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Kelly MS, Mohammed A, Okin D, Alba GA, Jesudasen SJ, Flanagan S, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Witkin AS, Hibbert KA, Kadar A, Gordan PL, Bebell LM, Hauptman M, Valeri L, Lai PS. Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19. Crit Care Explor 2023; 5:e0927. [PMID: 37332365 PMCID: PMC10270487 DOI: 10.1097/cce.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
Which social factors explain racial and ethnic disparities in COVID-19 access to care and outcomes remain unclear. OBJECTIVES We hypothesized that preferred language mediates the association between race, ethnicity and delays to care. DESIGN SETTING AND PARTICIPANTS Multicenter, retrospective cohort study of adults with COVID-19 consecutively admitted to the ICU in three Massachusetts hospitals in 2020. MAIN OUTCOME AND MEASURES Causal mediation analysis was performed to evaluate potential mediators including preferred language, insurance status, and neighborhood characteristics. RESULTS Non-Hispanic White (NHW) patients (157/442, 36%) were more likely to speak English as their preferred language (78% vs. 13%), were less likely to be un- or under-insured (1% vs. 28%), lived in neighborhoods with lower social vulnerability index (SVI) than patients from racial and ethnic minority groups (SVI percentile 59 [28] vs. 74 [21]) but had more comorbidities (Charlson comorbidity index 4.6 [2.5] vs. 3.0 [2.5]), and were older (70 [13.2] vs. 58 [15.1] years). From symptom onset, NHW patients were admitted 1.67 [0.71-2.63] days earlier than patients from racial and ethnic minority groups (p < 0.01). Non-English preferred language was associated with delay to admission of 1.29 [0.40-2.18] days (p < 0.01). Preferred language mediated 63% of the total effect (p = 0.02) between race, ethnicity and days from symptom onset to hospital admission. Insurance status, social vulnerability, and distance to the hospital were not on the causal pathway between race, ethnicity and delay to admission. CONCLUSIONS AND RELEVANCE Preferred language mediates the association between race, ethnicity and delays to presentation for critically ill patients with COVID-19, although our results are limited by possible collider stratification bias. Effective COVID-19 treatments require early diagnosis, and delays are associated with increased mortality. Further research on the role preferred language plays in racial and ethnic disparities may identify effective solutions for equitable care.
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Affiliation(s)
- Michael S Kelly
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Adna Mohammed
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Daniel Okin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - George A Alba
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Shelby Flanagan
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- New England Pediatric Environmental Health Specialty Unit, Boston, MA
| | - Nupur A Dandawate
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Alexander Gavralidis
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emily E Moin
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alison S Witkin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kathryn A Hibbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Marissa Hauptman
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Linda Valeri
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Peggy S Lai
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Intensive Care and Organ Support Related Mortality in Patients With COVID-19: A Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0876. [PMID: 36890875 PMCID: PMC9988289 DOI: 10.1097/cce.0000000000000876] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support. DATA SOURCES A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021. STUDY SELECTION Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients. DATA EXTRACTION Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included. DATA SYNTHESIS One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021. CONCLUSIONS We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.
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Radovanovic D, Santus P, Coppola S, Saad M, Pini S, Giuliani F, Mondoni M, Chiumello DA. Characteristics, outcomes and global trends of respiratory support in patients hospitalized with COVID-19 pneumonia: a scoping review. Minerva Anestesiol 2021; 87:915-926. [PMID: 34036769 DOI: 10.23736/s0375-9393.21.15486-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION To date, a shared international consensus on treatment of Coronavirus Disease 2019 (COVID-19) with invasive or non-invasive respiratory support is lacking. Patients' management and outcomes, especially in severe and critical cases, can vary depending on regional standard operating procedures and local guidance. EVIDENCE ACQUISITION Rapid review methodology was applied to include all the studies published on PubMed and Embase between December 15th 2019 and February 28th 2021, reporting in-hospital and respiratory support-related mortality in adult patients hospitalized with COVID-19 that underwent either continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV). Only English language studies with ≥100 patients and reporting data on respiratory failure were included. Data on comorbidities, ventilatory parameters and hospital-related complications were registered. EVIDENCE SYNTHESIS Fifty-two studies (287359 patients - 57.5% males, mean age 64 years (range 24-98)) from 17 different countries were included in the final analysis. 33.3% of patients were hospitalized in intensive care units. 44.2% had hypertension, 26.1% had diabetes, and 7.1% a chronic respiratory disease. 55% of patients underwent respiratory support (36% IMV, 62% NIV and 2% CPAP). Without considering a study with the highest number of patients treated with NIV (n=96729), prevalence of NIV and CPAP use was 12.5% and 13.5% respectively. Globally, invasive and non-invasive approaches were heterogeneously applied. In-hospital mortality was 33.7%, and IMV-related mortality was 72.6% (range: 4.3%-99%). Specific mortality in patients treated with CPAP or NIV was available for 53% of studies, and was 29% (range: 7.2%-100%). The median length of hospital stay was 13 days (range: 6-63). The most frequent hospital-related complication was acute kidney injury being reported in up to 55.7% of enrolled patients. CONCLUSIONS Global employment of respiratory supports and related outcomes are very heterogeneous. The most frequent respiratory support in patients with COVID-19 pneumonia is IMV, while NIV and CPAP are less frequently and equally applied, the latter especially in Europe, while data on NIV/CPAP-related mortality is often under-reported. Integrated and comprehensive reporting is desirable and needed to construct evidence-based recommendations.
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Affiliation(s)
- Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milano, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Stefano Pini
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Fabio Giuliani
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Milano, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Davide A Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milano, Italy - .,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milano, Italy
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Savel RH, Kupfer Y, Shiloh AL. Steady As She Goes: Practicing Evidence-Based Critical Care When the Evidence Is Limited. Chest 2021; 159:7-8. [PMID: 33422231 PMCID: PMC7787062 DOI: 10.1016/j.chest.2020.09.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Richard H Savel
- Adult Critical Care Service, Maimonides Medical Center and Clinical Medicine & Neurology, SUNY Downstate College of Medicine, Brooklyn, NY.
| | - Yizhak Kupfer
- Medical Critical Care, Medical ICU, Critical Care Fellowship, Maimonides Medical Center and Clinical Medicine, SUNY Downstate College of Medicine, Brooklyn, NY
| | - Ariel L Shiloh
- Critical Care Consult Service, Montefiore Medical Center, and Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
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