Racial Disparities in Patients Hospitalized for COVID-19

Abstract

Background

The COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites.

Methods

This is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups.

Results

Of 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (P<0.0001, z-test for proportions).

Conclusions

In this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.

Introduction

Pandemics occur once in a lifetime, and just over one hundred years after the 1918 Influenza Pandemic, the COVID-19 pandemic started. The disease surfaced at the end of 2019. It was officially declared a pandemic by the World Health Organization (WHO) on March 11, 2020, with many cities and towns worldwide already initiating lockdowns and other methods to contain the virus.¹ At the time of this writing, there have been over 630 million cases and over 6.5 million deaths worldwide. The United States (US) alone has over 95 million cases with over 1 million deaths. ² The pandemic is now largely over, with most viral restrictions being lifted and people returning to their normal lives throughout most of the United States. Nevertheless, there are variants of COVID-19 still seen, and thus it is vital to understand patterns in patient populations most affected by the pandemic.

Older adults are at risk for a variety of reasons. One theory is immunosenescence, or that the production of immune cells decreases and there is declination in both innate and acquired immunity. ³ There is also the idea that with age comes subclinical systemic inflammation, or a constant inflammatory state that viral illnesses accentuate, triggering immunologic cascades like cytokine storms that inadvertently cause further damage to the host. ^{4 , 5} Furthermore, older adults are more likely to have comorbidities like diabetes, hypertension, heart disease, chronic kidney disease, and chronic obstructive pulmonary disease (COPD).

Black communities are among several groups disproportionately affected by the COVID-19 pandemic. Early data in the pandemic reported higher mortality rates among urban and rural Black populations than other races and an almost two-fold higher mortality rate than White populations.⁶ For example, by June 2020, 70% of Lousianians who died from COVID-19 were Black, but Black Lousianians comprise only 32% of the state population. ⁷ Meta-analyses from 2021 confirmed this pattern and saw it worsened - they found Black individuals were more likely to contract COVID-19 (1.5-3.5 times more likely), be hospitalized (4 times more likely), and have a greater relative risk of ICU admission (1.93) compared to White ones. With regards to mortality there was some conflicting data, especially when comparing overall mortality (both confirmed and suspected COVID-19 infected individuals) versus case-fatality (deaths from confirmed COVID-19 infections)⁸. Black mortality rates were found to be less than that of White (14.4% vs. 16%) in overall mortality cohort studies, but also found it to be greater than that of Whites with 15% excess death in the Black population as well as 3.2 times the risk for overall mortality, but not about case-fatalities.^{8 , 9} Furthermore, lower socioeconomic status and uninsured status, disproportionately seen in the Black community, were associated with a higher mortality rate from COVID-19. ⁸

COVID-19 health disparities have also been demonstrated across Hispanic communities. Early in the pandemic (2020), a state-wide retrospective cohort in Rhode Island found hospitalized Hispanic patients were more likely to be younger and more likely to have Medicaid or no insurance. They were 2.66 times more likely to need an ICU admission and 3.67 times more likely to need intubation than non-Hispanic Whites. ¹⁰ In 2021, systematic reviews demonstrated that Hispanic community members had 4 times higher rates of COVID-19 infection and higher rates of hospitalization. ^{8 , 9} With regard to mortality, there were 21% excess deaths compared to other races and 3.2 times the mortality risk compared with non-Hispanic whites in overall mortality, but not higher case-fatality rates. ⁹ Like Blacks, Hispanics had a higher comorbidity rate, as well as a higher proportion of essential workers, but decreased access to care compared to non-Hispanic Whites. ⁸

