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Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals

Educational Objective
To understand the difference in mortality rate amongst patients hospitalized by COVID-19 based on race in 92 US hospitals
1 Credit CME
Key Points

Question  Is race associated with mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) in the United States?

Findings  In this cohort study of 11 210 individuals with COVID-19 presenting for care at 92 hospitals across 12 states, there was no difference in all-cause, in-hospital mortality between White and Black patients after adjusting for age, sex, insurance status, comorbidity, neighborhood deprivation, and site of care.

Meaning  In this study, race was not independently associated with in-hospital mortality after adjusting for differences in sociodemographic and clinical factors.


Importance  While current reports suggest that a disproportionate share of US coronavirus disease 2019 (COVID-19) cases and deaths are among Black residents, little information is available regarding how race is associated with in-hospital mortality.

Objective  To evaluate the association of race, adjusting for sociodemographic and clinical factors, on all-cause, in-hospital mortality for patients with COVID-19.

Design, Setting, and Participants  This cohort study included 11 210 adult patients (age ≥18 years) hospitalized with confirmed severe acute respiratory coronavirus 2 (SARS-CoV-2) between February 19, 2020, and May 31, 2020, in 92 hospitals in 12 states: Alabama (6 hospitals), Maryland (1 hospital), Florida (5 hospitals), Illinois (8 hospitals), Indiana (14 hospitals), Kansas (4 hospitals), Michigan (13 hospitals), New York (2 hospitals), Oklahoma (6 hospitals), Tennessee (4 hospitals), Texas (11 hospitals), and Wisconsin (18 hospitals).

Exposures  Confirmed SARS-CoV-2 infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample.

Main Outcomes and Measures  Death during hospitalization was examined overall and by race. Race was self-reported and categorized as Black, White, and other or missing. Cox proportional hazards regression with mixed effects was used to evaluate associations between all-cause in-hospital mortality and patient characteristics while accounting for the random effects of hospital on the outcome.

Results  Of 11 210 patients with confirmed COVID-19 presenting to hospitals, 4180 (37.3%) were Black patients and 5583 (49.8%) were men. The median (interquartile range) age was 61 (46 to 74) years. Compared with White patients, Black patients were younger (median [interquartile range] age, 66 [50 to 80] years vs 61 [46 to 72] years), were more likely to be women (2259 [49.0%] vs 2293 [54.9%]), were more likely to have Medicaid insurance (611 [13.3%] vs 1031 [24.7%]), and had higher median (interquartile range) scores on the Neighborhood Deprivation Index (−0.11 [−0.70 to 0.56] vs 0.82 [0.08 to 1.76]) and the Elixhauser Comorbidity Index (21 [0 to 44] vs 22 [0 to 46]). All-cause in-hospital mortality among hospitalized White and Black patients was 23.1% (724 of 3218) and 19.2% (540 of 2812), respectively. After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95% CI, 0.80 to 1.09).

Conclusions and Relevance  Although current reports suggest that Black patients represent a disproportionate share of COVID-19 infections and death in the United States, in this study, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: July 14, 2020.

Published: August 18, 2020. doi:10.1001/jamanetworkopen.2020.18039

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Yehia BR et al. JAMA Network Open.

Corresponding Author: Baligh R. Yehia, MD, MPP, Ascension Health, 4600 Edmundson Rd, St Louis, MO 63134 (baligh.yehia@ascension.org).

Author Contributions: Drs Winegar and Ottenbacher had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Yehia, Winegar, Fogel, Fakih, Jesser, Cacchione.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Yehia, Winegar, Jesser, Bufalino.

Critical revision of the manuscript for important intellectual content: Yehia, Fogel, Fakih, Ottenbacher, Jesser, Huang, Cacchione.

Statistical analysis: Winegar, Ottenbacher, Jesser, Bufalino.

Administrative, technical, or material support: Yehia, Winegar, Fogel, Fakih, Huang, Cacchione.

Supervision: Yehia, Winegar, Cacchione.

Conflict of Interest Disclosures: Dr Fogel reported being a physician-owner of St Vincent Heart Center of Indiana, with an ownership stake of less than 1%. No other disclosures were reported.

Additional Contributions: We are grateful to the Ascension clinical teams for their contributions to this work: Alabama (Timothy Bode, MD); Florida (Frank Gilberstadt, MD); Illinois (Stuart Marcus, MD); Indiana (Stephen Swinney, MD); Kansas (Edward Hett, MD); Maryland (Nancy Hammond, MD); Michigan (Donald Bignotti, MD); New York (Kathy Connerton, MD); Oklahoma (Timothy Young, MD); Tennessee (Gregory James, MD); Texas (Samson Jesudass, MD); and Wisconsin (Gregory Brusko, DO). Acquisition and validation of the data required for these analyses would not have been possible without the contributions of Ascension Texas institutional review board (Ryan Leslie, PhD), Ascension Data Sciences Institute (Joe Tansey, PhD, Joe Wallace, and Karthik Raja, MS), Ascension Data Discovery and Governance (Kelly Endermuhle, RN, MSN, Margie Cornwell, RDMS, PMP, Gagan Singh and their teams), and AMITA Health (Stuart Marcus, MD, and Monika Tickoo).

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