key: cord-0802117-w7bsxnkv
authors: Pieper, Sarah
title: COVID-19: Salt in the Wound of Health Care Inequality and the Cause of a New Healthcare Disparity
date: 2021-08-13
journal: Physician Assist Clin
DOI: 10.1016/j.cpha.2021.08.009
sha: aac67c7b05be0f4889fc0ccb0721d4d04b957549
doc_id: 802117
cord_uid: w7bsxnkv

The year 2020 will forever be associated with a new chapter in the history of global health, COVID-19. However, this new chapter would have a similar message as many other chapters written before it. The COVID-19 pandemic would disproportionately affect minorities, those of low socioeconomic class, and those with limited access to health care. However, this would also bring about a new health care disparity, the affect COVID-19 would have on those with non- COVID related medical needs.

hesitancy to receive medical care due to the risks of contracting COVID-19 have on overall outcomes and mortality for non-COVID related medical conditions? and Race: Salt in an Already Open Wound of Health Care Disparity

We know COVID-19 did not create health care inequalities but it has put salt in the open wound of health care inequality among racial groups in the United States. Just as the measles epidemic in 1989-1991, just like yellow fever epidemic in 1792, COVID-19 would write a new page in public health with the same message. It would disproportionately impact those of color. Per the CDC statistics 1 from November of 2020, cases of COVID-19 would be 2.6 x higher in African Americans than White, non-Hispanic persons. Hospitalizations would be 4.6 x higher and deaths would be 2.1 x higher among African Americans than white non-Hispanic persons. The higher rates of cases, hospitalizations, and death from COVID-19 would also be higher among American Indian/Alaskan Natives and Hispanic/Latino persons. See Figure 1 and Figure 2 from CDC surveillance data. As of Nov 13, 2020, the most up to date CDC surveillance data for rate of hospitalization is as follows. Demonstrating the disproportionate complications in people of color 1  465.4 / 100,000 for Hispanic or Latino.  459.3/100,000 for American Indian or Alaskan Native,  429.3/100,000 for Non-Hispanic Black,  114.6/100,000 for non-Hispanic White.

In a retrospective cohort study reported in an article published in the Journal of Racial and Ethical Health Disparities 2 data demonstrates higher rates of hospitalization and mortality in racial minorities with COVID-19. This study looked at 734 hospitalized patients from 3/10/20-4/13/20 in their affiliated NYC hospitals. Data demonstrated that Blacks in Brooklyn were twice as likely to require hospitalization for COVID-19 (42.9/100,000) compared with White patients (22.7/100,000). Hispanics had an increased risk of in-patient mortality (HR 1.84; 95 % Cl 1.21-2.80; p=0.005) along with Asian patients (HR 2.06; 95% Cl 1.08-3.93; p=0.03). Blacks were also disproportionally a higher percentage of the COVID-19 related deaths compared to White patients.

 It is known, that people of color may not trust their medical provider or medical system. We need to increase our cultural understanding with institutional training engaging all medical professionals. 4  Encourage a safe environment that embraces cultural humility.  Advocate for funding, education, research, and government initiatives aimed specifically at COVID-19 related barriers to care for minorities such as access to testing 5 .

Many argue that the reason for the staggering statistics among America's ethnic minorities are due to higher rates of comorbidities that are known to put those who contract COVID-19 at higher risk of mortality, hospitalization, and complications from COVID-19. Some argue that it is due to access to care, lack of insurance, or lack of access to testing. Some argue that it is due to their rate of low socioeconomic status and higher rates of minorities working in essential jobs that do not allow them to stay at home and thus put them at higher risk for contracting COVID-19. We can see that the reasons for this health care disparity is multifactorial, complex, and will take a multidisciplinary effort to improve.

In an article calling for action against health inequality with COVID-19 related disparities the potential reasons for this disparity are discussed as well as the multidisciplinary actions that need to occur in order to help heal this wound. 4 They note that people of color are likely to suffer more job loss due to the strains of the pandemic on the economy as 16.8% of Black workers and 17.6 % of Hispanic workers are employed in jobs most at risk due to the state of the economy. With this effect on employment, this could further affect more people of color losing their insurance; lack of insurance is a deterrent to seek medical care. People of color receive better care when cared for by providers of the same cultural identity; however, for example, 12% of the US population is Black but 5% of health care providers are Black. To combat this, it is recommended to form partnerships between schools to educate and expose students to health care occupations in their community. (citation?) As well as advocating with local political leaders, hospital administrators to aide in providing mentorship, and financial incentives to reduce economic hardship/barriers to get an education. One such example is the National COVID 19 Dislocated Worker Grant, which provides funds that many Americans are using towards education and learning new skills, improving that chance of employment 3

Due to numerous factors such as implicit bias by the medical community and prior history of people of color being failed by the medical system, a lot of people of color distrust medical treatment and medical providers. 4 This distrust can lead impact the community's perception of risk leading to myths, misconceptions of risk, and leads to less community involvement in safety measures such as wearing a mask or social distancing. To combat this, recommended interventions include: 4

 better training programs for healthcare professionals that represent the cultural makeup of the local communities they serve.

