ABSTRACT
Background Low- and middle-income countries (LMICs) shoulder a disproportionately high burden of critical illness with limited healthcare infrastructure. However, despite increased attention on critical care capacity due to Covid-19, LMIC intensive care unit (ICU) capacity remains largely undescribed-especially in East Africa. We sought to characterize barriers to critical care capacity and delivery in Rwanda, hypothesizing that gaps in specialized personnel, training, and supervision ('human resources') would be perceived as more important limitations to high-quality ICU care compared to gaps in beds, medications, and diagnostics ('facilities, materials, equipment'). Methods We performed a cross-sectional survey of all hospitals with dedicated ICUs in Rwanda using a mixed-methods approach, adapting conceptual frameworks for health services evaluation in global disaster response and emergency medicine. Using World Health Organization (WHO)-developed benchmarks for facility-level surgery and trauma evaluations, we created a set of tools for ICU assessment. Questionnaires for physicians, nurses, trainee physicians, and hospital leadership were developed and pilot tested using REDCap software. Inventories of ICU and hospital capacity using an adapted WHO tool were undertaken at each site. Descriptive statistics including percentages, means, and standard deviations were performed. IRB approval was obtained though Columbia University Medical Center and the University of Rwanda. Results Four hospitals in Rwanda were identified with dedicated ICUs. Total ICU beds were 27 (5- 8), total annual ICU admissions were 1128. The majority (96%) of invited ICU medical staff completed the survey, including nurses (N=60), trainee physicians (N=29), and attending physicians (N=10). Complete inventories were obtained from all 4 hospitals. Respondents identified insufficient staffing (63%), equipment/bed shortages (40%), lack of training opportunities (36%), and inadequate supervision (23%) as key obstacles to providing high quality critical care. Both human resources (39%) and material resources (28%) were identified as key gaps. Inability to treat common critical illnesses was frequently reported. Inventories at the hospital level clearly identified resource constraints. Conclusions In this study, gaps in both material and human resources were perceived as limiting ICU care, in line with provider perceptions of inadequate care quality. Obstacles to change include material gaps, lack of training, and institutional barriers. Notably, health system leadership in Rwanda on multiple levels is aware of these gaps and challenges with specific plans to improve training, support, and availability of equipment and supplies. This study emphasizes the complex nature of LMIC critical care limitations, providing insight into addressing them institutionally.
ABSTRACT
RATIONALE: Communities of color are bearing a disproportionate burden of coronavirus disease 2019 (COVID-19) morbidity and mortality. Social determinants of health have resulted in higher prevalence and severity of COVID-19 among minority groups. Published work on COVID-19 disparities has focused on higher transmission, hospitalization, and mortality risk among people of color, but studies on disparities in the post-acute care setting are scarce. Our aim was to identify socioeconomic disparities in health resource utilization after hospital discharge. METHODS: This was a retrospective study. We identified adult patients who were hospitalized at CUIMC or the Allen Hospital from March 1st through April 30th 2020, had a positive RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), developed severe hypoxemic respiratory failure requiring invasive mechanical ventilation, and were successfully discharged from the hospital without need for ventilator support. Patients who received a tracheostomy and were weaned off the ventilator prior to discharge were included. Exclusion criteria included transfer from or to another institution, prior tracheostomy, in-hospital death, and discharge with a ventilator. RESULTS: We identified 195 patients meeting inclusion criteria. The median age was 59 (IQR 47-67), and 135 (66.5%) were men. There were 25 (12.8%) patients who were uninsured and 116 (59.5%) patients who had public insurance. There were 121 (62%) Hispanic, 34 (17%) Black, and 18 (9%) White patients. Uninsured patients within our cohort were more likely to be Hispanic and Spanish-speaking (p=0.027;p<0.001, respectively). Uninsured patients were also more likely to be discharged to home (p<0.001) than to a rehabilitation facility. 8.8% of patients were readmitted to CUIMC within 30 days and 41.5% saw a medical provider at CUIMC within 30 days of discharge. Insurance status did not predict 30-day re-hospitalization or completion of outpatient follow-up, although our study was underpowered to answer these questions. CONCLUSION: Our study demonstrated that race/ethnicity and primary language are associated with insurance status with Hispanic and Spanish-speaking patients being more likely to be uninsured. Uninsured patients were more likely to be discharged home after hospitalization, rather than to facility for further care and rehabilitation. We did not demonstrate any short-term differences in 30-day re-hospitalization rates or follow-up visits but we suspect socioeconomic disparities represent a significant barrier to adequate follow-up care in the long term. We plan to investigate this further with longitudinal follow-up and survey data.
ABSTRACT
Rationale: Higher levels of circulating interleukin-6 (IL-6) and lower respiratory system compliance have each been associated with increased mortality in severe coronavirus 2019 (COVID-19). IL-6 levels are associated with disease severity and mortality in non-COVID-19-related acute respiratory distress syndrome (ARDS). The purpose of this study was to examine the relationship between IL-6 and respiratory mechanics in COVID-19-related ARDS. Methods: This retrospective cohort study took place at two Columbia University Irving Medical Center hospitals. We identified patients age >18 years with laboratory confirmed COVID-19, who were intubated from March 1st through April 30th, 2020, and met the Berlin definition of ARDS. Electronic medical records were reviewed for clinical data. Outcomes were censored at 90 days after intubation. For patients without IL-6 levels recorded on the initial day of intubation, serum samples were obtained from the Columbia University Biobank and tested using the Quantikine Human IL-6 Immunoassay. IL-6 values were log-transformed. The primary outcome was respiratory system compliance. Secondary outcomes were calculated ventilatory ratio, PaO2:FiO2 ratio, and mortality. Linear regression and logistic regression were used for statistical analyses. Results: During the study period, 483 patients had COVID-19-associated ARDS. Median time of follow up was 37 days (IQR 11-90). At 90 days, 260 (53.8%) patients were deceased, 206 (42.7%) had been discharged, and 17 (3.5%) were still admitted. Two hundred sixteen (44.7%) patients had available data on respiratory system compliance and serum IL-6 levels from the initial day of mechanical ventilation. The median IL-6 value was 204.1 pg/ml (IQR 110-469.7). Median compliance was 25.5 ml/cmH2O (IQR 21.4-33.3), median ventilatory ratio was 1.96 (IQR 1.51-2.57), and median PaO2:FiO2 ratio was 134 (IQR 87-196). In unadjusted linear regression, higher IL-6 was associated with lower respiratory system compliance (log [IL-6] coefficient-1.80, p = 0.001) (Figure 1). This relationship remained significant when adjusting for age, sex, body mass index, race, ethnicity, and Sequential Organ Failure Assessment (SOFA) score (coefficient-2.43, p<0.001). There was no significant association between IL-6 and ventilatory ratio (0.76 p=0.08) or PaO2:FiO2 ratio (-6.15 p=0.06). Higher IL-6 was associated with higher odds of death at 90 days (OR 1.35 per unit increase in log [IL-6], p-value 0.022) when adjusting for age, sex, body mass index, race, ethnicity, and SOFA score. Conclusion: In COVID-19-associated ARDS, higher levels of IL-6 were associated with lower respiratory system compliance even adjusting for measured confounders. Higher IL-6 was also associated with higher mortality.