Long-Term Air Pollution Exposure and COVID-19 Mortality: A Patient-Level Analysis from New York City.

Rationale: Risk factors for coronavirus disease (COVID-19) mortality may include environmental exposures such as air pollution. Objectives: To determine whether, among adults hospitalized with PCR-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), long-term air pollution exposure is associated with the risk of mortality, ICU admission, or intubation. Methods: We performed a retrospective analysis of SARS-CoV-2 PCR-positive patients admitted to seven New York City hospitals from March 8, 2020, to August 30, 2020. The primary outcome was mortality; secondary outcomes were ICU admission and intubation. We estimated the annual average fine particulate matter (particulate matter ⩽2.5 µm in aerodynamic diameter [PM2.5]), nitrogen dioxide (NO2), and black carbon (BC) concentrations at patients' residential address. We employed double robust Poisson regression to analyze associations between the annual average PM2.5, NO2, and BC exposure level and COVID-19 outcomes, adjusting for age, sex, race or ethnicity, hospital, insurance, and the time from the onset of the pandemic. Results: Among the 6,542 patients, 41% were female and the median age was 65 (interquartile range, 53-77) years. Over 50% self-identified as a person of color (n = 1,687 [26%] Hispanic patients; n = 1,659 [25%] Black patients). Air pollution exposure levels were generally low. Overall, 31% (n = 2,044) of the cohort died, 19% (n = 1,237) were admitted to the ICU, and 16% (n = 1,051) were intubated. In multivariable models, a higher level of long-term exposure to PM2.5 was associated with an increased risk of mortality (risk ratio, 1.11 [95% confidence interval, 1.02-1.21] per 1-µg/m3 increase in PM2.5) and ICU admission (risk ratio, 1.13 [95% confidence interval, 1.00-1.28] per 1-µg/m3 increase in PM2.5). In multivariable models, neither NO2 nor BC exposure was associated with COVID-19 mortality, ICU admission, or intubation. Conclusions: Among patients hospitalized with COVID-19, a higher long-term PM2.5 exposure level was associated with an increased risk of mortality and ICU admission.

Comparing two data collection methods to track vital events in maternal and child health via community health workers in rural Nepal.

BACKGROUND: Timely tracking of health outcomes is difficult in low- and middle-income countries without comprehensive vital registration systems. Community health workers (CHWs) are increasingly collecting vital events data while delivering routine care in low-resource settings. It is necessary, however, to assess whether routine programmatic data collected by CHWs are sufficiently reliable for timely monitoring and evaluation of health interventions. To study this, we assessed the consistency of vital events data recorded by CHWs using two methodologies-routine data collected while delivering an integrated maternal and child health intervention, and data from a birth history census approach at the same site in rural Nepal. METHODS: We linked individual records from routine programmatic data from June 2017 to May 2018 with those from census data, both collected by CHWs at the same site using a mobile platform. We categorized each vital event over a one-year period as 'recorded by both methods,' 'census alone,' or 'programmatic alone.' We further assessed whether vital events data recorded by both methods were classified consistently. RESULTS: From June 2017 to May 2018, we identified a total of 713 unique births collectively from the census (birth history) and programmatic maternal 'post-delivery' data. Three-fourths of these births (n = 526) were identified by both. There was high consistency in birth location classification among the 526 births identified by both methods. Upon including additional programmatic 'child registry' data, we identified 746 total births, of which 572 births were identified by both census and programmatic methods. Programmatic data (maternal 'post-delivery' and 'child registry' combined) captured more births than census data (723 vs. 595). Both methods consistently classified most infants as 'living,' while infant deaths and stillbirths were largely classified inconsistently or recorded by only one method. Programmatic data identified five infant deaths and five stillbirths not recorded in census data. CONCLUSIONS: Our findings suggest that data collected by CHWs from routinely tracking pregnancies, births, and deaths are promising for timely program monitoring and evaluation. Despite some limitations, programmatic data may be more sensitive in detecting vital events than cross-sectional census surveys asking women to recall these events.

Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal.