J o u r n a l P r e -p r o o f  Trainings at the institutional and individual level that seek to combat racism, implicit bias, and microaggressions  Polices in place that mandate interactive trainings for all staff that not only engage professionals, but also recognize the role of social determinants of health.  Clinicians and health care staff must nurture an environment that embraces cultural humility.  We must be advocates for research and funding geared toward patients that experience implicit bias and disparity in healthcare.

An article published in the American Journal of Public Health 5 , offered strategies combat barriers to care for those with COVID-19 in minority communities. With increased testing initiatives during the pandemic, access to testing has not been equivalent across races. Drive in testing and telehealth screenings have not been accessible due to lack of technology or transportation. Cost of care continues to be a barrier despite Medicaid/Medicaid and The Families First Coronavirus Response Act. A visit to the Emergency Room, beyond testing for COVID-19, can still lead to medical bills, deterring those in the community from seeking care. Partnerships among academic institutions and community organizations to fast track screening sites and resource testing centers in areas of need are recommended. There should also be a standard approach to counseling, educating patients of racial communities about health risks to contracting COVID 19, and making sure living conditions are discussed with those that do test positive for COVID-19. It also advised that the United States have been researched and drafted COVID-19 response and treatments primarily from China and Italy, two countries with populations racially unlike the US. We need to take a closer look at COVID-19 treatment, response strategies with our own data or with countries that have populations more like that of the US.

Patient X was diagnosed with Stage IV rectal melanoma in May, patient X had to wait 2 months for her colonoscopy which would ultimately make her diagnosis. Because of a delay in diagnosis she suffered a delay in surgical intervention, immunotherapy, and radiation treatment for her aggressive cancer. She would also find herself in an ER and then admitted to the hospital due to complications that could have been avoided had her diagnosis been made sooner. How many other patients faced similar experiences? According to a study done by the Epic Health Research Network 6 , the number of screening appointments for cervical, breast, and colon cancer was 86 %-94% lower in the early months of the pandemic than in prior years. In an opinion piece 6 in the New York Times from September 2020, Dr. Farrugia (president and CEO of the Mayo Clinic) advised that "in the case of cancer alone, our calculations show we can expect a quarter of a million additional preventable deaths annually if normal care does not resume." In the same opinion piece, Suzanne Steinbaum, DO, a preventive cardiologist and volunteer medical expert for the American Heart Association stated: "I'm seeing patients with preexisting heart problems who've gotten worse and had increases in blood pressure or blood sugar during the shelter in place. Even women without heart problems were eating and sleeping poorly, skipping exercise, and under lots of stress-all of which can contribute to heart disease, the leading cause of death in women in the U.S."

In May of 2020, canceled/postponed elective surgeries, outpatient procedures, and clinic appointments starting in March were recommended by the US surgeon general, the CDC, numerous medical societies, and state orders across the US. 7 A CDC report compared ER visits in April of 2020 with 2019 data, numbers of those presenting to the ED with nonspecific chest pain, MI decreased. ER visits for common atypical symptoms of MI also decreased. 9 Analysis of CDC data demonstrated that, in New York and New Jersey from March 15 to May 2 of 2020, 6000 more people died of an MI and 800 more people died of complications from DM than the same time frame in prior years.

In the UK during lockdown, the public message was to stay at home, leaving home for only essential needs just as it was in the US. In the UK and the US in March during the time of lockdown, there was much anxiety among the general public especially those with pre-existing conditions. In England alone, there was 29 % fewer Emergency Department attendances. The Office for National Statistics reported the highest death rate in England and Wales since the year 2000. There were 6082 more deaths than the five-year average and only 3475 of these deaths were related to COVID-19. 8 Raising more alarm that increased number of deaths were occurring unrelated to COVID-19 due to the strain on J o u r n a l P r e -p r o o f the health care system due and public resistance to see medical attention due to concerns for contracting COVID-19.

The use of telehealth and virtual visits have proven helpful for many people seeking non-urgent medical care. However, high risk populations such as minorities and the elderly may not have access to them. High literacy in technology, the internet, access to technology capable of accessing telemedicine are needed; which at risk patients may have difficulty to accessing. 10 The Israeli' Center for Disease Control recommends raising awareness, using media campaigns calling for patient to not neglect acute or chronic medical needs or screenings. 10 They also recommend calling patients in your practice or community who are known to be at risk are also equally important to promote community health for COVID-19 related practices and non COVID related medical needs like screening and medical appointments. 10 In the spring at the start of the pandemic, many hospitals asked patients to stay at home, not seek routine care, and not seek emergency room care with mild symptoms. The health care system is faced with a fine balance to not only treat those with COVID-19, but also those with non COVID related medical needs. 8 Ensuring that by focusing on treating and preventing COVID-19, we are not worsening morbidity and mortality for those with non COVID related medical needs. We must equitably care for both COVID-19 and non-COVID related patients. The IQVIA Institute for Human Data Science estimates there are 42 million mammograms performed annually, with a cancer detection rate of 5.1 per 1000 mammograms performed. So, this suggests that for each month screening mammograms are closed, 17,850 Americans with breast cancer will be undiagnosed. Short-term limitations may be needed as cases of COVID-19 rise, however medicine does not know yet the evidence-based risk benefit of short-term closings and if this is needed on an individual bases or as a population. 8 In an online interview 11 Tom Lindquist, CEO of Allina Health-Aeta, advises that besides reaching out to media interviews and recording podcasts encouraging at risk populations to seek care and encourage patients to return to routine care, they are making efforts to make sure at-risk patients feel safe for their visit. They are sending convenience packages to seniors that include thermometers, masks, hand sanitizer to help them feel safe to visit a clinic if they need or prefer this option over a virtual visit.

