Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine rollout: a retrospective, population-based cohort study
1. In this retrospective cohort study, ethnic minority groups were found to experience higher rates of death involving COVID-19 than the White British group during the second and third waves in England.
Evidence Rating Level: 2 (Good)
There has been a widely reported disproportionate impact of the coronavirus pandemic on ethnic minority groups. During the first and second waves in England, ethnic minority groups had higher rates of negative outcomes, which were mostly explained by geography, socioeconomic factors, and pre-existing health conditions. After the rollout of the coronavirus vaccination program, vaccine hesitancy was found to be highest among people in the Black ethnic groups; by December 2021, 3.7% of White British adults aged fifty or over had not received a COVID-19 vaccine compared with 26.2% of the Black Caribbean group and 17.4% of the Black African group. This retrospective, population-based cohort study aimed to investigate whether ethnic inequalities regarding death involving COVID-19 have continued into the third wave. Data was collected from the Office for National Statistics Public Health Data Asset, which included different datasets including the 2011 Census, mortality records, and vaccination data. Included were patients aged 30 – 100 years old at the time of the vaccine rollout, and the primary outcome was death involving COVID-19. Overall, the age-standardized mortality rates (ASMRs) for deaths involving COVID-19 were higher in all ethnic groups excluding the Chinese group for all ethnic minority groups. During the second wave, the age-adjusted hazard ratios (HRs) following adjustment for geographical factors, socioeconomic status, and pre-existing health conditions were elevated in the Bangladeshi, Pakistani, Indian, and ‘other’ groups and for men from the Black African and Black Caribbean group compared with the White British group. However, when adjusted for vaccination status, the rate of death involving COVID-19 for men from the Black Caribbean and White British groups were similar, though the excess rate remained for the Bangladeshi, Pakistani, Indian, ‘other’, and men from the Black African groups. During the third wave, similar trends were seen; after adjustment for vaccination status and other factors, HRs remained elevated for the Bangladeshi group and men from the Pakistani group when compared to the White British group, whereas rates of death involving COVID-19 for all other groups were similar to the White British group. Overall, through the rollout of the vaccination program, most ethnic groups continue to experience higher rates of death involving COVID-19 when compared to the White British group. When adjusted for other factors including vaccination status, the risk of COVID-19 mortality was similar to the White British group for all ethnic groups other than the Bangladeshi group and men from the Pakistani group. Thus, socioeconomic factors and vaccination status seem to contribute to the discrepancy between ethnic groups for risk of COVID-19 mortality. Our findings are consistent with previous studies that found ethnic inequalities in COVID-19 mortality in the first two waves of the pandemic, and our findings suggest that these inequalities have continued throughout the rollout of the vaccination program until late 2021. A major limitation of this study is that data is from the 2011 census, which may not accurately represent peoples’ situations during the COVID-19 pandemic. Further research should investigate if ethnic inequalities continue to persist past late 2021, and insight into these inequalities can contribute to future societal changes.
Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey
1. In this national survey study, the prevalence of hypertension significantly increased from 2004 – 2018 in community-dwelling adults in China.
