The association between neighbourhood marginalization and SARS-CoV-2 outcomes in patients presenting to emergency departments

Ivy Cheng^{1

2}, Rhonda J Rosychuk³, David Seonguk Yeom⁴, Ray L Jewett^{5

6}, Iwona A Bielska^{7

8}, Jake Hayward⁹, Jaspreet Khangura⁹, Rohit Mohindra^{10

11}, Megan Landes¹², Jeffrey P Hau⁴, Christiaan H Righolt¹³, Murdoch Leeies¹⁴, Jennifer Grant^{15

16}, Steven C Brooks¹⁷, Corinne M Hohl^{4

18}; Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) Investigators

Affiliations

¹ Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. ivy.cheng@sunnybrook.ca.
² Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. ivy.cheng@sunnybrook.ca.
³ Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
⁴ Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
⁵ Department of Geography and Planning, University of Toronto, Toronto, ON, Canada.
⁶ Centre for Social Accountability, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada.
⁷ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
⁸ Department of Health Policy and Management, Institute of Public Health, Jagiellonian University, Krakow, Poland.
⁹ Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
¹⁰ Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ North York General Hospital, Toronto, ON, Canada.
¹² Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
¹³ Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
¹⁴ Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
¹⁵ Divisions of Medical Microbiology and Infectious Diseases, University of British Columbia, Vancouver, BC, Canada.
¹⁶ Division of Infectious Diseases and Medical Microbiology, Vancouver Coastal Health, Vancouver, BC, Canada.
¹⁷ Departments of Emergency Medicine and Public Health Sciences, Queen's University, Kingston, ON, Canada.
¹⁸ Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada.

PMID: 39739247
DOI: 10.17269/s41997-024-00976-5

The association between neighbourhood marginalization and SARS-CoV-2 outcomes in patients presenting to emergency departments

Ivy Cheng et al. Can J Public Health. 2024.

. 2024 Dec 30.

doi: 10.17269/s41997-024-00976-5. Online ahead of print.

Authors

Affiliations

¹ Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. ivy.cheng@sunnybrook.ca.
² Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. ivy.cheng@sunnybrook.ca.
³ Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
⁴ Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
⁵ Department of Geography and Planning, University of Toronto, Toronto, ON, Canada.
⁶ Centre for Social Accountability, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada.
⁷ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
⁸ Department of Health Policy and Management, Institute of Public Health, Jagiellonian University, Krakow, Poland.
⁹ Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
¹⁰ Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ North York General Hospital, Toronto, ON, Canada.
¹² Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
¹³ Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
¹⁴ Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
¹⁵ Divisions of Medical Microbiology and Infectious Diseases, University of British Columbia, Vancouver, BC, Canada.
¹⁶ Division of Infectious Diseases and Medical Microbiology, Vancouver Coastal Health, Vancouver, BC, Canada.
¹⁷ Departments of Emergency Medicine and Public Health Sciences, Queen's University, Kingston, ON, Canada.
¹⁸ Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada.

PMID: 39739247
DOI: 10.17269/s41997-024-00976-5

Abstract
in English, French

Objective: Social and economic marginalizations have been associated with inferior health outcomes in Canada. Our objective was to describe the relationship between neighbourhood marginalization and COVID-19 outcomes among patients presenting to Canadian emergency departments (ED).

Methods: We conducted an observational study among consecutive COVID-19 patients recruited from 47 hospitals participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 3, 2020, and July 24, 2022. We linked data with the Canadian Marginalization Index (CAN-Marg). We used multivariable, multi-level logistic regression models to understand the association between dimensions of neighbourhood marginalization, and severe COVID-19 and in-hospital mortality.

Results: There were 55,588 eligible patients. Those from neighbourhoods with a higher proportion of recent immigrants (OR = 0.86 per unit increase [0.81, 0.92]), lower workforce participation (OR = 0.84 per unit increase [0.75, 0.94]), and more housing insecurity (OR = 0.81 per unit increase [0.77, 0.86]) were less likely to present to EDs with severe COVID-19. However, patients from materially marginalized neighbourhoods had increased odds of dying in hospital (OR = 1.19 per unit increase [95% CI 1.09, 1.30]) compared to patients from less materially marginalized neighbourhoods. Patients living in neighbourhoods with a higher proportion of recent immigrants (OR = 0.83 per unit increase [0.78, 0.91]) and lower participation in the workforce (OR = 0.77 per unit increase [0.66, 0.87]) experienced lower odds of dying.

Conclusion: Despite no association with severe COVID-19 at ED presentation, the only marginalization domain associated with in-hospital mortality was material deprivation. Our findings present insights on ED-seeking behaviour, hospital access, and care that population studies could not.

