Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients With COVID-19 at an Urban Safety-net Medical Center

Boston, Massachusetts, 2020

Heather E. Hsu, MD; Erin M. Ashe, MPH; Michael Silverstein, MD; Melissa Hofman, MSIS; Samantha J. Lange, MPH; Hilda Razzaghi, PhD; Rebecca G. Mishuris, MD; Ravin Davidoff, MBBCh; Erin M. Parker, PhD; Ana Penman-Aguilar, PhD; Kristie E.N. Clarke, MD; Anna Goldman, MD; Thea L. James, MD; Karen Jacobson, MD; Karen E. Lasser, MD; Ziming Xuan, ScD; Georgina Peacock, MD; Nicole F. Dowling, PhD; Alyson B. Goodman, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(27):864-869. 

In This Article

Abstract and Introduction

Introduction

As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19–associated deaths had been reported in the United States.[1] Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19.[2–4] Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness.[5] Safety-net hospitals, such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1–May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged ≥60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged <60 years. A higher proportion of non-ICU inpatients were experiencing homelessness (24.3%), compared with homeless patients who were admitted to the ICU without mechanical ventilation (15.9%), with mechanical ventilation (15.1%), or who died (15.3%). Patient characteristics associated with illness and clinical severity, such as age, race/ethnicity, homelessness, and underlying medical conditions can inform tailored strategies that might improve outcomes and mitigate strain on the health care system from COVID-19.

All adult patients who had a positive reverse transcription–polymerase chain reaction test result for SARS-CoV-2 in ambulatory or inpatient settings at BMC during March 1–May 18, 2020, were included in the analysis. SARS-CoV-2 testing was requisitioned by treating clinicians who were following guidance from the Massachusetts Department of Public Health§.[6] Data on patient age, sex, race/ethnicity, underlying medical conditions, living situation (including homelessness or residing in a nursing home), and clinical status were extracted from BMC's electronic health records. The study was reviewed by the Boston Medical Center and Boston University Medical Campus Institutional Review Board and received a designation of nonhuman subjects research; no identifying information was extracted from the electronic health record because all data were extracted as aggregate counts. Data were collected as part of public health response activities and were determined by CDC not to constitute human subject research. Patient outcomes were assigned to one of five mutually exclusive categories designed to reflect each patient's highest level of COVID-19 clinical severity: exclusive outpatient management, non-ICU inpatient hospitalization, ICU hospitalization without mechanical ventilation, ICU with mechanical ventilation, and all-cause death that occurred in any location (inpatient or otherwise). Hospitalization status as of May 18, 2020, and the highest level of care received by those who died were also determined. All patients who died had been hospitalized; for this analysis, exclusive outpatient management and all categories of hospitalization refer to cases that did not result in death. Underlying medical conditions were defined using International Classification of Diseases, Tenth Revision codes from patients' active condition lists or encounter diagnoses within the electronic health record. Obesity was defined as body mass index ≥30 kg/m2. Homelessness was identified by an encounter registration screening question, use of an inpatient homeless discharge planning service, or registration address listed as a known homeless shelter. Clinical outcomes were examined by demographic characteristics, underlying medical conditions, and living situation. All analyses are descriptive, and no statistical testing was performed.

Among 2,729 patients with laboratory-confirmed COVID-19, 928 (34.0%) were aged ≥60 years, and 1,417 (51.9%) were female (Table 1). Race/ethnicity was known for 91.3% of patients, including 44.6% who identified as black, 30.1% as Hispanic, 13.5% as white, and 3.1% as another race/ethnicity. Overall, approximately one half of all patients (1,543; 56.5%) were managed exclusively as outpatients; 1,088 (39.9%) were hospitalized, including 900 (33.0%) who received non-ICU inpatient care, 69 (2.5%) who received ICU care without mechanical ventilation, 119 (4.4%) who received ICU care with mechanical ventilation, and 98 (3.6%) who died. As of May 18, 2020, among 1,088 hospitalized patients, 104 (9.6%) remained hospitalized. Among 984 patients discharged after hospitalization, 140 (14.2%) were discharged to a BMC-affiliated COVID-19 respite center which opened on April 9, 2020, for persons unable to self-isolate during the post-discharge recovery period.

Older age, male sex, and having one or more underlying medical conditions were more prevalent among patients who were hospitalized or died (Table 1). For example, patients aged ≥60 years accounted for 24.0% (371 of 1,543) of outpatients, but 81.6% (80 of 98) of deaths. In addition, whereas 63.3% of outpatients had one or more underlying medical conditions, 93.3% of those who received mechanical ventilation and 90.8% of those who died had one or more underlying conditions. A higher proportion of black patients had one or more (80.7%) or two or more (61.2%) underlying conditions than did other racial and ethnic groups, whereas a higher proportion of white patients were aged ≥80 years (13.0%) (Table 2). The prevalence of homelessness was higher among those who experienced non-ICU hospitalization (24.3%) than among those who experienced more severe clinical outcomes: prevalence of homelessness was 15.9% among ICU hospitalizations without mechanical ventilation, 15.1% among ICU hospitalizations with mechanical ventilation, and 15.3% among those who died (Table 1).

The clinical severity of illness among patients with COVID-19 varied by race/ethnicity and age. Overall, the hospitalization rate was higher among Hispanic patients (382 of 821, 46.5%) than among black (481 of 1,218; 39.5%) or white (127 of 369; 34.4%) patients (Figure). In particular, among patients aged <60 years, 43.2% (275 of 636) of Hispanic patients were hospitalized, compared with 30.8% (228 of 740) of black patients and 29.8% (61 of 205) of white patients. Although the highest number of deaths occurred among black patients, the highest percentage of deaths occurred among white patients (21 of 369; 5.7%), compared with black (48 of 1,218; 3.9%) and Hispanic (18 of 821; 2.2%) patients. Among patients aged ≥60 years, 11.0% of white, 9.0% of black, and 5.4% of Hispanic patients died.

Figure.

Clinical severity* of illness in patients with COVID-19, by age and race/ethnicity (N = 2,729) — Boston Medical Center, March 1–May 18, 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
*Inpatients include surviving patients whose highest level of care included non–intensive care unit hospitalization or intensive care unit hospitalization with or without invasive mechanical ventilation.

*These authors contributed equally.
https://www.ncbi.nlm.nih.gov/books/NBK401306.
§Guidance from Massachusetts Department of Public Health (MADPH) on clinical and epidemiologic criteria for molecular SARS-CoV-2 testing evolved throughout the study period. Treating clinicians required approval from MADPH to requisition tests until March 15, 2020. In-hospital testing became available at Boston Medical Center on March 24, 2020, and routine testing of all hospitalized patients began on April 27, 2020. MADPH recommended routine molecular testing of persons identified as close contacts of patients with confirmed COVID-19 beginning on May 11, 2020.
https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=83cd09e1c0f5c6937cd9d7513160fc3f&pitd=20180719&n=pt45.1.46&r=PART&ty=HTML.

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