Jeffrey Bendix, Senior Editor

Disparities in diabetes care may be contributing to the higher rates of hospitalization and death from COVID-19 among racial and ethnic minority groups, according to a newly published 

 researchers from the US and UK reviewed existing literature comparing the prevalence and impact of COVID-19 and its comorbidities—including diabetes—among ethnic minority communities, and between those communities and whites. They cite a UK study of people with Type 1 diabetes showing that individuals from South Asian, Black, mixed, and other ethnic groups had “significantly higher” mortality risk from COVID-19 compared with white populations.

The same study showed that for people with Type 2 diabetes, the risk of in-hospital mortality was greater among Asian, Black and people of mixed ethnicity, although not among other groups in the study such as Vietnamese and Japanese.

Similarly, a multi-site observational U.S. study of COVID-19 patients with Type 1 diabetes showed that Black and Hispanic people were, on average, 3.63 times more likely to be hospitalized than non-Hispanic white patients. While results from the few existing studies of COVID-19 among ethnic minority populations are mixed, the authors say, “there is some suggestion that rates of hospitalization and mortality are higher than those of White populations.”

The authors also summarize results of studies looking at factor that may cause worse COVID-19 outcomes among ethnic minorities. These include:

Increased exposure to the disease due to minorities being overrepresented in occupations classified as essential, especially among health care workers;

Increased vulnerability to COVID-19, resulting from a higher prevalence of comorbid conditions in ethnic minority populations;

Socioeconomic factors, such as overcrowded housing and lack of access to health care;

Less effective measures for limiting community spread of COVID, due to language barriers, poor uptake or access to screening, structural discrimination, and lack of trust in the health care system; and

Biological differences. The authors note that in studies identifying risk for COVID-19 in Black, Hispanic or other minority ethnic groups, the risk remains even after adjusting for comorbidities and socioeconomic factors. “This suggests there are biological differences underlying differential responses of ethnicity to COVID-19,” they write.

The researchers observe that many of the same factors that contributed to high rates of diabetes among ethnic minorities before the pandemic also caused the disease to disproportionately affect these groups, and therefore need to be addressed.

Among these are a need for more affordable housing, equal access to educational and employment opportunities, and reducing food insecurity.

“Only by taking a long-term, holistic view of health and health care will we, and particularly our most vulnerable populations, be better able to weather future pandemics,” they conclude.

This article originally appeared on Medical Economics.

Articles

Studies tie disease to higher risk of COVID-related hospitalizations and deaths

Diabetes and Poorer COVID-19 Outcomes in Minority Communities 

Progress in treating and preventing Type 2 diabetes in the U.S. has stalled over the past decade, and regaining momentum will require a coordinated effort among lawmakers, clinicians and public and commercial payers, according to a recent article in 

Currently about 37 million Americans have diabetes, a 40% increase from 10 years ago, the article notes. Moreover, inequities in access to care and preventive services mean that Black and Hispanic adults are 1.5 to 2 times more likely to develop the disease, and significantly more likely to die from it, than are non-Hispanic white adults.

The authors say much of the backsliding in diabetes prevention and treatment is due to fragmentation in the nation’s health care system, which they define as “siloed or heterogeneous health services that occur because of the lack of unified goals, policies, incentives, and information across stakeholders.” This results in “uncoordinated and highly variable care that deviates from evidence-based recommendations, thereby undermining population health goals and equity.”

Fragmentation has been especially harmful to diabetes treatment and prevention when it comes to health policy and governance, payers and reimbursement design, and service delivery. In health policy and governance, they cite the example of division of authority between Medicare, which is a federal program, and Medicaid, where states largely control the design and implementation of the program.

“Fragmentation…at different levels diminishes accountability and coordination, both of which are necessary to prevent and manage diabetes,” they write.

An example of harmful fragmentation in the category of payers and reimbursement design, they say, is Americans’ frequent movement among health systems. This undermines those institutions’ incentives for preventive care and treatment of chronic conditions such as diabetes. The problem is exacerbated by fee-for-service reimbursements, which reward volume and high-cost services and offer little incentive for services such as nutritional counseling that patients with diabetes need.

In service delivery, the authors say, people with diabetes are harmed by the siloing of services, often finding it difficult to navigate between those provided by primary care physicians and specialists, as well as different specialties. In addition, when patients transition between health care systems, it creates a high risk of discontinuity for their personal health information due to widespread lack of information sharing. The result, they say, is “discontinuity of care, weate, and disjointed surveillance across systems and states.”

The authors offer three broad remedies for addressing the problems fragmentation creates for people with diabetes, including:

Legislating coverage for evidence-based services:

 Mandating that payers provide full coverage of specific preventive and treatment services grounded in clinical trial data, they say, “expands the reach of evidence-based preventive and therapeutic options to bend the population curve of diabetes burdens.”

