Disaggregating Asian Race Reveals COVID-19 Disparities Among Asian American Patients at New York City’s Public Hospital System

Objectives: Data on the health burden of COVID-19 among Asian American people of various ethnic subgroups remain limited. We examined COVID-19 outcomes of people of various Asian ethnic subgroups and other racial and ethnic groups in an urban safety net hospital system. Methods: We conducted a retrospective analysis of 85 328 adults aged ≥18 tested for COVID-19 at New York City’s public hospital system from March 1 through May 31, 2020. We examined COVID-19 positivity, hospitalization, and mortality, as well as demographic characteristics and comorbidities known to worsen COVID-19 outcomes. We conducted adjusted multivariable regression analyses examining racial and ethnic disparities in mortality. Results: Of 9971 Asian patients (11.7% of patients overall), 48.2% were South Asian, 22.2% were Chinese, and 29.6% were in other Asian ethnic groups. South Asian patients had the highest rates of COVID-19 positivity (30.8%) and hospitalization (51.6%) among Asian patients, second overall only to Hispanic (32.1% and 45.8%, respectively) and non-Hispanic Black (27.5% and 57.5%, respectively) patients. Chinese patients had a mortality rate of 35.7%, highest of all racial and ethnic groups. After adjusting for demographic characteristics and comorbidities, only Chinese patients had significantly higher odds of mortality than non-Hispanic White patients (odds ratio = 1.44; 95% CI, 1.04-2.01). Conclusions: Asian American people, particularly those of South Asian and Chinese descent, bear a substantial and disproportionate health burden of COVID-19. These findings underscore the need for improved data collection and reporting and public health efforts to mitigate disparities in COVID-19 morbidity and mortality among these groups.

Health Policy in Asia

The book assesses the policy actions of select Asian governments (China, India, Hong Kong, South Korea, Singapore and Thailand) to address critical health system functions from a policy design perspective. The findings show that all governments in the region have made tremendous strides in focussing their attention on the core issues and, especially, the interactions among them. However, there is still insufficient appreciation of the usefulness of public hospitals and their efficient management. Similarly, some governments have not made sufficient efforts to establish an effective regulatory framework which is especially vital in systems with a large share of private providers and payers. A well-run public hospital system and an effective framework for regulating private providers are essential tools to support the governance, financing, and payment reforms underway in the six health systems studied in this book.

Making sense of the French public hospital system: a network-based approach to hospital clustering using unsupervised learning methods

Background Hospitals in the public and private sectors tend to join larger organizations to form hospital groups. This increasingly frequent mode of functioning raises the question of how countries should organize their health system, according to the interactions already present between their hospitals. The objective of this study was to identify distinctive profiles of French hospitals according to their characteristics and their role in the French hospital network. Methods Data were extracted from the national hospital database for year 2016. The database was restricted to public hospitals that practiced medicine, surgery or obstetrics. Hospitals profiles were determined using the k-means method. The variables entered in the clustering algorithm were: the number of stays, the effective diversity of hospital activity, and a network-based mobility indicator (proportion of stays followed by another stay in a different hospital of the same Regional Hospital Group within 90 days). Results Three hospital groups were identified by the clustering algorithm. The first group was constituted of 34 large hospitals (median 82,100 annual stays, interquartile range 69,004 – 117,774) with a very diverse activity. The second group contained medium-sized hospitals (with a median of 258 beds, interquartile range 164 - 377). The third group featured less diversity regarding the type of stay (with a mean of 8 effective activity domains, standard deviation 2.73), a smaller size and a higher proportion of patients that subsequently visited other hospitals (11%). The most frequent type of patient mobility occurred from the hospitals in group 2 to the hospitals in group 1 (29%). The reverse direction was less frequent (19%). Conclusions The French hospital network is organized around three categories of public hospitals, with an unbalanced and disassortative patient flow. This type of organization has implications for hospital planning and infectious diseases control.

Cluster analysis of clozapine consumer perspectives and comparison to consumers on other antipsychotics

Despite its unique efficacy, clozapine remains underutilized in the United States. Perceptions about clozapine and barriers to its use have been examined among prescribers, but insufficiently studied among consumers. We surveyed 211 antipsychotic consumers (86 on clozapine and 125 on other antipsychotics) on their medication-related perspectives in a public hospital system in Atlanta, Georgia, USA. In contrast to their previous regimen, 72% of clozapine consumers reported they were more satisfied with clozapine. When compared to consumers taking other antipsychotics, clozapine consumers reported more side effects, but did not differ on other measures of satisfaction or efficacy. We found Caucasians to be overrepresented among clozapine, as compared to other antipsychotic consumers. Side effects most strongly associated with poor safety ratings were sedation, limb jerking, and dizziness when standing. However, clozapine was only rated less safe by consumers who experienced more than one of these side effects. We used an unsupervised clustering approach to identify three major groups of clozapine consumers. Cluster A (19%) had the lowest safety ratings, aversion to blood work, and a high rate of side effects that associate with lower safety ratings. Cluster B (25%) experienced more hospitalizations and reported satisfaction with clozapine that correlated with efficacy ratings, irrespective of safety ratings. Cluster C (56%) experienced fewer hospitalizations, fewer previous drug trials, greater educational attainment, lower rates of smoking, and rated clozapine more highly. This work identifies common side effects that influence subjective safety of clozapine and suggests that attitudes toward clozapine depend on context-specific factors.

Impact of a Novel Emergency Department Forward Treatment Area During the New York City COVID-19 Surge

Introduction: Coronavirus disease 2019 (COVID-19) caused a disproportionate number of patients to seek emergency care at hospitals in New York City (NYC) during the initial crisis. Our urban emergency department (ED), a member of the NYC public hospital system had to process the increased volume while also differentiating our patients’ critical needs. We established a forward treatment area (FTA) directly in front of the ED to accomplish these goals from March 23–April 16, 2020. Methods: A clinical greeter evaluated patients 18 years and older who presented to the walk-in entrance of the ED where they were screened for COVID-19-like complaints. If they did not appear critically ill and could ambulate they were directed into the FTA. Clinical and non-clinical staff worked in concert to register, evaluate, and process patients with either a disposition of directly home or into the ED for further care. Results: A total of 634 patients were seen in the FTA from March 23–April 16, 2020. Of the 634 patients evaluated, 135 (21%) were referred into the ED for further evaluation, of whom 81 (12.7% of the total) were admitted. These patients were disproportionately male (91 into the ED and 63 admitted) and tended to have a higher heart rate (105.4 vs 93.7), a higher respiratory rate (21.5 vs 18.1), and lower oxygen saturation (93.9% vs 97.8%). Conclusion: A forward treatment area is an effective method to rapidly screen and process an increased volume of COVID-19 patients when resources are limited. This treatment area helped decompress the ED by being rapidly deployable and effectively screening patients for safe discharge home.