BACKGROUND: The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal. METHODS: A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the recommendations are tabulated and discussed in the context of an adapted CoCM in rural Nepal. RESULTS: The clinical team discussed 1174 patient encounters (1162 unique patients) during panel reviews throughout the study period. The consultant psychiatrist made 214 recommendations for 192 (16%) patients. The most common recommendations were to revisit the primary mental health diagnosis (16%, n = 34), add or increase focus on counselling and psychosocial support (9%, n = 20), increase the antidepressant dose (9%, n = 20), and discontinue inappropriate medications (6%, n = 12). CONCLUSIONS: In this CoCM study, the majority of treatment plans did not require significant change. The recommendations highlight the challenge that non-specialists face in making an accurate mental health diagnosis, the relative neglect of non-pharmacological interventions, and the risk of inappropriate medications. These results can inform interventions to better support non-specialists in rural areas.

Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal.

BACKGROUND: Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women's groups suggests that group care models may both improve access to care and the quality of care delivered through women's empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. METHODS: The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. RESULTS: A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1-91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. CONCLUSION: Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal.

BACKGROUND: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. METHODS: The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. RESULTS: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. CONCLUSION: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02330887 , registered 01/05/2015, retroactively registered.

Transition to active learning in rural Nepal: an adaptable and scalable curriculum development model.

BACKGROUND: Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning. METHODS: The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted. RESULTS: Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3-6, maintained at 31% through months 6-12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site. CONCLUSION: We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally.

Impact of the roll out of comprehensive emergency obstetric care on institutional birth rate in rural Nepal.

BACKGROUND: Increasing institutional births rates and improving access to comprehensive emergency obstetric care are central strategies for reducing maternal and neonatal deaths globally. While some studies show women consider service availability when determining where to deliver, the dynamics of how and why institutional birth rates change as comprehensive emergency obstetric care availability increases are unclear. METHODS: In this pre-post intervention study, we surveyed two exhaustive samples of postpartum women before and after comprehensive emergency obstetric care implementation at a hospital in rural Nepal. We developed a logistic regression model of institutional birth factors through manual backward selection of all significant covariates within and across periods. Qualitatively, we analyzed birth stories through immersion crystallization. RESULTS: Institutional birth rates increased after comprehensive emergency obstetric care implementation (from 30 to 77%, OR 7.7) at both hospital (OR 2.5) and low-level facilities (OR 4.6, p < 0.01 for all). The logistic regression indicated that comprehensive emergency obstetric care availability (OR 5.6), belief that the hospital is the safest birth location (OR 44.8), safety prioritization in decision-making (OR 7.7), and higher income (OR 1.1) predict institutional birth (p ≤ 0.01 for all). Qualitative analysis revealed comprehensive emergency obstetric care awareness, increased social expectation for institutional birth, and birth planning as important factors. CONCLUSION: Comprehensive emergency obstetric care expansion appears to have generated significant demand for institutional births through increased safety perceptions and birth planning. Increasing comprehensive emergency obstetric care availability increases birth safety, but it may also be a mechanism for increasing the institutional birth rate in areas of under-utilization.

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal.

BACKGROUND: Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation. PARTNERSHIPS NETWORK: We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community. CONCLUSIONS: We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

BACKGROUND: Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. METHODS: We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. RESULTS: We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. CONCLUSION: The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Determinants of institutional birth among women in rural Nepal: a mixed-methods cross-sectional study.

BACKGROUND: Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality. METHODS: Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth. RESULTS: The institutional birth rate for the hospital's catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20-0.28) and as income increased (ORs in the range of 1.38-1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth. CONCLUSION: Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness.

Strengthening Nepal's Female Community Health Volunteer network: a qualitative study of experiences at two years.