Health disparities disproportionately impacting minoritized populations were studied and demonstrated across disease entities before the COVID-19 pandemic. Uninsured rates for Native American (22%), Hispanic (19%), and Black (12%) populations have been higher than White populations (8%) compounded by non-Whites living in areas with fewer medical offices and access to services. ⁶ Furthermore, the proportion of the population living in poverty for Native Americans (24%), Blacks (22%), and Hispanics (19%) is higher than Whites (9%), further jeopardizing their access to medical care. ⁶ Black patients have disproportionately higher rates of comorbidities, specifically hypertension, diabetes, obesity, and chronic renal disease, which are also risk factors for severe COVID-19 infections. ^{6 , 11} Black patients have been found to present with critical illnesses at a younger age. However, there are racial disparities within hospitals, as minorities are less likely to be admitted timely to cardiac and critical care units. ¹¹ Even at the Intensive Care Unit (ICU) level, Black patients have higher mortality, are less likely to receive early antibiotics and tracheostomy, and have lower quality end-of-life care than White patients.¹²

We conducted a national retrospective study of COVID-19 patients to investigate whether racial/ethnic disparities existed in hospital length-of-stay and in-hospital morbidity.

Study Design and Methods

This is a retrospective cohort study of de-identified patient data from our central billing system comprising over 8.6 million emergency visits annually in over 178 United States hospitals in the HCA Healthcare system¹³. The study received an exempt determination by our institutional review board (study #2021-597). Inclusion criteria were adults aged 18 years and older, a presentation to one of our hospital emergency departments (freestanding and main), and an admission for COVID-19 infection from January 1, 2019, to December 31, 2021. Patients were excluded if they were under 18 years old, were discharged, or developed COVID-19 in the hospital after admission. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Disease severity was defined as mild/moderate if patients were admitted to the medical floor, acute disease defined as the highest level of care being intensive care unit (ICU) and requiring mechanical ventilation and/or vasopressor support, and severe disease characterized as the highest level of care being ICU but not meeting criteria for critical illness. Discharge disposition was further categorized by location (i.e. discharged home, expired in hospital). Outcomes were stratified by sex (male versus female) and racial groups: White, Black, Hispanic, and Other. Statistical analysis consisted of summary statistics (distributions) with medians and interquartile ranges reported for non-normally distributed variables. Linear regression analyses determined factors predictive of outcome. A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using JMP Pro 14.1 for Windows®.

Results

The dataset consisted of 45,360 patients. The cohort was 22% Black, 35% Hispanic, 37% White, and 6% Other. The overall mortality was 15% across all groups (figure 1 ). White patients had the highest mortality rate at 17% compared to 10% in Blacks, 14% in Hispanics, and 15% in Other (ANOVA, p<0.0001). Whites were significantly older upon admission (Wilcoxon rank sum, p<0.0001) with a median age of 71 years (IQR 59-80), compared to Blacks with a median age of 60 years (IQR 46-71), Hispanics with a median age of 57 years (IQR 44-70), and Other races with a median age of 61 years (IQR 48-73) (figure 2 ). Race remained significantly significant in a multivariate model that included age, sex, and race.

Figure 1.

Mortality by Race. Note that White patients had the highest mortality rate.

Figure 2.

Age distribution across races. Note that White patients had the highest median age.

A total of 6484 patients required ICU admission and intubation with hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (P<0.0001, z-test for proportions). Comparatively, 17% of Hispanics required ICU admission and intubation (Figure 3 ). The frequency of treatment with antivirals, steroids, and antibiotics did not vary amongst Blacks, Whites, and Hispanics.

Figure 3.

Percentage of patients admitted to the ICU and intubated, categorized by race. Note that White patients had the lowest ICU and intubation rates.

The overall median hospital length of stay (HLOS) for all races was five days (IQR 3-11). The median HLOS for all non-Whites was 5 days, whereas for Whites, it was six days (p<0.0001). Whites were significantly less likely to be discharged home (P<0.001). A significantly higher proportion of Blacks (3.3%) and Hispanics (4.9%) were on Medicaid compared to Whites (1.6%) (p<0.0001) (Figure 4 ).

Figure 4.

Insurance status broken down by racial group. Black patients have a higher proportion of Medicaid and commercial insurance, while White patients have a higher proportion of Medicare insurance.