Key Points:

 Provide education to our patients on the risk of contracting COVID-19 during unrelated hospital admission vs benefit of the hospital admission for non COVID related illness.  Discuss COVID-19 with our patients with the truthful data and up to date CDC guidelines to prevent transmission is crucial. Such as of wearing mask, social distancing, avoiding crowds, just as we counsel them on smoking cessation and wearing their seatbelt.  Advising and educating patients on the risks benefit of having an elective procedure, being admitted to the hospital vs their actual risk of contracting COVID-19.  Proactively reaching out to patients, encourage medical screening exams, their need for urgent, emergent, and routine care. While, reassuring patients measures we are doing to ensure their safety.

 Telemedicine and virtual visits have increased access; however, we need to have a way to call or reach our elderly patients and those at risk who may not have access to them to raise awareness for need for routine, acute and chronic medical needs

At the start of the pandemic, and still currently, there has been a significant decline in hospital admissions for non-COVID related pathology. This is thought to be partly due to patients' anxiety about contracting COVID-19 and = anxiety about the risk of mortality associated with contracting COVID-19 during a hospital stay. One thing we as providers can do to encourage patients to agree to admission or seek emergency medical care is educate and counsel patients that their risk for contracting COVID-19 during a non-COVID related admission, although there is still risk, is relatively low. Patient's being admitted to the hospital actually have a greater risk to contracting COVID-19 in the community than as a nosocomial infection. 12 The risk of contracting COVID-19 during hospital admission and the risk of mortality was evaluated by the COPE-Nosocomial Study 12 COVID 19 disproportionately affects people of color in terms of hospital admission, severity of illness, and mortality. This is a multifactorial problem with multiple coordinated events that need to align in order to help improve the lives of those at risk for COVID-19 not just at the level of the health care delivery system but at the city, state, and federal levels. We need to increase our own training in diversity and promote cultural humility for not only ourselves, but for the organizations we work for. We know that COVID-19 is affecting those with non-COVID related medical needs and ultimately increasing morbidity and mortality from non-COVID related medical conditions. We as providers can take simple yet big measures in health promotion and wellness to combat both disparities in the face of COVID-19. We need to ensure that our patients are educated on the need to seek help when they need it, continue to receive routine care during the pandemic, and educate our patients on the risk of contracting COVID-19 vs the larger risk of suffering morbidity and mortality form their non-COVID related medical illness. We need to increase health promotion and wellness with our minority patients disproportionally at risk should they contract COVID-19. Not only do we have to increase health promotion around COVID-19, but we also have to ensure that they have access to care and testing and recognize things we can do in our community or practice to ensure they have these capabilities.  People of color are at greater risk for hospitalization, complications, and death from COVID-19. We as medical providers need to increase contact with our patients at risk within our practice and community. We need to incorporate health promotion and wellness around COVID-19 in our patients of color. We need to take measures to ensure they have access to care, testing. We need to ensure our patients of color trust us by promoting cultural humility in our practices.  There is a fine balance between preventing COVID-19, treating those who contract COVID-19 while still treating those who need medical screening and have non-COVID related medical needs. We need to incorporate health promotion, wellness and education to our patients on the needs to seek care when they truly need it and the risk/benefit of contracting COVID-19 vs risk of morbidity and mortality for non COVID related medical needs.

Covid-19 Cases

Racial Ethn Health Disparities Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at the Height of the New York City Pandemic

Covid-19 Dislocated Worker Grant. Employment and Training Administration

J Racial Ethnic Health Disparities. 2020; Racism, COVID-19, and Health Inequity in the USA; a Call to Action

COVID-19 Disparities and the Black Community: A Health Equity-Informed Rapid Response is Needed

The Hidden Toll of Covid-10

Elective Surgery Cancellations Due to the COVID-19 Pandemic: Global Predictive Modeling to Inform Surgical Recovery Plans

Patients Left Behind: Ethical Challenges in Caring for Indirect Victims of the Covid-19 Pandemic

Impact of COVID-19 Pandemic Associated Lockdown on Admissions Secondary to Cardiac Ailments in a

Social Distancing and Dangers of Access Block to Health Care Services During COVID-19 Pandemic

COVID Has Actually Amplified the Reason for Value-Based Care

Age-adjusted COVID-19 associated hospitalization rates by race and ethnicity-COVID-NET