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Race, Hospital Factors, and Mortality in COVID-19
Quick Takes
- In this cohort of 44,217 Medicare beneficiaries hospitalized with COVID-19, Black patients had 11% greater adjusted odds of inpatient mortality or discharge to hospice, as compared with White patients.
- This difference was eliminated after adjustment for the hospitals where patients received care.
Study Questions:
Are differences in coronavirus disease 2019 (COVID-19) hospital mortality rates between Black and White patients attributable to patient characteristics and hospital factors?
Methods:
This cohort study was based on administrative claims data on Medicare beneficiaries, obtained from a national commercial health insurer. Black and White patients hospitalized with COVID-19 from January–August 2020 were included. The main outcome measure was a composite of inpatient mortality or discharge to hospice within 30 days of initial admission. Logistic regression models were used to determine the effects of patient-level sociodemographic characteristics and admitting hospital on patient outcomes. The authors also conducted a simulation to investigate how outcomes for Black patients would have differed if they had been admitted to the hospitals in the sample based on the same distribution as White patients.
Results:
A total of 44,217 patients (76% White, 24% Black; 45% male, 55% female; mean age 76.3 years) and 1,188 hospitals were included. Black patients had more comorbidities, such as diabetes, hypertension, chronic kidney disease, and obesity. Black and White patients were distributed differently among hospitals. The proportion of Black patients ranged from 33% in quintile 1 (the quintile of hospitals with the highest proportion of Black patients) to 6% in quintile 5. More Black patients than White patients were treated in hospitals with ≥450 beds (46% vs. 40%). Geographically, more Black patients than White patients were admitted to hospitals in the South (54% vs. 34%), and fewer Black patients were admitted to hospitals in the Northeast (21% vs. 28%) and Midwest (24% vs. 33%).
Among Black patients, 1,100 (10%) died in the hospital and 350 (3%) were discharged to hospice; among White patients, 2,634 (8%) died in the hospital and 1,670 (5%) were discharged to hospice. Compared with White patients, Black patients had similar unadjusted odds of 30-day inpatient mortality or discharge to hospice (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.99-1.12; p = 0.10). After multivariable adjustment for clinical and sociodemographic factors, Black patients had greater odds of inpatient mortality or discharge to hospice (OR, 1.11; 95% CI, 1.03-1.19; p = 0.005). This difference was no longer statistically significant after adjustment for hospital-level effects (OR, 1.02; 95% CI, 0.94-1.10; p = 0.71). Simulation showed that had Black patients been admitted to hospitals in the same distribution as White patients, their overall population risk of 30-day inpatient mortality or discharge to hospice would have declined from the observed 13.48% to 12.23%, similar to the 12.86% observed for White patients.
Conclusions:
Black Medicare beneficiaries hospitalized with COVID-19 had greater odds of inpatient mortality or discharge to hospice as compared with White patients. Adjustment for hospital-level effects eliminated this difference.
Perspective:
This study is a sobering reminder of the impact of structural racism on health outcomes in the United States, thrown into sharp relief in the context of the pandemic. Residential segregation and unequal distribution of resources contribute to the “tale of two hospitals” phenomenon, in which Black patients are more likely to be treated in facilities with less subspecialty care and poorer procedural outcomes (Capers Q, Sharalaya Z. J Racial and Ethn Health Disparities 2014;1:171-80). Previous work by the authors of this study has shown that improved hospital outcomes were associated with COVID-19 case rate declines in their respective communities (Asch DA, et al. JAMA Intern Med 2021;181:471-8), suggesting that successful community vaccination efforts could indirectly benefit patients treated for COVID-19 at previously overburdened hospitals. Given that the geographic distribution of Black and White patients was so different in this study, state- and federal-level interventions to improve equitable care should be considered.
Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Hypertension
Keywords: African Americans, Coronavirus, COVID-19, Diabetes Mellitus, Geriatrics, Hospices, Hospital Mortality, Hypertension, Inpatients, Medicare, Metabolic Syndrome, Obesity, Outcome Assessment, Health Care, Patient Discharge, Primary Prevention, Racism, Renal Insufficiency, Chronic, Vaccination
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