Aligning incentives with high-value services:

 Central to this is moving from fee-for-service to value-based alternative payment models such as capitation. Doing so would increase providers’ incentives to offer high-value services to patients with or at risk for diabetes while reducing providers’ doctors’ administrative burdens and reducing costs for health systems.

“Compared with the US, experiences in countries with greater payer and delivery alignment are characterized by more stable coverage and access to services and medications,” they note.

Promoting continuity and quality through information management:

 “Health information sharing is a critical tool for measuring, monitoring, and rewarding improvements in outcomes,” the authors say. “However, to achieve this in the pluralistic market-based US health care landscape, over-arching government policy and regulation, along with funding support, are likely to be the only credible paths toward establishing sustainable business models that incorporate health information sharing.”

1. Chehak PK, Selvin E, DeVoe JE, Mangione CM, Ali MK. Diabetes and the fragmented state of US health care and policy. 

. 2022 Jul;41(7):939-946. doi: 10.1377/hlthaff.2022.00299. Epub 2022 Jun 27.

More financial incentives for high-value services, greater data interoperability are needed to address problem

Care Fragmentation Thwarts Progress in Diabetes Reduction

Language used to describe patients in electronic health records may be perpetuating racial bias and other negative stereotypes in health care, a new study suggests.

Using machine learning techniques, researchers analyzed potentially stigmatizing language in more than 40,000 history and physical notes in EHRs from 18,459 adult patients at an academic medical center in Chicago. They found that the odds of Black patients having one or more negative terms, such as “refused,” “(not) compliant” and “agitated” applied to them were more than twice (2.54) those of white patients, even after adjusting for sociodemographic and health characteristics.

The differences were not solely race-based. Medicare and Medicaid beneficiaries, for example, were more likely to have negative descriptors applied to them than were patients with commercial or employer-based insurance, as were unmarried patients compared to patients who were married.

The findings are especially troubling, they say, given that other studies have found that less than 20% of text in inpatient progress notes are original, with most of the rest imported from prior documentation. As a result, “subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” they write.

The researchers found that notes written for outpatient visits were less likely to have negative descriptors included in the patient’s EHR than inpatient encounters. They theorize this may result from inpatient settings being inherently more stressful, thereby increasing the risk of doctors using stereotypes as “cognitive shortcuts.”

They also found that race-based differences in the use of negative descriptors narrowed after March 1, 2020. They theorize this was due to the stark racial differences in care and outcomes highlighted by the COVID-19 pandemic, and the pandemic’s overlap with “a historically defining moment of national response to racialized state violence” created by the killings of George Floyd and other Black Americans.

“These social pressures may have sensitized providers to racism and increased empathy for the experiences of racially minoritized communities,” they note.

Fixing the problem, the authors say, will require medical institutions to better address the issue of implicit racial bias among providers. They cite the example of a physician’s use of the term “aggressive” as reflecting the physician’s personal bias regarding Black men. Once such a negative label becomes part of the patient’s record, “it potentially affects the perceptions and decisions of future providers regardless of whether future providers hold a bias about Black men being aggressive,” they note.

They also recommend that regulatory bodies, such as the Accreditation Council for Graduate Medical Education, develop specific recommendations for the use of non-stigmatizing, patient-centered language to prevent the transmission of bias.

The need is especially important, they say, in light of the OpenNotes policies medical institutions are adopting, which allow patients full access to their EHRs, including chart notes. Without paying attention to the language used to describe patients, they risk “harming the patient-provider relationship with downstream effects on patient satisfaction, trust, and even potential litigation.”

The study, “Negative Patient Descriptors” Documenting Racial Bias In The Electronic Health Record” appears in the February, 2022 issue of 

Clinicians need to avoid negative terms in describing patients

The Effect of Electronic Health Record Notes on Racial Bias

N95 and KN95 masks are the most effective in preventing the spread of COVID-19, according to 

 from the Centers for Disease Control and Prevention (CDC). At the same time, the agency continues to urge Americans to consistently use the most protective type of masking available so long as it’s comfortable and will be worn consistently.

In its latest guidance, posted on its website on January 14, the CDC ranks different types of 

 according to the level of protection they provide. “Loosely woven cloth products provide the least protection, layered finely woven products offer more protection, well-fitting disposable surgical masks and KN95s offer even more protection, and well-fitting NIOSH [National Institute for Occupational Safety and Health]-approved respirators (including N95s) offer the highest level of protection,” the guidance states.

But regardless of the type of mask chosen, the CDC adds, it should fit closely on the face and be comfortable enough when worn correctly (covering the nose and mouth) that it can be used when needed.

The updated guidance also explains the difference between masks and respirators. Masks are designed primarily to contain droplets that the wearer sneezes, breathes or coughs out, while also offering some protection from viruses spread by others.

Respirators are meant to provide protection by filtering the air and fitting closely on the face to filter out particles, but they also have some ability to contain droplets the wearer emits. “A respirator has better filtration, and if worn properly the whole time it is in use, can provide a higher level of protection than a cloth or procedural mask,” according to the guidance.