RéSUMé: OBJECTIF: La marginalisation sociale et économique est associée à de moins bons résultats cliniques au Canada. Nous avons voulu décrire la relation entre la marginalisation des quartiers et l’évolution de la COVID-19 chez les patients se présentant aux urgences au pays. MéTHODE: Nous avons mené une étude observationnelle de patients consécutifs avec COVID-19 recrutés dans 47 hôpitaux du CCEDRRN (Canadian COVID-19 Emergency Department Rapid Response Network) entre le 3 mars 2020 et le 24 juillet 2022. Nous avons lié les données à l’indice de marginalisation canadien (CAN-Marg). Nous avons ensuite utilisé des modèles de régression logistique multivariés à niveaux multiples pour comprendre l’association entre, d’une part, les dimensions de la marginalisation des quartiers et d’autre part, la COVID-19 sévère et la mortalité hospitalière. RéSULTATS: Il y avait 55 888 patients admissibles. Ceux venant de quartiers ayant une proportion élevée d’immigrants récents (RC = 0,86 par unité d’augmentation [0,81, 0,92]), une faible participation à la population active (RC = 0,84 par unité d’augmentation [0,75, 0,94]) et un indice de précarité du logement élevé (RC = 0,81 par unité d’augmentation [0,77, 0,86]) étaient moins susceptibles de se présenter aux urgences avec une COVID-19 sévère. Néanmoins, les patients venant de quartiers marginalisés sur le plan matériel étaient plus susceptibles de mourir à l’hôpital (RC = 1,19 par unité d’augmentation [IC de 95% 1,09, 1,30]) que les patients venant de quartiers moins marginalisés sur le plan matériel. Chez les patients venant des quartiers ayant une proportion élevée d’immigrants récents (RC = 0,83 par unité d’augmentation [0,78, 0,91]) et une faible participation à la population active (RC = 0,77 par unité d’augmentation [0,66, 0,87]), la probabilité de mourir était inférieure. CONCLUSION: Malgré l’absence d’association avec la COVID-19 sévère chez les patients se présentant aux urgences, le seul domaine de marginalisation associé à la mortalité hospitalière était la défavorisation matérielle. Nos constats jettent un éclairage que les études démographiques ne peuvent pas apporter sur les comportements de présentation aux urgences, l’accès à l’hôpital et les soins.

Keywords: COVID-19; Emergency department; Equity; Neighbourhood marginalization; Outcomes; SARS-CoV-2.

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Conflict of interest statement

Declarations. Ethics approval: The University of BC Clinical Research Ethics Board reviewed and approved the study protocol (H20-01015) with a waiver for informed consent, allowing us to capture a complete sample. Consent to participate: Not applicable. Consent for publication: Not applicable. Conflict of interest: Righolt has received research funding from Pfizer for an unrelated study. Hohl received salary support through a Health Research BC Health Professional Investigator Award during the study period. Authors otherwise declare no competing interests.

References

1. Bates, D., Mächler, M., Bolker, B., & Walker, S. (2015). Fitting linear mixed-effects models using lme4. Journal of Statistical Software, 67, 1–48. https://doi.org/10.18637/jss.v067.i01 - DOI
1. Buuren, S., & Groothuis-Oudshoorn, C. (2011). MICE: Multivariate imputation by chained equations in R. Journal of Statistical Software, 45. https://doi.org/10.18637/jss.v045.i03
1. Diez Roux, A. V. (2001). Investigating neighborhood and area effects on health. American Journal of Public Health, 91(11), 1783–1789. - DOI - PubMed - PMC
1. Gupta, S, & Aitken, N. (2022). COVID-19 mortality among racialized populations in Canada and its association with income. Statistics Canada. Catalogue no. 45–28–0001.
1. Hohl, C. M., Rosychuk, R. J., Archambault, P. M., O’Sullivan, F., Leeies, M., Mercier, É., Clark, G., Innes, G. D., Brooks, S. C., Hayward, J., Ho, V., Jelic, T., Welsford, M., Sivilotti, M. L. A., Morrison, L. J., Perry, J. J., for the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) investigators for the Network of Canadian Emergency Researchers and the Canadian Critical Care Trials Group. (2022a). The CCEDRRN COVID-19 Mortality Score to predict death among nonpalliative patients with COVID-19 presenting to emergency departments: A derivation and validation study. CMAJ Open, 10(1), E90–E99. https://doi.org/10.9778/cmajo.20210243 - DOI - PubMed - PMC

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The association between neighbourhood marginalization and SARS-CoV-2 outcomes in patients presenting to emergency departments

Affiliations

The association between neighbourhood marginalization and SARS-CoV-2 outcomes in patients presenting to emergency departments

Authors

Affiliations

Abstract
in English, French

Conflict of interest statement

References

Grants and funding

LinkOut - more resources

Full Text Sources

Miscellaneous

Abstract in English, French

Conflict of interest statement

References

Grants and funding

LinkOut - more resources

Full Text Sources

Miscellaneous

Abstract
in English, French