A new study released Thursday, and considered the largest of its kind to date, finds that for black patients hospitalized with the coronavirus, the quality of the hospitals they are admitted to can play a disproportionate role in determining whether they survive. Hospitals mattered more than any other individual trait like age, income, or other medical conditions.
The study, published in the JAMA Network Open, comes after a brutal year in which the coronavirus pandemic and a reinvigorated civil rights movement collided to highlight racial and economic disparities in healthcare. While the virus has killed fewer people in rich white enclaves, it has crushed low-income communities of color – and the chronically underfunded and effectively separated hospitals that served them. Blacks account for about a third of COVID-19 deaths in the United States, even though they only make up about 13% of the population.
“It’s no surprise that black patients can live [near] and therefore go to hospitals that have fewer financial resources and therefore have a harder time providing optimal care, ”David Asch, a professor of medicine at the University of Pennsylvania who led the study, told BuzzFeed News. “There are a variety of elements of our historical past that have tended to create white neighborhoods and black neighborhoods, rich neighborhoods and poor neighborhoods. It is the legacy of our nation’s racial history.
Asch’s team looked at Medicare Advantage data for more than 44,000 patients admitted with COVID-19 at a total of nearly 1,200 hospitals in the United States from January through September of last year. And they looked at the number of people who have died, measured by either dying in hospital or being sent to hospice for end-of-life care within one month of hospital admission.
In their analysis, the researchers took into account differences in other traits – such as age, gender, income, and medical conditions unrelated to COVID-19 – between the groups of black and white patients who died. Even when the other factors were equal, black patients were more likely to die.
Their increased chances of dying did not appear to be rooted in differences in health, such as chronic illnesses like diabetes and heart disease seen in large numbers in black patients. Instead of individual factors, the most direct connection to who ended up dying was where they were hospitalized. Black patients were on average more likely to be admitted to hospitals where patients of all races died at higher rates, according to the analysis. In contrast, white patients tended to attend hospitals where overall survival rates were higher.
Survival rates for blacks and whites could fundamentally stabilize, the researchers calculated, if black patients were treated in the same hospitals and in the same distribution as white patients.
“There are of course many reasons why black patients often perform worse than white patients. But often one of the reasons is that black patients, for various reasons, end up in hospitals with worse outcomes for everyone, ”Asch said.
But her team’s finding matches what is already known about the relationship between segregation of hospitals and the quality of care people of color receive for other conditions, said Amal Trivedi, professor at Brown University. School of Public Health, which was not involved in the study, by email.
It is a dynamic that precedes the pandemic. Black patients are more likely than white patients to have surgery in poor quality hospitals in remote areas. They are more likely to be undertreated and die from pneumonia in hospitals that primarily serve black patients, compared to white patients in hospitals that primarily serve whites.
The reasons for these differences go back even earlier in history – to the Jim Crow era and its aftermath. When black families were legally prohibited from buying homes in the suburbs and denied conventional mortgages, they were unable to accumulate generational wealth and were effectively forced to live in racially segregated neighborhoods. And when downtown neighborhoods became predominantly black, their hospitals closed in greater proportions than those in white neighborhoods.
Many hospitals that still serve low-income minority communities were already hanging by a thread when COVID-19 struck. On the south side of Chicago, where about 1 in 5 people live below the poverty line, Roseland Community Hospital quickly peaked when the virus struck last spring. “We are understaffed, understaffed, underfunded and no one is coming to help us,” the hospital chief told the Chicago Tribune in April 2020. When South Los Angeles became a hot spot of COVID-19 over the winter, sick patients flooded the Martin Luther King Jr. Community Hospital with 131 beds. “The hospital is surrounded by a sea of chronic disease and a lack of access to healthcare,” the CEO told The Guardian.
In some places in the United States, there wasn’t even a hospital to turn to. A record 19 rural hospitals closed in 2020, disproportionately cutting access to health care for black communities in the south and southeast as COVID-19 cases and deaths increased.
The quality of hospitals also likely affected patient care before the pandemic, preparing people for worse outcomes, said Ruqaiijah Yearby, a law professor specializing in racial disparities in health care at the Law School of the United States. University of Saint Louis. “It’s probably a place they went for all of their care, which left them without proper care, and therefore they were more vulnerable to death from COVID-19,” she said.
Previous studies examining racial disparities among COVID-19 deaths in hospitals have been based on smaller data sets from one or a handful of health systems. The largest study to date was based on data from more than 11,000 patients in 92 Catholic hospitals in the Ascension Network, a large private health system. The researchers came to a conclusion similar to that of the study published Thursday, although worded differently: When they controlled the hospitals patients went to, black COVID-19 patients had basically the same chances of survival as their white counterparts.
But experts still wonder what characteristics of a hospital, exactly, could make the biggest differences. This may be a certain volume of COVID-19 cases, the number and training of health workers, or access to key equipment like ventilators. Baligh Yehia, senior vice president of Ascension, said he is trying to unravel these granular factors in future research.
“What about the hospital? “Is the next question,” Yehia said.
The new study also did not examine whether, in the hospitals themselves, black and white COVID-19 patients might be treated differently by staff and whether those differences affect their health. For most other health issues, these two scenarios are important, noted Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis. “Black patients usually have worse outcomes even in the same hospital, AND black patients usually receive care in lower quality hospitals, so the worst outcomes are due to BOTH things,” she said via email. .
Throughout the pandemic, black patients have expressed fear that they will not be taken seriously – sometimes with fatal results, as in the case of Susan Moore, a black doctor who was hospitalized with COVID-19 in an Indiana University hospital late last year. In a viral Facebook video, Moore complained that her white doctors were ignoring her pain and not treating it appropriately. After her death, an investigation concluded that although the medical care she received did not contribute to her death, Moore suffered at the hands of providers who “lacked empathy, compassion and awareness of racial prejudice. implicit ”. The hospital system has apologized for its failures and pledged to increase its diversity and equity education.
And not everyone who is killed by COVID-19 will die in hospital. To understand why black Americans are dying in greater numbers, researchers say it is necessary to explore why many black Americans may not feel comfortable going to the hospital in the first place and may instead die, for example, at home.
“It’s not just about making sure that hospitals in a predominantly black neighborhood are of high quality,” Yearby said. “It’s about making sure it’s a place these patients want to go, feel comfortable, and receive the highest quality care in those places.