2. Hypertension awareness, treatment, and control remained low throughout the entire study period.
Evidence Rating Level: 2 (Good)
Hypertension is a prevalent risk factor associated with negative outcomes, responsible for over 10 million deaths worldwide per year. Evidence indicates that control of hypertension leads to reductions in cardiovascular events and death. The prevalence of hypertension has declined in recent years owing to its improved treatment and control in several high-income countries. Within China specifically, large nationwide initiatives have started for further control of hypertension, but unfortunately, there is a paucity of high-quality evidence regarding the burden of hypertension in China. This retrospective study examined trends in the prevalence and number of adults with hypertension as well as awareness, treatment, and control of hypertension. Outcomes studied included presence, awareness, treatment, and control of hypertension. Data was collected from six rounds of the China Chronic Disease and Risk Factor Surveillance (CCDRFS) survey. Overall, 642 523 community-dwelling adults were included in the study from 2004 – 2018. The prevalence of hypertension increased from 24.9% (95% CI 24.4% – 25.3%) to 38.1% (37.8% – 38.3%) during the 2004 – 2018 study period. Trends in prevalence were similar in urban and rural areas for both sexes. From 2004 – 2018, hypertension awareness increased from 30.8% (28.0% – 33.6%) to 38.3% (36.3% – 40.4%), treatment rose from 25.9% (23.5% – 28.4%) to 34.6% (32.6% – 36.7%), and control rose from 7.1% (6.0% – 8.2%) to 12% (10.6% –13.4%), all of which were statistically significant (P<.001). Annual changes in awareness and treatment were higher in rural areas than in urban areas yet control in urban areas increased at a higher pace than in rural areas, though without statistical significance. Both sexes had higher awareness, treatment, and control of hypertension in urban areas than in rural areas. Overall, this study found that the prevalence of hypertension decreased overall from 2004 – 2018, and awareness, treatment, and control remained low throughout the study period. In addition, inequalities between rural and urban areas persisted with respect to the prevalence, awareness, treatment, and control of hypertension. A limitation of this study is the survey format, and non-response may lead to non-response bias affecting the results of this study. This study is an important first step to evaluate the current steps being taken to decrease the prevalence of hypertension and for future steps to identify and address the causes of this low hypertension awareness, treatment, and control.
Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection
1. In this retrospective study, non-Hispanic Black and Hispanic patients were more likely to experience a delay or discontinuation of cancer treatment or pharmacotherapy following COVID-19 infection when compared to non-Hispanic White patients,
Evidence Rating Level: 2 (Good)
The COVID-19 pandemic has disrupted oncologic screening, diagnostic, and treatment practices. Ethnic communities including the Black and Hispanic communities shoulder a disproportionate burden of poor cancer outcomes and have been found to be similarly disproportionately impacted by COVID-19. This study aimed to evaluate associations of patient-level factors and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following a positive COVID test result. Data were collected from the American Society for Clinical Oncology (ASCO) COVID-19 registry. The primary outcome of interest was delayed (≥ 14 days) or discontinued cancer treatment compared with the timely receipt of cancer treatment (on schedule or within 14 days). Overall, from April 2020 to September 2022, 4 678 patients with cancer were included in the analysis. These patients had a laboratory-confirmed SARS-CoV-2 infection. With respect to the primary outcome, non-Hispanic Black patients were more likely to experience delays or discontinuations of at least 14 days for any cancer treatment (RR, 1.35 [95% CI, 1.22-1.49]; P<.001) and pharmacotherapy (RR, 1.37 [95% CI, 1.23-1.52]; P<.001) relative to non-Hispanic White patients. Hispanic patients had a higher likelihood of delay or discontinuation of any cancer treatment (RR, 1.14 [95% CI, 1.00-1.28]; P=.04) and pharmacotherapy (RR, 1.17 [95% CI, 1.03-1.33]; P=.02) compared to non-Hispanic White patients though this was not significant with multiple comparisons correction. Race and ethnicity were not associated with surgery or radiotherapy delays or discontinuation. Sex and age were not associated with delay or discontinuation of any treatment mortality. Area-level SDOHs were also not associated with delayed or discontinued surgery, pharmacotherapy, and radiotherapy. The time to restart pharmacotherapy was 19% longer (HR, 0.81 [95% CI, 0.67-0.97]; P=.03) for non-Hispanic Black than non-Hispanic White patients. The findings from this study highlight that non-Hispanic Black patients and Hispanic patients are more likely to experience delay or discontinuation of cancer treatment or pharmacotherapy when compared to non-Hispanic White patients. A limitation of this study was the exclusion of decreased patients, as it contributed to selection biased given the differences that were observed between decreased patients and those in the analytical sample. This study was an important analysis of the consequences of the COVID-19 pandemic on cancer treatment, especially in ethnic minority groups, and will hopefully inspire further research into these racial inequalities.
