Impact of Race and Socioeconomic Status on Outcomes in Patients Hospitalized with COVID-19

BackgroundThe impact of race and socioeconomic status on clinical outcomes has not been quantified in patients hospitalized with coronavirus disease 2019 (COVID-19).ObjectiveTo evaluate the association between patient sociodemographics and neighborhood disadvantage with frequencies of death, invasive mechanical ventilation (IMV), and intensive care unit (ICU) admission in patients hospitalized with COVID-19.DesignRetrospective cohort study.SettingFour hospitals in an integrated health system serving southeast Michigan.ParticipantsAdult patients admitted to the hospital with a COVID-19 diagnosis confirmed by polymerase chain reaction.Main MeasuresPatient sociodemographics, comorbidities, and clinical outcomes were collected. Neighborhood socioeconomic variables were obtained at the census tract level from the 2018 American Community Survey. Relationships between neighborhood median income and clinical outcomes were evaluated using multivariate logistic regression models, controlling for patient age, sex, race, Charlson Comorbidity Index, obesity, smoking status, and living environment.Key ResultsBlack patients lived in significantly poorer neighborhoods than White patients (median income: $34,758 (24,531–56,095) vs. $63,317 (49,850–85,776), p < 0.001) and were more likely to have Medicaid insurance (19.4% vs. 11.2%, p < 0.001). Patients from neighborhoods with lower median income were significantly more likely to require IMV (lowest quartile: 25.4%, highest quartile: 16.0%, p < 0.001) and ICU admission (35.2%, 19.9%, p < 0.001). After adjusting for age, sex, race, and comorbidities, higher neighborhood income ($10,000 increase) remained a significant negative predictor for IMV (OR: 0.95 (95% CI 0.91, 0.99), p = 0.02) and ICU admission (OR: 0.92 (95% CI 0.89, 0.96), p < 0.001).ConclusionsNeighborhood disadvantage, which is closely associated with race, is a predictor of poor clinical outcomes in COVID-19. Measures of neighborhood disadvantage should be used to inform policies that aim to reduce COVID-19 disparities in the Black community.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06527-1.KEY WORDS: COVID-19, disparities, disadvantage, socioeconomic status, race     

Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion

Context

 Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care.

Objective

 To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution''s sports medicine department, the clinician''s sex, and other factors.

Design

 Cross-sectional study.

Setting

 Web-based survey of National College Athletic Association member institutions.

Patients or Other Participants

 A total of 789 athletic trainers and 111 team physicians from 530 institutions.

Main Outcome Measure(s)

 We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions'' sports medicine departments, and the division of competition in which their institutions participate.

Results

 We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did.

Conclusions

 Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.Key Words: conflict of interest, organizational structure, sex, college

Key Points

• More than half of sports medicine clinicians had experienced pressure from coaches and athletes to return athletes to participation prematurely after a concussion.
• Clinicians experienced greater pressure from coaches at schools where the sports medicine department reported to the athletic department than at schools where the sports medicine department reported to an independent medical institution.
• Female clinicians experienced greater pressure from coaches than male clinicians experienced.
• More research is needed to determine how pressure affects clinical practice and whether pressure on clinicians affects return-to-participation decisions.

