Black patients hospitalized with Covid-19 were more likely to die or be discharged to hospice than White patients even after adjusting for social, demographic, and clinical factors—and the disparity hinged on the different hospitals to which Black and White patients were admitted, researchers found.
Since the Covid-19 pandemic first began in 2020, Black patients have faced worse outcomes than White patients—they have been more likely to become infected with SARS-CoV-2, to be hospitalized with Covid-19, and to die from the disease. Despite this, David A. Asch, MD, MBA, of the Division of General Internal Medicine at University of Pennsylvania in Philadelphia, and colleagues pointed out that most early studies of hospitalized patients found no differences in mortality by race after adjusting for patient-level characteristics.
“However, even if statistical adjustment for patient characteristics explains racial differences in outcome, it does not excuse them if those factors are disproportionately represented in Black populations as a result of discrimination,” Asch and colleagues wrote in JAMA Network Open. “If so, adjusting for such factors risks obscuring, rather than highlighting, the structural mechanisms that disadvantage Black patients. Racial differences in the outcomes of patients with Covid-19 might also arise if Black patients disproportionately receive care at hospitals delivering worse care for all.”
Asch and colleagues used a large national database of Medicare Advantage beneficiaries hospitalized with Covid-19 to examine differences in mortality between Black and White patients, noting that unlike previous studies, their analysis “focused explicitly on isolating the association of mortality with patient-level factors and the admitting hospital.”
Their findings suggested that, while differences in mortality outcomes between Black and White patients were partly explained by adjustment for social, demographic, and clinical factors also associated with race, racial differences in the mortality of patients hospitalized with Covid-19 persisted after adjusting for these factors.
“Those differences are almost entirely explained by the hospitals to which Black and White patients were admitted,” they wrote. “Addressing hospital segregation and the uneven resourcing and quality of hospitals that provide care to a disproportionate number of Black patients may help address racial differences in the mortality rate.”
“It has been said that statistics are people with the tears washed away,” David W. Baker, MD, MPH, of The Joint Commission in Oakbrook Terrace, Illinois, wrote in an invited commentary accompanying the study. “Every death in these figures represents a loss for a family and community. It is time for a reckoning, a full elucidation, of why Covid-19 mortality disparities occurred. The study by Asch and colleagues provides important insights into one facet of the problem: disparities in mortality for hospitalized patients.”
Baker argued that the long legacy of structural racism is largely to blame for disparities in hospital care, noting that prior to the passage of Medicare in 1965, Black patients were often denied hospital admission or admitted to separate facilities—and even after Medicare integrated hospitals, “there were no major policies or funding initiatives to ensure that the inferior conditions in hospitals that disproportionately cared for Black patients were rectified,” he pointed out.
Black communities have persistently suffered from financial challenges and limited resources due to structural racism, he added, with communities subjected to redlining, predatory lending practices, unequal schooling and limited job opportunities that contribute to lower community income, and low revenues for local hospitals. What’s more, Black communities were likely hit harder during the early days of the Covid-19 pandemic due to higher proportions of “people working in essential services, lack of paid sick time, lack of clear public health messaging targeting Black communities, distrust of public health messages and the health care system, poor access to testing, and financial and nonfinancial barriers to care.”
Baker concluded that to make headway in the fight to address racial disparities in health care outcomes, “we must understand the full set of root causes for disparities in Covid-19 incidence and mortality and use a broad combination of policies and programs to mitigate them and move our country toward equity. But we must dig deep. We must trace these roots to their origin, for there we find the legacy of structural racism, the most difficult and lasting cause that we must finally address if we are to succeed.”
For their analysis, Asch and colleagues pulled data on Medicare beneficiaries hospitalized with a diagnosis of Covid-19 in 1,188 U.S. hospitals from Jan. 1 through Sept. 21, 2020. The primary outcome was a composite of either inpatient mortality or discharge to hospice within 30 days of initial admission for Covid-19. The study authors explained that this composite offered a more complete representation of the outcome of interest than mortality alone, since it “reflects an outcome closer to 30-day any-site mortality, given known racial differences in hospice use.”
The study authors estimated the association of patient-level characteristics—age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since Jan. 1, 2020 (as later admission dates might impact patient outcomes as hospitals gained experience fighting Covid-19)—with differences in outcome among Black and White patients. To examine the association with the hospital itself, they also adjusted for the specific hospitals to which patients were admitted.
They also used simulation modeling to estimate mortality among Black patients if they had instead been admitted to the hospitals where White patients were primarily admitted.
The final analysis consisted of 44,217 Medicare beneficiaries hospitalized with Covid-19 (24,281 [55%] women; mean [SD] age, 76.3 [10.5]; 33,459 [76%] White, 10,758 [24%] Black).
Among the findings:
- “Overall, 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 within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients.
- “Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients.”
- After adjusting for patient-level characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19)—a difference which “became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10).”
Furthermore, Asch and colleagues found that, if Black patients were instead admitted to the same hospitals as White patients in the same distribution, the rate of mortality or discharge to hospice would be lower than that of White patients, dropping from 13.48% to 12.23% (95% CI for difference, 1.20%-1.30%). “This is a novel finding,” they wrote, “and it adds to the evidence of structural factors that disproportionately burden the health of Black people in the U.S.”
In his commentary, Baker noted several strengths of the analysis by Asch et al, including its large, national patient sample, including information about comorbidities, and using discharge to hospice as part of the composite outcome. However, he also acknowledged that there was no evidence of differential outcomes within individual hospitals that could raise concerns of differential treatment, as Black and White patients had similar outcomes after adjusting for site of care.
“This should not be interpreted as evidence that there was no differential treatment of Black and White patients within individual hospitals, since the study was not designed to examine this,” he argued. “However, it does suggest that although disparities are usually due to a combination of who you are (individual characteristics) and where you go for care (structural factors), for outcomes after Covid-19 hospitalization, the latter plays the larger role and must be addressed if we are to eliminate disparities.”
Study limitations included restricting the analysis to Medicare Advantage beneficiaries from a single U.S. insurer, the inability to measure out-of-hospital mortality rates, and a lack of measurement of morbidity and disability outcomes among survivors.
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Even after adjusting for patient-level factors, Black patients hospitalized with Covid-19 were more likely to die or be discharged to hospice than White patients, a difference that was primarily attributable to the different hospitals to which Black and White patients were admitted.
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If Black patients with Covid-19 were instead admitted to the same hospitals as White patients in the same distribution, the rate of mortality or discharge to hospice would have declined.
John McKenna, Associate Editor, BreakingMED™
The sources referenced in this article had no relevant relationships to disclose.
Cat ID: 190
Topic ID: 79,190,585,730,933,190,926,192,927,151,928,925,934
