From Clinical Trial Awareness to Practice: Factors Associated with Intent to Omit Axillary Surgery Based on the SOUND Clinical Trial.

Numerous studies have examined the association between ambient air pollution exposure and the risk of death from COVID-19 illness. Studies that examined the impact of the cumulative health effects from long-term, ambient air pollution exposure on risk of COVID-19 death found stronger associations, and were less prone to bias, than studies examining the impact of short-term ambient air pollution exposure. The biological plausibility of this relationship is supported by evidence demonstrating an association between chronic air pollution exposure and direct cellular damage and oxidative stress that may result in multi-organ dysfunction in COVID-19 illness. Furthermore, long-term exposure to outdoor air pollution is associated with health conditions that increase the risk of severe COVID-19 outcomes. Previous studies examining this relationship have yielded inconsistent findings, potentially due to methodological biases. Prior ecological studies often aggregated exposure and outcome data across large spatial boundaries (i.e., city, county, region), increasing the risk for exposure misclassification and ecological fallacy. Prior cohort studies have been susceptible to selection bias. Compared to the general population, hospital-based cohort studies often over-represented subjects with factors associated with hospitalization, such as high comorbidity burdens. During the first pandemic year, studies that defined mortality based on COVID-19 diagnosis alone risked underestimation of COVID-19 deaths. This was thought to be due to observed, erroneous over-reporting of mortality due to other, non-respiratory illnesses (i.e., heart disease), and selection bias driven by disparate access to COVID-19 testing and out-of-hospital COVID-19 deaths. In response, numerous studies concluded that excess all-cause mortality may be a better measure of COVID-19 deaths during the first pandemic year to account for the multi-level impacts of the pandemic on population health and healthcare access. Prior literature has also highlighted the risk of unmeasured influence from social factors associated with health vulnerability to environmental exposures. These social factors are often structural in origin, and concentrated in urban communities composed of residents from racial and ethnic minoritized groups, low-income households, and essential occupations (e.g., healthcare, public transportation, and food services). During the first pandemic wave, reported COVID-19 deaths in New York City (NYC) were disproportionately high in such communities, paralleling trends in other United States (U.S.) cities. For example, during the first pandemic wave, out-of-hospital deaths rose nearly 300% in NYC, which was disproportionately driven by out-of-hospital deaths observed in communities with a higher proportion of inhabitants with Black race and less than a high-school education. A NYC-based study population, therefore, provides an opportunity to answer calls to action to identify the impact of social and structural drivers of environmental vulnerability on associations between chronic air pollution exposure and COVID-19 deaths, accounting for various biases identified in existing literature.