Addressing the health burden of mild traumatic brain injury from sport is increasingly considered a public health priority.¹ More than 450 000 college students participate in organized interscholastic sports each year.^2,3 Among collegiate athletes in contact and collision sports, Daneshvar et al⁴ estimated that 43 concussions are sustained per 100 000 athlete-exposures to a game or practice, which is nearly twice the rate of diagnosed concussions sustained by high school athletes competing in the same sports. This estimate likely understates the true incidence of concussions because many are undiagnosed.^5–8 Recent evidence^9–14 has suggested that repeated concussive and subconcussive brain trauma can lead to neurologic problems later in life, including changes in cognition and behavior.Conflict of interest in the care of concussed athletes is a topic of growing ethical discourse.^15–19 Writing for the Chronicle of Higher Education about US collegiate sport, Wolverton²⁰ painted a picture of colleges fraught with pressure on physicians and athletic trainers (ATs) from coaches and athletic administrators. A total of 101 clinicians who provide patient care for football teams in the National Collegiate Athletic Association (NCAA) Division I Football Bowl Subdivision participated in the non–peer-reviewed study, and more than half reported that they had “felt pressure from football coaches to return concussed players to action before they were medically ready.”²⁰ Some of this pressure was attributed to conflicts of interest inherent in the organizational structure and incentives of sports medicine departments. In some instances, ATs reported directly to head football coaches.²⁰ Even in substantially lower-stakes youth sports, Bramley et al²¹ reported that a sample of hockey coaches indicated they would be more likely to allow an athlete who had sustained a concussion to continue participating if the game was considered important, such as for a championship. Consequently, clinicians in collegiate sports medicine departments may find themselves in a challenging situation: having ethical responsibilities to provide appropriate medical care to their patients while facing perceived or real pressure from their employers to return athletes to participation.^15–19,22 In a survey of sports medicine physicians in New Zealand, Anderson and Gerrard²³ observed that whereas all respondents expressed a sense of responsibility to their athlete patients, 72% also believed they had a responsibility to the team coach, and 55% believed they had a responsibility to team management.The National Athletic Trainers'' Association recently released a consensus statement detailing best practices for sports medicine management in secondary schools and colleges, including the advantages and disadvantages of different models of supervisory relationships in sports medicine.²⁴ Supervisory models in which ATs or team physicians are employed by athletic departments are described as having the potential for conflict of interest in the medical care provided to athletes. Pecci and Laursen²⁵ and Laursen²⁶ have advocated for sports medicine departments to be nested within medical units, such as university health centers, rather than athletic departments. They suggested that this organizational structure would reduce real and perceived conflicts of interest in the care of athletes and would have additional benefits, such as easier access to other health care providers and more centralized oversight of medical care.^25,26 Whereas these arguments are intuitive, no researchers have conducted an empirical evaluation of whether supervisory structure is systematically associated with different types of pressure on clinicians regarding the care of collegiate athletes who have sustained concussions.Another potentially important variable that could modify the pressure that clinicians experience is their sex. Approximately half of all ATs are women, but women represent only about one-quarter of full-time staff ATs and only 1 in 8 head ATs in collegiate sports medicine departments.^27–30 Some investigators³¹ have suggested that male and female ATs may have different experiences interacting with coaches and other ATs in the collegiate athletic environment. Mazerolle et al³¹ conducted qualitative interviews with 14 female NCAA Division I ATs and described how they “often encountered gender discrimination when working with a team sport coached by a man.” They described a perception that coaches view female ATs as “more sympathetic and less pragmatic” than male ATs and that this judgment undermines the coaches'' confidence in the care they provide athletes. This differential perception is reinforced by 2 surveys^32,33 in which male collegiate athletes reported being more comfortable receiving care from male ATs. Stereotypical judgments about women in the workplace tend to be strongest when women are an underrepresented minority, as is the case with female ATs in collegiate sports environments, and can inform the control strategies of individuals in positions of power.³⁴ Quantifying the extent to which pressure is experienced in the care of concussed athletes and whether it is modified by clinician characteristics such as sex are important steps in understanding whether institution-level intervention is needed.Therefore, the purpose of our study was to obtain empirical evidence about whether clinicians who provide care to US collegiate sports teams experienced pressure to prematurely clear athletes for participation after a concussion. We hypothesized that clinicians in sports medicine departments reporting to the athletic department would experience greater pressure from coaches and athletes than clinicians in departments reporting to medical institutions and that female clinicians would experience greater pressure from coaches and athletes than male clinicians would experience.     

Self-Rated Health Among Saudi Adults: Findings from a National Survey, 2013

Self-rated health reflects a person’s integrated perception of health, including its biological, psychological, and social dimensions. It is a predictor of morbidity and mortality. To assess the current status of self-rated health and associated factors in the Kingdom of Saudi Arabia, we analyzed data from the Saudi Health Interview Survey. We conducted a large national survey of adults aged 15 years or older. A total of 10,735 participants completed a standardized health questionnaire. Respondents rated their health with a five-point scale. Data on socio-demographic characteristics, chronic diseases, health-related habits and behaviors, and anthropometric measurements were collected. Associated factors of self-rated health were analyzed using a backward elimination multivariate logistic regression model. More than 77 % of respondents rated their health as excellent/very good. Female sex [odds ratio (OR) 1.52, 95 % confidence interval (CI) 1.24–1.88], decades of age (OR 1.35, 95 % CI 1.25–1.46), diagnosed diabetes mellitus (OR 1.54, 95 % CI 1.22–1.93), diagnosed hypercholesterolemia (OR 1.37, 95 % CI 1.06–1.79), diagnosed hypertension (OR 1.55, 95 % CI 1.22–1.96), number of other diagnosed chronic diseases (OR 1.69, 95 % CI 1.41–2.03), limited vigorous activity (OR 3.59, 95 % CI 2.84–4.53), need for special equipment (OR 2.62, 95 % CI 1.96–3.51), and more than 3 h of daily television/computer screen time (OR 1.59, 95 % CI1.11–2.29) were positively associated with poor/fair health. Smoking, obesity, and physical inactivity were not associated with self-reported health. We found that preventable risk factors are not associated with Saudis’ self-rated health. This optimistic perception of health poses a challenge for preventive interventions in the Kingdom and calls for campaigns to educate the public about the harm of unhealthy behaviors.     