Given the greater protection respirators afford, the CDC says they “may be considered in certain situations and by certain people when greater protection may be needed or desired.” These include:

When caring for someone who is sick with COVID-19

If a person is at increased risk for severe illness, such as those who are immunocompromised, are over 65, or have certain underlying medical conditions

Working in a job that requires interacting with large numbers of the public particularly when not everyone is 

When using public transportation, such as buses, planes and trains

In crowded settings where physical distancing isn’t possible

Not being up-to-date on COVID-19 vaccinations

In a statement announcing the updates the CDC said they “reflect the science on masking, including what we have learned in the past two years, and will provide people the information they need to improve how well their 

 them. We will continue to share the science of masking as it becomes available.”

This article was originally published by Medical Economics.

With increased infectivity of Omicron, the CDC has updated the guidance on the best mask types to use.

Mask Updates: CDC Recommends N95 and KN95 

With the COVID-19 pandemic reaching an unprecedented crescendo and pediatric cases continuing to become more prominent with each new variant of the disease, an understanding of how many pediatric cases that initially present and receive testing in an emergency department experience a severe outcome or death is more important than ever. A 

 aims to find the proportion of pediatric patients who experience such outcomes within 14 days.

Investigators performed a prospective cohort study with 14-day follow-up that enrolled participants between March 2020 and June 2021. They included children and adolescents aged younger than 18 years who were tested for COVID-19 infection at an emergency department in 10 countries: Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Infection was confirmed via a polymerase chain reaction test. Severe outcomes were either the occurrence of a complication such as encephalitis or cardiac arrest or the performance of an intervention linked to a severe occurrence such as chest drainage or positive pressure ventilation, as well as death.

There were 3221 patients included in the study, with 2007 coming from the United States and 484 self-reporting a chronic illness. The median age of the cohort was 3 years. Following 14 days of follow-up, 735 children required hospitalization; 107 recorded severe outcomes; and 4 children had died. Investigators noted that there were several characteristic that were linked to severe outcomes, including being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). In a subcohort of patients who were sent home from the emergency department after being tested and completed the 14 days of follow-up, 50 were subsequently hospitalized and 12 had severe outcomes.

The investigators concluded that about 3% of pediatric patients who tested positive for COVID-19 in the emergency department had severe outcomes within 2 weeks of their initial visit. The risk was much less for children who were sent home from the emergency department than among those who were kept in the hospital. The risk factors noted such as age and underlying chronic illness could be useful when determining a patient’s clinical care.

This article was originally published on 

Funk A, Florin T, Kupperman N, et al. Outcomes of SARS-CoV-2–positive youths tested in emergency departments: the global PERN–COVID-19 study. 

. 2022;5(1):e2142322. doi:10.1001/jamanetworkopen.2021.42322

A global study examines how often severe outcomes occur within 14 days of a positive COVID-19 test occurring in an emergency department (ED).

Severe COVID-19 in Children: Study

 used in the U.S. lose some of their ability to prevent breakthrough infections over time, but they remain highly effective at preventing hospitalizations and deaths, a new study finds.

The study, a collaboration between the University of North Carolina-Chapel Hill and the North Carolina Department of Health and Human Services, sought to determine whether COVID-19 breakthrough infections are the result of waning immunity provided by vaccines or the greater transmissibility of the disease’s variants.

To find out, researchers looked at vaccination histories and health outcomes of 10.6 million North Carolina residents who received either the Pfizer, Moderna or Johnson & Johnson vaccine between December 2020 and September 2021. The data did not include outcomes from the omicron variant, which emerged after the study concluded. Results were published in the 

The researchers found that the mRNA Pfizer and Moderna vaccines, both of which require two doses, were 95% effective at lowering the risk of COVID-19 two months after the first dose. After seven months the Moderna vaccine dropped to 80% effectiveness, while the Pfizer vaccine was 67% effective. The effectiveness of both vaccines dropped significantly during June and July, when the COVID-19 Delta variant was at its height in the state.

The Johnson & Johnson adenovirus vaccine, which requires a single dose, was 75% effective after one month and 60% effective after five months. Based on these findings, the authors conclude that the reduced protection against COVID-19 infection was due to both declining immunity and the emergence of the delta variant.

However, all three vaccines have been more effective at preventing hospitalizations due to severe COVID-19. 

 reached peak effectiveness of 96% at two months and was about 90% after seven months.

Effectiveness of the Moderna vaccine was 97% and 94%, respectively, at the same points. The Johnson & Johnson vaccine peaked at 86% effectiveness at two months and was higher than 80% through six months. All three vaccines were more effective against death than hospitalization.

“The primary takeaway message from our study is that unvaccinated people should get vaccinated right away,” Danyu Lin, PhD, professor of biostatistics at the UNC Gillings School of Global Public Health said in an accompanying news release. “The results of our study also underscore the importance of booster shots, especially for older adults.”

This article was originally posted by Medical Economics.

But protection against hospitalization and death remain strong.