Uneven hospital quality associated with higher COVID-19 death rate for black patients

The COVID-19 death rate for black patients would be 10% lower if they had access to the same hospitals as white patients, according to a new study. Researchers at the University of Pennsylvania’s Perelman School of Medicine and OptumLabs, part of the UnitedHealth Group, analyzed data from tens of thousands of hospitalized COVID-19 patients and found that black patients were dying at higher rates than white patients. But the study, published today in JAMA network open, determined that this should not have been the case if more black patients were able to seek care at different hospitals.

Our study finds that black patients perform poorer in large part because they tend to go to poorer performing hospitals. Because patients tend to visit hospitals near their homes, these new findings tell a story of residential racial segregation and reflect the racial history of our country that has been brought to light by the pandemic. “

David Asch, MD, first author of the study, executive director of Penn Medicine’s Center for Health Care Innovation

For many years, housing segregation has been explicitly practiced in the United States. “Redlining,” a term for the systematic denial of housing finance in predominantly black neighborhoods, has resulted in the economic stagnation of communities and limitations on upward mobility among the people who live there. Redlining has cast a shadow over the decades since it was explicitly made illegal: A recent study showed that three out of four neighborhoods marked in red still experience economic hardship, which often includes a lack of access to social resources – y including medical care.

Recently, Asch and other researchers published another study showing the interwoven nature of where patients receive care and whether they survive hospitalization with COVID-19. The study found that the most important factor explaining the differences in hospital death rates was the level of the virus in the community surrounding a hospital: whether there were high rates of COVID-19 cases in the community. , hospital death rates were worse.

In the current study, researchers continued to examine hospital-level differences by examining 10 months of anonymized hospitalization data from more than 44,000 Medicare patients from 1,188 hospitals in 41 states and the District of Columbia. About 33,500 patients were white and nearly 11,000 were black. Looking at the death rate of inpatients within 30 days of admission for each group and including those discharged from palliative care, the researchers show that the overall mortality for white patients was around 12.9%. and 13.5% for black patients.

Part of the reason for the increased mortality in black patients was lower income levels and more comorbid illnesses in these populations. However, the authors wrote in their article that “even though statistical adjustment for patient characteristics explains the racial differences in outcomes, it does not excuse them if these factors are disproportionately represented in black populations due to racist forces “.

Rachel Werner, MD, PhD, executive director of Penn’s Leonard Davis Institute of Health Economics and study co-author, notes that this is not the only problem.

“People often assume that the differences in mortality between blacks and whites are due to higher rates of chronic health problems among blacks,” she said. “But time and time again, research has shown that where black patients receive their care is much more important and that if you factor in where people are hospitalized, the differences in mortality disappear.”

Finally, the researchers performed simulations modeling what would happen if the black patients in the cohort had instead been admitted to the same hospitals as the white patients, and in the same proportion. The death rate in black patients fell from 13.5 percent to 12.2, a drop of just one percentage point that translated into a one-tenth drop in the overall risk of death.

“Our analyzes tell us that if black patients went to the same hospitals as white patients and in the same proportions, we would see equal results,” said Nazmul Islam, PhD, statistician at OptumLabs and co-author of the study. .

While they haven’t explicitly tracked each patient’s place of residence, Asch said the study provides a clue as to how residential segregation policies – such as the now illegal loan denial policies known as the name “redlining” – continue to affect the access of people of color to social services. like health care.

“It is intolerable that we live in a society where black patients are more likely to go to hospitals where death is also more likely,” Asch said. “Centuries of racism have brought us to this level of residential segregation, but one action we can take today is to change policies so that not all hospitals are so dependent on local resources to maintain their quality. COVID-19 has provided a lens through which we can see how much more we still have to travel to achieve justice. “

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