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Abstract
Background Ethnic minorities account for 34% of critically ill patients with COVID-19 despite constituting 14% of the UK population. Internationally, researchers have called for studies to understand deterioration risk factors to inform clinical risk tool development.
Methods Multicentre cohort study of hospitalised patients with COVID-19 (n=3671) exploring determinants of health, including Index of Multiple Deprivation (IMD) subdomains, as risk factors for presentation, deterioration and mortality by ethnicity. Receiver operator characteristics were plotted for CURB65 and ISARIC4C by ethnicity and area under the curve (AUC) calculated.
Results Ethnic minorities were hospitalised with higher Charlson Comorbidity Scores than age, sex and deprivation matched controls and from the most deprived quintile of at least one IMD subdomain: indoor living environment (LE), outdoor LE, adult skills, wider barriers to housing and services. Admission from the most deprived quintile of these deprivation forms was associated with multilobar pneumonia on presentation and ICU admission. AUC did not exceed 0.7 for CURB65 or ISARIC4C among any ethnicity except ISARIC4C among Indian patients (0.83, 95% CI 0.73 to 0.93). Ethnic minorities presenting with pneumonia and low CURB65 (0–1) had higher mortality than White patients (22.6% vs 9.4%; p<0.001); Africans were at highest risk (38.5%; p=0.006), followed by Caribbean (26.7%; p=0.008), Indian (23.1%; p=0.007) and Pakistani (21.2%; p=0.004).
Conclusions Ethnic minorities exhibit higher multimorbidity despite younger age structures and disproportionate exposure to unscored risk factors including obesity and deprivation. Household overcrowding, air pollution, housing quality and adult skills deprivation are associated with multilobar pneumonia on presentation and ICU admission which are mortality risk factors. Risk tools need to reflect risks predominantly affecting ethnic minorities.
- COVID-19
- pneumonia
- respiratory infection
- viral infection
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Footnotes
Twitter @marinasoltan_
Contributors MAS collected data, undertook data analysis, designed this study and wrote this paper. MAS, BS, CRM, JV, DRT, DPD and WC made substantial contributions to the conception, design of the work and supported data interpretation. All authors revised the final manuscript. All authors contributed to and approved the final version of the manuscript.
Funding DT is funded by the MRC (MR/L002736/1). MS is a funded NIHR Academic Clinical Fellow and reports grants from AstraZeneca (C278.10033.65855).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Press Release New clinical risk management tools are needed to prevent COVID-19 deaths, say expertsA new study exposes the dire need for new clinical risk management tools to help hospital healthcare workers prevent the deaths and intensive care admissions of ethnic minority COVID-19 patients with pneumonia, say researchers.The call for healthcare policy change comes after a new study led by the University of Birmingham has revealed COVID-19 patients from areas with the highest levels of household overcrowding, air pollution, poor housing quality and adult skills deprivation are more likely to be admitted to hospital suffering pneumonia and requiring intensive care. Ethnic minority groups including: Indian, Pakistani, African, Caribbean, Chinese, Bangladeshi and mixed ethnicity patients were all more likely than Caucasians to be admitted from an area with at least one form of deprivation.The first of its kind study of 3,671 patients with COVID-19 admitted to four Midland hospitals provides new important and detailed insights into the stark contrasts between ethnic minority subgroups and Caucasians. It found 81.5% of ethnic minority COVID-19 patients were admitted to hospital from regions of highest air pollution deprivation compared with 46.9% of Caucasians. 81.7% of hospitalised ethnic minority COVID-19 patients were admitted from regions of highest household overcrowding deprivation compared with 50.2% of Caucasians. Crucially, the study found that existing tools used by medics to predict or measure risk and manage the care of COVID-19 patients with pneumonia are insufficient, and can result in underscoring of ethnic minority patients. This is particularly due to the fact that often they do not take into consideration that several ethnic minority subgroups are at greater risk of serious illness with COVID-19 at a younger age than Caucasians. The study found that of those patients hospitalised, on average, Indian, Pakistani, African, Chinese, Bangladeshi and any other non-Caucasian ethnic group were under the age of 65, while Caucasians were older than 65.Existing admission scoring mechanisms also do not take into account important risk factors that many ethnic ethnic minority groups are much more exposed or vulnerable to including suffering multiple pre-existing underlying health conditions, e.g-obesity, and deprivation, such as living in overcrowded households, areas of high pollution, poor housing quality or education deprivation. The researchers say underscoring can potentially lead to triage to an inappropriate level of care as clinicians are left falsely reassured regarding the severity of illness and risk of a patient’s deterioration. The results showed that on the most widely used pneumonia severity scoring system in hospitals, CURB65, ethnic minority patients with low CURB65 scores had higher mortality than Caucasians (22.6% vs 9.4% respectively). Africans were at highest risk (38.5%), followed by Caribbean (26.7%), Indian (23.1%), and Pakistani (21.2%) patients.The research, carried out in collaboration with Birmingham City Council, the University of Manchester, and University Hospitals North Midlands NHS Trust, was supported by the National Institute for Health Research (NIHR). Lead author Dr Marina Soltan, a NIHR Academic Clinical Fellow in Respiratory Medicine at the University of Birmingham and a clinician at University Hospitals Birmingham NHS Foundation Trust, said: “As the COVID-19 pandemic has progressed, there has been a greater spotlight on health inequalities and it has become increasingly clear that research is needed to explore the underlying factors further and understand why ethnic minority patients are at greater risk of requiring intensive care admission and, sadly, dying. “Our findings demonstrate an urgent need for the development of new admission risk tools to support frontline clinical decision-making. “Currently, admission clinical risk management tools for COVID19 or pneumonia don’t typically account for socioenvironmental risk factors including air pollution deprivation, household overcrowding deprivation, housing quality deprivation and adult skills deprivation. When reviewing patients in the clinical environment, the hidden socioenvironmental risk factors to which patients have been exposed may not be immediately obvious and may not be scored in the risk triage process, yet may be important risks to consider. Clinical risk tools need to be reflective of socioenvironmental risk factors and risk factors to which ethnic minorities are predominantly predisposed. “This work has implications for how we train healthcare professionals to recognise multi-ethnic risk factors and public health implications regarding the minimisation of health inequalities.“Meanwhile, significant investment and partnership with both government and industry is needed to invest in preventing the rise in number of patients with multiple chronic illnesses and reducing inequalities and deprivation, ensuring everyone has access to suitable housing, employment and education opportunities, regardless.”
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