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A study in JAMA Network Open shows that differences in hospital admission and racial residential segregation could account for increased risks of inpatient mortality and hospice discharge seen among Black patients with COVID-19.
Black patients hospitalized with COVID-19 were 11% more likely to die in the hospital or be sent to hospice, and the differences in the hospitals themselves may be the reason, a study in JAMA Network Open shows.
The study, published Thursday, examined 44,217 Medicare beneficiaries who were hospitalized between Jan. 1, 2020, and Sept. 21, 2020,and looked at inpatient deaths or discharges to hospice within 30 days of admission. The study focused on the association of mortality with patient-level factors and the admitting hospital.
It has been known that COVID-19 was hitting harder among minority populations, but in smaller studies limited to a single hospital or health system, differences in mortality were found not to be statistically significant when researchers adjusted for clinical or individual patient differences. In this latest study, by researchers from the University of Pennsylvania, the large, geographically diverse data set allowed comparisons across hospitals.
The results suggest that racial residential segregation played a substantial role in the different rates of hospital admission among Black and White patients, that hospitals located in disadvantaged communities may lack adequate financial resources and may provide suboptimal care due to differences in payer mix or community supports.
Differences in exposure or responses to referral patterns may also account for differences in mortality rates among Black and White patients.
The data set. The study population included 33,459 (76%) White participants and 10,758 (24%) Black participants, and observed a total-mortality equivalent rate of 12.86% for White patients and 13.48% for Black patients; 2,634 (8%) White patients and 1,100 (10%) Black patients died as inpatients, and 1,670 (5%) White patients and 350 (3%) Black patients were discharged to hospice.
In an unadjusted comparison with White patients, Black patients had similar likelihoods of dying or being discharged to hospice (OR, 1.06; 95% CI, 0.99-1.12). After adjustment for clinical and sociodemographic patient characteristics, Black patients had greater likelihoods of dying or being discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19).
To further examine these results, researchers used simulation modeling to approximate the change in mortality rates among Black patients if they had instead been admitted to the hospitals where White patients were admitted. In the modeling, researchers observed that Black patients’ rate of mortality or discharge to hospice would have declined from 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%).
“This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients,” the authors wrote. “However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.”
Other differences can be explained by adjustment for social, demographic, and clinical factors linked to race. The authors discussed hospital-level solutions, including a greater focus on quality improvement resources to low-quality hospitals. State regulators should incorporate resources and quality improvement initiatives to all hospitals within a state, the authors said.
Mary Caffrey contributed to this report.