BACKGROUND: Nepal's Female Community Health Volunteer (FCHV) program has been described as an exemplary public-sector community health worker program. However, despite its merits, the program still struggles to provide high-quality, accessible services nation-wide. Both in Nepal and globally, best practices for community health worker program implementation are not yet known: there is a dearth of empiric research, and the research that has been done has shown inconsistent results. METHODS: Here we evaluate a pilot program designed to strengthen the Nepali government's FCHV network. The program was structured with five core components: 1) improve local FCHV leadership; 2) facilitate structured weekly FCHV meetings and 3) weekly FCHV trainings at the village level; 4) implement a monitoring and evaluation system for FCHV patient encounters; and 5) provide financial compensation for FCHV work. Following twenty-four months of program implementation, a retrospective programmatic evaluation was conducted, including qualitative analysis of focus group discussions and semi-structured interviews. RESULTS: Qualitative data analysis demonstrated that the program was well-received by program participants and community members, and suggests that the five core components of this program were valuable additions to the pre-existing FCHV network. Analysis also revealed key challenges to program implementation including geographic limitations, literacy limitations, and limitations of professional respect from healthcare workers to FCHVs. Descriptive statistics are presented for programmatic process metrics and costs throughout the first twenty four months of implementation. CONCLUSIONS: The five components of this pilot program were well-received as a mechanism for strengthening Nepal's FCHV program. To our knowledge, this is the first study to present such data, specifically informing programmatic design and management of the FCHV program. Despite limitations in its scope, this study offers tangible steps forward for further research and community health worker program improvement, both within Nepal and globally.

Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City.

BACKGROUND: Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality. METHODS: In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality. RESULTS: ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality. CONCLUSIONS: Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.

Medication persistence of HIV-infected drug users on directly administered antiretroviral therapy.

Patient and regimen persistence in HIV-infected drug users are largely unknown. We evaluated patterns of medication non-persistence among HIV-infected drug users enrolled in a prospective, 6-month randomized controlled trial of directly administered antiretroviral therapy (DAART). Medication-taking behavior was assessed via direct observation and MEMS data. Of 74 participants who initiated DAART, 59 (80%) subjects were non-persistent with medication for 3 or more consecutive days. Thirty-one participants (42%) had 2 or more episodes of non-persistence. Higher depressive symptoms were strongly associated with non-persistence episodes of ≥ 3 days (AOR: 17.4, P = 0.02) and ≥ 7 days AOR: 5.4, P = 0.04). High addiction severity (AOR 3.2, P = 0.03) was correlated with non-persistence ≥ 7 days, and injection drug use (AOR: 15.2, P = 0.02) with recurrence of non-persistence ≥ 3 days. Time to regimen change was shorter for NNRTI-based regimens compared to PI-based ones (HR: 3.0, P = 0.03). There was no significant association between patterns of patient non-persistence and virological outcomes.

COVID-19 subphenotypes at hospital admission are associated with mortality: a cross-sectional study.

BACKGROUND: We have an incomplete understanding of COVID-19 characteristics at hospital presentation and whether underlying subphenotypes are associated with clinical outcomes and therapeutic responses. METHODS: For this cross-sectional study, we extracted electronic health data from adults hospitalized between 1 March and 30 August 2020 with a PCR-confirmed diagnosis of COVID-19 at five New York City Hospitals. We obtained clinical and laboratory data from the first 24 h of the patient's hospitalization. Treatment with tocilizumab and convalescent plasma was assessed over hospitalization. The primary outcome was mortality; secondary outcomes included intubation, intensive care unit (ICU) admission and length of stay (LOS). First, we employed latent class analysis (LCA) to identify COVID-19 subphenotypes on admission without consideration of outcomes and assigned each patient to a subphenotype. We then performed robust Poisson regression to examine associations between COVID-19 subphenotype assignment and outcome. We explored whether the COVID-19 subphenotypes had a differential response to tocilizumab and convalescent plasma therapies. RESULTS: A total of 4620 patients were included. LCA identified six subphenotypes, which were distinct by level of inflammation, clinical and laboratory derangements and ranged from a hypoinflammatory subphenotype with the fewest derangements to a hyperinflammatory with multiorgan dysfunction subphenotypes. Multivariable regression analyses found differences in risk for mortality, intubation, ICU admission and LOS, as compared to the hypoinflammatory subphenotype. For example, in multivariable analyses the moderate inflammation with fever subphenotype had 3.29 times the risk of mortality (95% CI 2.05, 5.28), while the hyperinflammatory with multiorgan failure subphenotype had 17.87 times the risk of mortality (95% CI 11.56, 27.63), as compared to the hypoinflammatory subphenotype. Exploratory analyses suggested that subphenotypes may differential respond to convalescent plasma or tocilizumab therapy. CONCLUSION: COVID-19 subphenotype at hospital admission may predict risk for mortality, ICU admission and intubation and differential response to treatment.KEY MESSAGEThis cross-sectional study of COVID patients admitted to the Mount Sinai Health System, identified six distinct COVID subphenotypes on admission. Subphenotypes correlated with ICU admission, intubation, mortality and differential response to treatment.

