Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City

BACKGROUND

Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality.

METHODS

In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality.

RESULTS

ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality.

CONCLUSIONS

Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.

Using Public Health Detailing to Increase Access and Confidence in COVID-19 Vaccines and Reinvest in Disproportionately Impacted NYC Communities

CONTEXT

COVID-19 vaccination rates in New York City (NYC) began to plateau in the spring of 2021, with unacceptable inequities in vaccination rates based on race.

PROGRAM

To address racial inequities in vaccination rates and COVID-19 health outcomes, the New York City Department of Health and Mental Hygiene adapted a preexisting provider outreach and education program for public health emergency use with the goals of community reinvestment and increasing patient confidence and access to the COVID-19 vaccines. The Vaccine Public Health Detailing (VPHD) program was delivered as part of a larger community outreach initiative and brought timely updates, materials, and access to technical assistance to primary care providers and staff in NYC neighborhoods experiencing COVID-19 health inequities. Outreach representatives also collected feedback from providers on resource needs to inform the agency's response.

IMPLEMENTATION

Sixteen outreach representatives were rapidly trained on COVID-19-related content and strategic communication techniques and launched a 3-wave campaign across targeted neighborhoods throughout NYC. The campaign ran from May 2021 to March 2022 and was conducted in coordination with other community engagement initiatives aimed at the general public to promote greater collective impact.

EVALUATION

In total, 2873 detailing sessions were conducted with 2027 unique providers at 1281 sites. Outreach representatives successfully completed visits at more than 85% of practices that were in scope and operating. Approximately 20% (285) of the sites requested a referral for technical assistance to become a COVID-19 vaccination site or enroll in the Citywide Immunization Registry. Qualitative information shared by providers offered a more in-depth understanding of vaccine-related sentiments and challenges faced by providers on the ground.

DISCUSSION

VPHD is an effective method for supporting community providers, gathering feedback on resource needs and practice challenges, and increasing health systems efficacy during a public health emergency while also prioritizing racial equity and community reinvestment.

Payers and Public Health: A Novel Collaboration to Support Covid-19 Vaccination Uptake

The New York City (NYC) Department of Health and Mental Hygiene, as a local health department, partnered with health plans to pay for provider-initiated outreach for Covid-19 vaccine counseling for unvaccinated people through a program called the Vaccine Outreach and Counseling Program (VOCP). The collective effort and use of emergency contracting — with a budget of $35 million in funding from the government of NYC — allowed for an idea-to-execution period of 6 weeks. Seven insurance companies covering more than 90% of the NYC Medicaid market and a significant portion of the NYC Medicare Advantage market (insurance products that have a disproportionately large representation of people of color in NYC) administered the program as an in-kind contribution to the effort. Providers implementing the VOCP reported that they felt counseling efforts were valuable in increasing vaccination uptake, but also described operational challenges. Shortly after launching the VOCP, the federal government reached out to the health department to learn more about the program. Two months later, the U.S. Centers for Medicare & Medicaid Services authorized state Medicaid programs to cover such counseling. New York State’s Medicaid program subsequently adopted a reimbursement policy with similar guidance for counseling while addressing some of the operational challenges of the VOCP model.

Reparations for Black American descendants of persons enslaved in the U.S. and their potential impact on SARS-CoV-2 transmission

Background

In the United States, Black Americans are suffering from a significantly disproportionate incidence of COVID-19. Going beyond mere epidemiological tallying, the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored.

Methods

We compared the COVID-19 time-varying R_t curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates βi→j for 4 cells of the simplified next-generation matrix (from which R₀ is calculated for structured models) for the outbreak in Louisiana. Lastly, we considered the potential structural effects monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention βi→j and consequently R₀.

Results

Once their respective epidemics begin to propagate, Louisiana displays R_t values with an absolute difference of 1.3–2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring R_t below 1. Reasoning through the consequences of increased equity via matrix transmission models, we demonstrate how the benefits of a successful reparations program (reflected in the ratio βb→b/βw→w) could reduce R₀ by 31–68%.

Discussion

While there are compelling moral and historical arguments for racial-injustice interventions such as reparations, our study considers potential health benefits in the form of reduced SARS-CoV-2 transmission risk. A restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would also be distributed across racial groups, benefiting the population at large.

Diagnostic ultrasound for suspected appendicitis: does the added cost produce a better outcome?

Acute appendicitis is one of the most common abdominal surgical emergencies in North America. Although the treatment of appendicitis has remained the same for over 250 years, diagnostic techniques have changed immensely. Most recently, graded compression ultrasonography has received much support. In an attempt to determine whether ultrasonography has improved the outcome in acute appendicitis, we retrospectively reviewed the records of all patients undergoing appendectomy and/or ultrasound for suspected appendicitis during two separate 12-month periods. We began using ultrasound in the diagnosis of appendicitis in 1987; therefore, 1986 was used as our pre-ultrasound year; 1989 was used as our comparison year because ultrasound had become widely applied in the diagnosis of acute appendicitis by this time. Data was tabulated on all patients undergoing appendectomy in both study years, as well as those also undergoing ultrasonography in 1989. The populations in 1986 and 1989 were similar for all data tabulated. The diagnostic accuracy rate actually decreased after the implementation of ultrasonography (85.6% vs 77.0%, P < 0.05). This trend was seen in both male and female patients, reaching statistical significance in the male population (P < 0.05). The incidence of perforation and complications were not statistically decreased after the implementation of ultrasound. Ultrasound did not decrease the length of hospital stay, and in addition added approximately $48,000 to the treatment cost of appendicitis in 1989. Thus, despite adding cost, ultrasonography for appendicitis did not improve our ability to diagnose or accurately treat appendicitis.