19 cases are missing a large proportion of race/ethnicity data. Out of the 65 percent of states that have reported race and ethnicity data, Black patients accounted for a greater proportion of covid-19 cases compared to the Black population in those states.  For example, Louisiana reported 59 percent of their confirmed covid-19 cases in Black patients, with  Mississippi reporting 66 percent, and the District of Columbia reporting 75 percent. 

A brand new study in JAMA Network Open entitled"Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals" aims to understand the impact of race on covid-19 hospital mortality. This study evaluated patients 18 years and older presenting to Ascension hospitals from February 19, 2020 to May 31, 2020. Patients who were admitted during this time period were tracked until June 25, 2020. Individuals who were in the hospital beyond this date were not included in the time-to-event analyses. The Ascension hospitals that were included in this study spanned across 12 states, included 92 hospitals, and 11,210 patients. Approximately, 37.3 percent of the participants in this study were Black.

  Compared to White patients, Black patients were younger with the median age being 66 and were more likely to have Medicaid insurance. Further they had a greater neighborhood deprivation index (NDI) score which is a composite of material and social deprivation derived from American Community Survey (ACS) variables that focuses on poverty, employment, education, and housing. The higher the number, the higher the associated deprivation score. This study also revealed a higher Elixhauser Comorbidity Index (ECI) for Black patients which is a calculated comorbidity assessment. 

This study also revealed that Black and White patients were admitted to intensive care units and required invasive mechanical ventilation at similar rates. Among all hospitalized patients, mortality for White patients was 23.1 percent and 19.2 percent for Black patients. For patients sick enough to need the ICU, mortality for White patients was 36.4 percent  and 35.2 percent for Black patients. 

In this study older age was the strongest risk factor for mortality among hospitalized patients. Male sex, chronic kidney disease, coronary artery disease were also associated with an increased risk of dying. It was also noted that patients with Medicare and unknown insurance statuses had a higher risk of mortality. Overall, race was not associated with an increased risk of mortality for those who were able to access hospital care and were admitted. However this study does have its limitations, since authors did not follow up with patients during the discharge period.  There was also variable race data available, and the researchers studied only patients admitted to the hospital. This implies that a combination of pre-existing conditions and other societal factors (such as disparities in long term healthcare access and structural racism), and not hospital care itself, most likely explains the fact that higher percentages of Black people have required hospitalization for covid-19 than census data would predict.  


POLICY BRIEFING

Americans get more than ballots by mail. They also get their medications

The Trump Administration has claimed that voting by mail might compromise the integrity of the general election in November, despite the fact that there is no evidence to suggest widespread fraud has occurred in the past or will occur. Nevertheless, the administration has turned undermining the United States Postal Service into a political tool, with reports of mailboxes being removed all over the country last week.

Here's the problem. Many Americans rely on the mail to receive their prescription drugs (let alone their paychecks and bills). Policies that intentionally slow down the delivery of mail could lead millions of Americans to lose access to medications that they rely on, ranging from medications that reduce the odds of heart attacks and strokes to diabetic crises. This could cause a massive increase in demand in Urgent Care clinics, doctors offices, and emergency rooms. A slowdown in the flow of mail--which we note is a completely preventable choice being made by government officials in Washington--could not come at a worse time. As the fall approaches, cold and flu season is expected to increase demand for all kinds of medical services, regardless of the continued extent of the covid-19 crisis.

The American College of Physicians (ACP) released a statement yesterday highlighting these problems. The ACP has over 163,000 internal medicine physicians (internists) as members and is the largest medical specialty organization in the United States. It is unusual for the ACP to make statements related to public policy that are not explicitly related to health and medicine. However, in this case, the ACP has correctly identified the potential for medical mayhem that the administration's reckless policy stands to impart. 

After substantial outcry from the public, it was announced that no more mailboxes would be removed from city streets for the time being. However, removal of mail sorting machines, which are away from the public eye, may still continue. With the health of millions of Americans on the line, it is worth noting that those over 60 years of age have traditionally had the highest rates of voting. Older voters are also the most likely to use vote-by-mail options.


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