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal.

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

Crossing the quality chasm in resource-limited settings.

Over the last decade, extensive scientific and policy innovations have begun to reduce the "quality chasm"--the gulf between best practices and actual implementation that exists in resource-rich medical settings. While limited data exist, this chasm is likely to be equally acute and deadly in resource-limited areas. While health systems have begun to be scaled up in impoverished areas, scale-up is just the foundation necessary to deliver effective healthcare to the poor. This perspective piece describes a vision for a global quality improvement movement in resource-limited areas. The following action items are a first step toward achieving this vision: 1) revise global health investment mechanisms to value quality; 2) enhance human resources for improving health systems quality; 3) scale up data capacity; 4) deepen community accountability and engagement initiatives; 5) implement evidence-based quality improvement programs; 6) develop an implementation science research agenda.

Factors associated with COVID-19 vaccine receipt at two integrated healthcare systems in New York City: a cross-sectional study of healthcare workers.

OBJECTIVES: To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination. DESIGN: Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers. SETTING: Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine. PARTICIPANTS: 1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff. PRIMARY OUTCOME MEASURES: The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers. RESULTS: Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients. CONCLUSIONS: Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

Cross-sectional study evaluating the seroprevalence of SARS-CoV-2 antibodies among healthcare workers and factors associated with exposure during the first wave of the COVID-19 pandemic in New York.

OBJECTIVE: Estimate the seroprevalence of SARS-CoV-2 antibodies among New York City Health and Hospitals (NYC H+H) healthcare workers during the first wave of the COVID-19 pandemic, and describe demographic and occupational factors associated with SARS-CoV-2 antibodies among healthcare workers. DESIGN: Descriptive, observational, cross-sectional study using a convenience sample of data from SARS-CoV-2 serological tests accompanied by a demographic and occupational survey administered to healthcare workers. SETTING: A large, urban public healthcare system in NYC. PARTICIPANTS: Participants were employed by NYC H+H and either completed serological testing at NYC H+H between 30 April 2020 and 30 June 2020, or completed SARS-CoV-2 antibody testing outside of NYC H+H and were able to self-report results from the same time period. PRIMARY OUTCOME MEASURE: SARS-CoV-2 serostatus, stratified by key demographic and occupational characteristics reported through the demographic and occupational survey. RESULTS: Seven hundred and twenty-seven survey respondents were included in analysis. Participants had a mean age of 46 years (SD=12.19) and 543 (75%) were women. Two hundred and fourteen (29%) participants tested positive or reported testing positive for the presence of SARS-CoV-2 antibodies (IgG+). Characteristics associated with positive SARS-CoV-2 serostatus were Black race (25% IgG +vs 15% IgG-, p=0.001), having someone in the household with COVID-19 symptoms (49% IgG +vs 21% IgG-, p<0.001), or having a confirmed COVID-19 case in the household (25% IgG +vs 5% IgG-, p<0.001). Characteristics associated with negative SARS-CoV-2 serostatus included working on a COVID-19 patient floor (27% IgG +vs 36% IgG-, p=0.02), working in the intensive care unit (20% IgG +vs 28% IgG-, p=0.03), being employed in a clinical occupation (64% IgG +vs 78% IgG-, p<0.001) or having close contact with a patient with COVID-19 (51% IgG +vs 62% IgG-, p=0.03). CONCLUSIONS: Results underscore the significance that community factors and inequities might have on SARS-CoV-2 exposure for healthcare workers.

Cross-cultural adaptation of motivational interviewing for use in rural Nepal.

BACKGROUND: Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person's behaviors. METHODS: We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment. RESULTS: Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not "allow" it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone's motivations and align those with the patient's needs. CONCLUSIONS: MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient's autonomy and their role as a member of a complex social fabric to facilitate behavior change.