Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Patient perceptions of the readability and helpfulness of bilingual clinical forms: a survey study

Abstract Background Patients with limited English proficiency (LEP) are rarely provided with translated clinical materials. Typically, healthcare clinics cite high costs of translation and lack of professional translators as barriers to this service. The purpose of the current study was to investigate the perceptions of LEP dental patients regarding the readability, understanding, and helpfulness of translated clinical forms produced by dental student doctor translators. Methods We used a survey design and convenience sampling to recruit LEP patients from a dental school clinic. Participants completed a 9-question (8 Likert-type items and 1 open-ended item) paper survey about translated forms. The bilingual survey was a combination of English and 8 other languages (Arabic, Dari, Pashto, Russian, Spanish, Ukrainian, Urdu, or Vietnamese) and assessed the type of form received; self-reported literacy; design, readability, and helpfulness of the form; overall understanding of the form; understanding of medical and dental terms; helpfulness for patient-provider communication; and comfort level with dental care after receiving the form. Demographic characteristics of participants were collected from the clinic’s electronic health record. Survey responses were analyzed descriptively, and Spearman’s correlation was used to examine the relationship between outcomes. Results Ninety-seven LEP patients (61.9% [60] female, 78.4% [70] Spanish speakers) completed 140 surveys for various translated forms in Dari, Pashto, Spanish, Urdu, or Vietnamese. Participants positively rated translated clinical forms: range, 50.4% (70) for design of the form to 80.0% (112) for comfort level with dental care after receiving the form. For the open-ended item, participants indicated the translations were good, and no improvements were needed. They also thought providing the form was evidence of good customer service. When examining relationships between outcomes, positive correlations were found between self-reported literacy and readability (Spearman r = .57, P < .001), overall understanding and understanding of medical and dental terms (Spearman r = .58, P < .001), and type of form and helpfulness for patient-provider communication (Spearman r = .26, P = .005). Conclusions Study results suggested the translated clinical forms were perceived as helpful and beneficial by LEP dental patients. Similar approaches should be considered to reduce language barriers in healthcare

Four-year review of presenteeism data among employees of a large United States health care system: a retrospective prevalence study

Abstract Background Historically, in an effort to evaluate and manage the rising cost of healthcare employers assess the direct cost burden via medical health claims and measures that yield clear data. Health related indirect costs are harder to measure and are often left out of the comprehensive overview of health expenses to an employer. Presenteeism, which is commonly referred to as an employee at work who has impaired productivity due to health considerations, has been identified as an indirect but relevant factor influencing productivity and human capitol. The current study evaluated presenteeism among employees of a large United States health care system that operates in six locations over a four-year period and estimated loss productivity due to poor health and its potential economic burden. Methods The Health-Related Productivity Loss Instrument (HPLI) was included as part of an online Health Risk Appraisal (HRA) administered to employees of a large United States health care system across six locations. A total of 58 299 HRAs from 22 893 employees were completed and analyzed; 7959 employees completed the HRA each year for 4 years. The prevalence of 22 specific health conditions and their effects on productivity areas (quantity of work, quality of work, work not done, and concentration) were measured. The estimated daily productivity loss per person, annual cost per person, and annual company costs were calculated for each condition by fitting marginal models using generalized estimating equations. Intra-participant agreement in reported productivity loss across time was evaluated using κ statistics for each condition. Results The health conditions rated highest in prevalence were allergies and hypertension (high blood pressure). The conditions with the highest estimated daily productivity loss and annual cost per person were chronic back pain, mental illness, general anxiety, migraines or severe headaches, neck pain, and depression. Allergies and migraines or severe headaches had the highest estimated annual company cost. Most health conditions had at least fair intra-participant agreement (κ ≥ 0.40) on reported daily productivity loss. Conclusions Results from the current study suggested a variety of health conditions contributed to daily productivity loss and resulted in additional annual estimated costs for the health care system. To improve the productivity and well-being of their workforce, employers should consider presenteeism data when planning comprehensive wellness initiatives to curb productivity loss and increase employee health and well-being during working hours

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19

International audienc