Coronary artery disease is associated with the ratio of apolipoprotein A-I/B and serum concentration of apolipoprotein B, but not with paraoxonase enzyme activity in Iranian subjects

To determine the association of serum apolipoprotein (apo) A-I and B concentrations, and paraoxonase (PON) high-density lipoprotein (HDL) associated enzyme activity with angiographically determined coronary artery disease (CAD) in Iranian diabetic and non-diabetic CAD patients and non-diabetic control subjects, 251 subjects aged 30-70 years, who underwent their first coronary angiography were matched and randomly assigned into three groups: CAD(+)DM(+), CAD(+)DM(-), and CAD(-)DM(-) (control). Stenosis of > or =50% in one or more coronary arteries was classified as CAD(+). CAD(-) was defined as a maximum stenosis of 10% in any coronary artery. Fasting serum concentrations of cholesterol (TC), triglycerides (TGs), LDL-C, HDL-C, apo A-I/B and PON activity were determined. Apolipoprotein concentrations were measured in a fasting serum sample by immunoturbidometric assay and paraoxonase/arylesterase activities by spectrophotometric assay of p-nitrophenol/phenol production following addition of paraoxon/phenylacetate. Information concerning non-lipid risk factors were collected by questionnaires. No significant difference was observed in HDL-C, LDL-C, apo A-I, and PON/arylesterase activity between the study groups. The values of TC (213+/-38 vs 196+/-45, P<0.05), TGs (209+/-187 vs 151+/-113, P<0.01), apo B (99+/-22 vs 96+/-24, P<0.0001), TC/HDL-C (4.8+/-1.5 vs 4.0+/-1.3, P<0.001) and LDL-C/HDL-C (2.9+/-1.1 vs 2.4+/-1.1, P<0.05) were higher and apo A-I/B (1.7+/-0.4 vs 2.0+/-0.6, P<0.01) was lower in CAD(+)DM(+) patients than in control subjects. In CAD(+)DM(-) group, only the level of apo B (96+/-24 vs 85+/-18, P<0.01), and the ratio of apo A-I/B (1.8+/-0.4 vs 2.0+/-0.6, P<0.01), were significantly higher than those of control group. On multiple logistic regression analysis, the best markers for discrimination between CAD(+) groups and CAD(-) control subjects were the ratio of apo A-I/B in diabetic and apo B in non-diabetic patients. The results suggest that in Iranian diabetic and non-diabetic patients with CAD the concentration of apolipoproteins are better markers than traditional lipid parameters in discriminating between CAD(+) and CAD(-) subjects. Lack of significant difference in PON activity between CAD patients and CAD(-) controls supports the concept of interethnic variability in PON polymorphism and unimodal distribution of its activity in non-Europid populations observed in other studies.     

Short-term survival of the trabecular metal cup is similar to that of standard cups used in acetabular revision surgery: Analysis of 2,460 first-time cup revisions in the Swedish Hip Arthroplasty Register

Background and purpose — The use of trabecular metal (TM) cups in revision surgery has increased worldwide during the last decade. Since the introduction of the TM cup in Sweden in 2006, this design has gradually replaced other uncemented designs used in Sweden. According to data from the Swedish Hip Arthroplasty Register (SHAR) in 2012, one-third of all uncemented first-time cup revisions were performed using a TM cup. We compared the risk of reoperation and re-revision for TM cups and the 2 other most frequently used cup designs in acetabular revisions reported to the SHAR. The hypothesis was that the performance of TM cups is as good as that of established designs in the short term.

Patients and methods — The study population consisted of 2,384 patients who underwent 2,460 revisions during the period 2006 through 2012. The most commonly used cup designs were the press-fit porous-coated cup (n = 870), the trabecular metal cup (n = 805), and the cemented all-polyethylene cup (n = 785). 54% of the patients were female, and the median age at index revision was 72 (19–95) years. Reoperation was defined as a second surgical intervention, and re-revision—meaning exchange or removal of the cup—was used as endpoint. The mean follow-up time was 3.3 (0–7) years.

Results — There were 215 reoperations, 132 of which were re-revisions. The unadjusted and adjusted risk of reoperation or re-revision was not significantly different for the TM cup and the other 2 cup designs.

Interpretation — Our data support continued use of TM cups in acetabular revisions. Further follow-up is necessary to determine whether trabecular metal cups can reduce the re-revision rate in the long term, compared to the less costly porous press-fit and cemented designs.     

Persistence of hepatitis B vaccine immunity in hemodialysis patients

Although the efficacy of hepatitis B vaccines in patients undergoing chronic hemodialysis (HD) treatment has been documented, the persistence of immunity in this population remains largely unknown. In this study we evaluated the persistence of hepatitis B vaccine immunity in HD patients. We followed 37 hepatitis B vaccinated HD patients (following a four-dose vaccination schedule of 40 mug injections intramuscularly in the deltoid muscle at 0, 1, 2, and 6 months) for up to one year to evaluate the persistence of immunity (as indicated by serum levels of hepatitis B surface antibody (anti-HBs) equal to or higher than 10 IU/L). One year after vaccination, 18.9% of patients had lost their anti-HBs (transient responders), while 81.1% still had detectable antibodies in the serum (persistent responders). From 81.1% of persistent responders 11.5% and 88.5% were weak and high responders, respectively. There was no significant difference between persistent and transient responders regarding age, sex, or nutritional factors. We did not find any factors that related to maintaining protective levels of anti-HBs in HD patients. It seems that an antibody titer above 100 IU/L following vaccination is necessary in order to maintain that level of antibody one year later.