Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With COVID-19 in New York City

IMPORTANCE

Black and Hispanic populations have higher rates of coronavirus disease 2019 (COVID-19) hospitalization and mortality than White populations but lower in-hospital case-fatality rates. The extent to which neighborhood characteristics and comorbidity explain these disparities is unclear. Outcomes in Asian American populations have not been explored.

OBJECTIVE

To compare COVID-19 outcomes based on race and ethnicity and assess the association of any disparities with comorbidity and neighborhood characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted within the New York University Langone Health system, which includes over 260 outpatient practices and 4 acute care hospitals. All patients within the system's integrated health record who were tested for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and April 8, 2020, were identified and followed up through May 13, 2020. Data were analyzed in June 2020. Among 11 547 patients tested, outcomes were compared by race and ethnicity and examined against differences by age, sex, body mass index, comorbidity, insurance type, and neighborhood socioeconomic status.

EXPOSURES

Race and ethnicity categorized using self-reported electronic health record data (ie, non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and multiracial/other patients).

MAIN OUTCOMES AND MEASURES

The likelihood of receiving a positive test, hospitalization, and critical illness (defined as a composite of care in the intensive care unit, use of mechanical ventilation, discharge to hospice, or death).

RESULTS

Among 9722 patients (mean [SD] age, 50.7 [17.5] years; 58.8% women), 4843 (49.8%) were positive for COVID-19; 2623 (54.2%) of those were admitted for hospitalization (1047 [39.9%] White, 375 [14.3%] Black, 715 [27.3%] Hispanic, 180 [6.9%] Asian, 207 [7.9%] multiracial/other). In fully adjusted models, Black patients (odds ratio [OR], 1.3; 95% CI, 1.2-1.6) and Hispanic patients (OR, 1.5; 95% CI, 1.3-1.7) were more likely than White patients to test positive. Among those who tested positive, odds of hospitalization were similar among White, Hispanic, and Black patients, but higher among Asian (OR, 1.6, 95% CI, 1.1-2.3) and multiracial patients (OR, 1.4; 95% CI, 1.0-1.9) compared with White patients. Among those hospitalized, Black patients were less likely than White patients to have severe illness (OR, 0.6; 95% CI, 0.4-0.8) and to die or be discharged to hospice (hazard ratio, 0.7; 95% CI, 0.6-0.9).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients in a large health system in New York City, Black and Hispanic patients were more likely, and Asian patients less likely, than White patients to test positive; once hospitalized, Black patients were less likely than White patients to have critical illness or die after adjustment for comorbidity and neighborhood characteristics. This supports the assertion that existing structural determinants pervasive in Black and Hispanic communities may explain the disproportionately higher out-of-hospital deaths due to COVID-19 infections in these populations.

Assessment of internal medicine trainee sign-out quality and utilization habits

Transfers of care have been associated with adverse events. High quality sign-out may help mitigate this risk. The authors sought to characterize the clinical questions asked of physicians covering patients overnight and to determine the adequacy of current sign-out practice to anticipate inquiries. The authors conducted a prospective, self-report study of interns' overnight experience at two hospitals. We collected data from novice interns (July 7-August 3, 2010) and experienced interns (March 2-March 29, 2011) in an Internal Medicine residency program. Interns recorded information about overnight inquiries regarding cross-covered patients. For each inquiry about a patient, the intern was asked to record what the situation was about, who initiated the contact, where the intern found the desired information, whether all required data was located, whether the call could have been anticipated by the primary team, if so, whether the call was anticipated, whether the sign-out was sufficient, the time required to address the question, and whether the patient was physically visited. Twenty-one interns (13 novice, 8 experienced) reported 167 overnight inquiries. Most were from nursing staff (87%) about a wide range of topics, with orders (25%) and plan of care (20%) being most common. Trainees used the oral or written sign-out to answer 56% of inquiries. The proportion of inquiries successfully anticipated (47% overall) significantly decreased as the academic year progressed (AOR = 0.4, 95% CI 0.2, 0.8). Trainees rely on sign-out to answer nearly half of overnight inquiries, but the quality of sign-out may decrease over the course of the academic year. The deterioration of sign-out quality from novice to experienced interns and the common use of sign-out as a reference by covering interns suggest continued education, support and oversight by supervising physicians may be beneficial.

Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE)

AIM

The Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students' sign-out skills using a real-time assessment tool, the Hand-off CEX.

SETTING

Thirty-two 4th year medical students participated as part of an elective course.

PROGRAM DESCRIPTION

One week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video.

PROGRAM EVALUATION

Internal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the "Mini-CEX," which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre- and post-student self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4-9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post- vs. 27% pre-reporting 'well-prepared,' p<0.009).

DISCUSSION

This brief, standardized hand-off training exercise improved students' confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s11606-009-1170-y) contains supplementary material, which is available to authorized users.

What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff

OBJECTIVES

To characterise and assess sign-out practices among internal medicine house staff, and to identify contributing factors to sign-out quality.

DESIGN

Prospective audiotape study.

SETTING

Medical wards of an acute teaching hospital.

PARTICIPANTS

Eight internal medicine house staff teams.

MEASUREMENTS

Quantitative and qualitative assessments of sign-out content, clarity of language, environment, and factors affecting quality and comprehensiveness of oral sign-out.

RESULTS

Sign-out sessions (n = 88) contained 503 patient sign-outs. Complete written sign-outs accompanying 50/88 sign-out sessions (57%) were collected. The median duration of sign-out was 35 s (IQR 19-62) per patient. The combined oral and written sign-outs described clinical condition, hospital course and whether or not there was a task to be completed for 184/298 (62%) of patients. The least commonly conveyed was the patient's current clinical condition, described in 249/503 (50%) of oral sign-outs and 117/306 (38%) of written sign-outs. Most patient sign-outs (298/503, 59%) included no questions from the sign-out recipient (median 0, IQR 0-1). Five factors were associated with a higher rate of oral content inclusion: familiarity with the patient, sense of responsibility for the patient, only one sign-out per day, presence of a senior resident and a comprehensive written sign-out. Omissions and mischaracterisations of data were present in 22% of sign-outs repeated in a single day.

CONCLUSIONS

Sign-outs are not uniformly comprehensive and include few questions. The findings suggest that several changes may be required to improve sign-out quality, including standardising key content, minimising sign-outs that do not involve the primary team, templating written sign-outs, emphasising the role of sign-out in maintaining patient safety and fostering a sense of direct responsibility for patients among covering staff.