Discussion

The COVID-19 pandemic has revealed weaknesses in our healthcare system and the structural and social factors perpetuating health disparities. Although our study noted a higher mortality among White patients (17%), the average age on admission (71) was significantly higher than for other races, a known association with COVID-19 deaths irrespective of race.⁴ The average age of our Black patients on admission was 60, which means a Black patient was likely to be as sick as a White patient more than a decade older. This also suggests that Black patients suffer from baseline poorer health and earlier deterioration from the virus than White patients. While Black patients had a lower in-hospital mortality rate (10%), they were more likely to require the ICU, intubation, hemodynamic support, and overall more interventions which have associated short- and long-term health consequences. We found that a higher proportion of our Black patients compared to our White patients were on Medicaid, suggesting more limited financial resources in this population and thus limited access to healthcare.

Although our results highlighted these findings in the setting of the COVID-19 pandemic, studies in the ICU have long revealed racial and ethnic disparities in care and outcomes. A 2013 study of ICU patients noted that Black Americans were more likely to die from sepsis and other illnesses. Still, there were fewer admissions to cardiac care units and a delay in access to the intensive care unit.¹¹ Furthermore, Black patients were found to have higher ICU admission rates overall, typically required more aggressive measures such as mechanical ventilation, had a higher mortality rate, and were less likely to use or be offered end-of-life care compared to White patients¹⁴. It is widely recognized that these results are related to structural racism and barriers to health care. ¹²

In our study, Hispanic patients had the second-highest mortality rate at 15% compared to 17% of Whites and 10% for Blacks, despite a lower median age of 57 compared with non-Hispanic Whites (71) and Blacks (60). These results, along with a Rhode Island retrospective cohort study that found a similar trend amongst Hispanic patients requiring admission at a younger age as well as an increased need for aggressive measures such as mechanical ventilation and ICU admission, support that Hispanics are more likely to be more adversely affected at a younger age. ¹⁰ Thus, a greater segment of the Hispanic community is at risk from COVID-19-induced morbidity and mortality than other racial/ethnic groups. Similar to the Black community, the Hispanic community is more likely to be uninsured and disproportionately have lower socio-economic status. Our results demonstrate that a higher proportion of Hispanics were on Medicaid than Whites.⁶

One significant factor that affects Blacks and Hispanics more than Whites is the type of job often held by these communities. While approximately 30% of Whites were able to work from home, only 20% of Blacks were able to. ⁶ Furthermore, Blacks and Hispanics were more likely to be “essential workers” - delivery drivers, warehouse workers, housekeepers, janitors, cooks, waitresses, nurses, medical techs, subway/transit operators, and other jobs that require physicality (or strain on the body increasing the risk of infection) and interaction with other people. Many had to continue these jobs due to financial instability and could not “shelter in place” which may have contributed to higher transmission rates and risk for younger patients.

Finally, another contributing component may be testing. A 2021 study of 7061 patients in southeastern Michigan found that Blacks were tested less often but had higher mortality¹⁵. This could result in the sicker Black patients never actually making it to the hospital, which could account for why we found lower mortality among Black patients in our cohort.

Limitations

Our study has several limitations. While we could analyze data from Black and Hispanic populations, we did not analyze other racial/ethnic and identity groups such as Asian American, LGBTQI+, Native American, Alaskan Native, Pacific Islander, Middle Eastern, refugee and other minority communities. Like Blacks and Hispanics, Native Americans also suffered disproportionately high COVID-19 infection rates, hospitalizations, and mortality, but there also is a paucity of studies on this population. ^{6 , 9} Hospital Corporation of America (HCA) has no hospitals on Native American reservations or Pacific Islands. We also lack data regarding uninsured status and primary language, two impactful social determinants of health. Future studies can address these knowledge gaps and follow-up after hospital discharge for assessment of quality of life and comorbidities as much is unknown about COVID-19 “long-haulers.”

Conclusion

This data suggests a multifactorial etiology behind the varying impact of COVID-19 on patients of different racial/ethnic groups in the US. White patients had a higher in-patient mortality rate compared to non-White patients hospitalized for COVID-19; however, Black and other non-White patients were hospitalized for COVID-19 at a much younger age than White patients. Black patients were significantly more likely to require admission to the ICU with the need for mechanical ventilation and hemodynamic support. More granular examinations of other social determinants of health are warranted in order to understand COVID-19 health disparities throughout minority populations fully.

Disclaimer

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.