Addition of preoperative transversus abdominis plane block to multimodal analgesia in open gynecological surgery: a randomized controlled trial
1. In this randomized controlled trial, adding a transversus abdominis plane (TAP) block to the multimodal analgesia protocol decreased the rescue morphine use compared to patients who did not receive the TAP block in patients receiving elective open gynecologic surgery
Evidence Rating Level: 1 (Excellent)
Enhanced recovery after surgery (ERAS) protocols are designed to minimize stress created by surgery and to improve patient recovery following surgery. Most ERAS pathways avoid opioid use with multimodal pain management, which can lead to decreased opioid-related adverse effects such as nausea and vomiting. Ultrasound-guided transversus abdominis plane (TAP) block is performed by injecting local anesthetic between muscle layers of the trunk and has been performed in various abdominal surgeries as a pain relief tool. Open gynecological surgeries have been known to cause moderate to severe postoperative pain, and this randomized controlled trial aimed to investigate whether adding TAP block to a multimodal analgesia (MMA) protocol would confer additional benefits after open gynecologic surgery. 63 patients were enrolled in this study between November 2020 and August 2021 and randomized in a 1:1 ratio to receive a TAP block with either 20 mL ropivacaine 0.375% or the same volume of 0.9% saline. The primary outcome measured was rescued morphine within 24 hours following surgery. In the first 24 hours postoperatively, the study group had significantly less rescued morphine than the control group (P=.013). The study group also had statistically lower NRS pain scores at 1, 2, and 6 hours, and a lower incidence of nausea at 48 hours compared with the control group. Otherwise, there was no significant difference in the pain scores at 24 and 48 hours, as well as the incidence of vomiting or need for rescue anti-emetics. The findings from this study demonstrate the benefit of preoperative TAP block when used as part of MMA for open gynecologic surgery, resulting in less use of rescue morphine within the first 24 hours postoperatively. However, a limitation of this study includes that the TAP block was performed after anesthesia induction, so the range of the block could not be assessed. The findings from this study are an excellent first step in improving MMA for patients undergoing open gynecologic surgery, and further research should investigate ideal concentrations of local anesthetic for TAP blocks in this context to confer the greatest effect.
Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care
1. In this retrospective cohort study, emergency departments (EDs) in the United States with high levels of ED pediatric readiness were associated with lower short-term and long-term mortality among a heterogenous group of hospitalized children receiving emergency care.
Evidence Rating Level: 2 (Good)
There are more than 30 million ED visits by children each year in the United States, and more than 97% of emergency departments caring for children are nonchildren’s hospitals, accounting for approximately 83% of pediatric ED visits. The National Pediatric Readiness Project (NPRP) was created as a national quality improvement initiative to improve the quality and consistency of pediatric care in EDs in the United States. High levels of ED pediatric readiness are associated with lower mortality among children with critical illness. Previous research has found an association between high ED pediatric readiness and survival to 1 year in trauma centers but not in other pediatric populations. This retrospective cohort study aims to evaluate the association between ED pediatric readiness and in-hospital and 1-year mortality among injured and medically ill patients receiving emergency care in the United States. Included were pediatric patients receiving emergency care in 983 Eds from January 1, 2012, to December 31, 2017. The primary outcome studied was in-hospital mortality including deaths in the ED. Overall, 796937 pediatric patients were hospitalized and met the inclusion criteria within the previously stated time. With respect to the primary outcome, the adjusted odds of dying in the hospital were 60% lower among children cared for in high-readiness EDs in the injury cohort (wPRS quartile 4 vs 1, adjusted odds ratio [aOR], 0.40; 95% CI, 0.26-0.60) and 76% lower in the medical cohort (aOR, 0.24; 95% CI, 0.17-0.34). The benefit of care in high pediatric readiness EDs was evident across all age groups. Even after accounting for ED structure, pediatric volume, ED admission volume, hospital type, and trauma level, the association between high pediatric readiness EDs and lower mortality remained. Overall, the findings of this cohort study suggest that a high level of ED pediatric readiness was associated with lower short-term and long-term mortality among a heterogenous group of hospitalized children receiving emergency care, A limitation of the study is the inclusion of only 11 states and the exclusion of low-volume EDs, which may have affected the findings. This study shows evidence of the consequences of low ED pediatric readiness and is an important step toward improving ED pediatric readiness across the United States.
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