COVID-19 Outcomes Tied to Hospital,
Not Just Race

Patrice Wendling

November 19, 2020

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Findings from a national registry reinforce the role racial health disparities play in COVID-19 outcomes but also highlight the contribution hospitals make to the variation in poor outcomes.

Researchers studied 7868 patients hospitalized across 88 sites from January 1 to July 22 of this year in the American Heart Association’s COVID-19 Cardiovascular Disease (CVD) Registry, established early in the pandemic to better understand hospital outcomes and CV complications.

Over the study period, there were 1447 deaths (18.4%) and 768 of these, or 53%, were among Black and Hispanic patients.

In-hospital deaths occurred in 17.6% of Black, 16% of Hispanic, and 19.3% of Asian patients, compared with 21.1% of non-Hispanic White patients (P < .001).

Contrary to expectations, race and ethnicity were not associated with mortality in logistic regression analyses that adjusted for sociodemographic, clinical, and presentation factors and included a random intercept for hospitals to account for variation within and across hospitals.

The fully adjusted odds ratios (ORs) for mortality were 0.93 (95% CI, 0.76 - 1.14) for Black individuals, 0.90 (95% CI, 0.73 - 1.11) for Hispanic patients, and 1.31 (95% CI, 0.96 - 1.80) for Asian persons, compared with non-Hispanic White patients.

"Our headline is not [that] there's no racial or ethnic differences in mortality," Fatima Rodriguez, MD, MPH, assistant professor of medicine (cardiovascular), Stanford University Medical Center, California, told | Medscape Cardiology.

"Black and Hispanic patients made up more than half the deaths, so even if they weren't more likely to die when hospitalized, that still represents a disproportionate burden of mortality just by the sheer number," she said.

Rodriguez pointed out that smaller studies have also found no association between race/ethnicity and mortality. And, importantly, Black and Hispanic patients were overrepresented in the AHA registry, at 25.5% and 33%, but comprised only 10.6% and 9% of the population, respectively, in local census data based on zip codes of the participating hospitals.

"It turns out that where a patient was treated was more significant in terms of the magnitude of the association for mortality differences than race or ethnicity," Rodriguez said.

The median odds ratio across hospitals was 1.99 (95% CI, 1.74 - 2.48) in the fully adjusted model, suggesting the odds of in-hospital death for a patient was 99% higher at one hospital compared with a similar patient treated at another hospital.

"That really suggests that early in the pandemic, we don't have a great evidence base; everybody's kind of figuring it out as we go, and there's different protocols," she said.

Results were similar for the secondary outcome of major adverse cardiovascular events (MACE), which occurred in 21.4% of patients and was defined as death, myocardial infarction, stroke, new-onset heart failure, or cardiogenic shock.

Unadjusted MACE rates were lower in Black (21.4%) and Hispanic (17.7%) patients than in White patients (24.7%, P <.001) but were no longer different after full adjustment.

In the final model, the odds ratios were 0.99 for Black (95% CI, 0.82 - 1.20), 0.88 for Hispanic (95% CI, 0.72 - 1.08), and 1.28 for Asian (95% CI, 0.95 - 1.72) patients, compared with White patients.

The median adjusted odds ratio for MACE across hospitals was 1.92 (95% CI, 1.69 - 2.36).

Most of the feared cardiovascular complications of COVID-19 did not occur as often as anticipated, Rodriguez noted. "Rates of myocarditis were very low; even rates of blood clots, DVTs/pulmonary embolisms were relatively low, under 5%. So that was surprising."

At admission, Black and Hispanic patients were substantially younger, at 60 and 57 years, than White and Asian patients, at 69 and 64 years, and had more adverse socioeconomic factors.

Black patients had the highest prevalence of obesity, hypertension, diabetes, prior cerebrovascular disease, and advanced kidney disease, whereas White patients had the highest prevalence of prior coronary artery disease and pulmonary disease.

Hispanic patients did not have more comorbidities than other racial/ethnic groups. Asian patients had the highest cardiorespiratory disease severity at presentation.

With regard to COVID-19 specific therapies, hydroxychloroquine was the most common. Remdesivir was infrequently used, particularly among Black patients despite a greater need for mechanical ventilation. This may be explained by more advanced kidney disease and lower rates of COVID-19 trial participation among blacks, Rodriguez said.

Table. COVID-19 Specific Therapies

Therapy Non-Hispanic White Black Hispanic Asian/Pacific Islander
Hydroxychloroquine (%) 40.0 42.2 44.4 46.6
Remdesivir (%)  8.0  6.1  9.5  9.2
Tocilizumab (%)  7.5  7.1  6.6  9.4
Steroids (%) 22.3 22.3 19.0 24.1
Convalescent serum (%)  2.9  3.3  2.3  2.8


The results were presented alongside other registry findings during the virtual AHA Scientific Sessions and came days after the AHA issued an advisory statement on structural racism. At its meeting this week, the American Medical Association also formally recognized racism as an urgent threat to public health.

"It's been long coming and long overdue but I'm really proud of our society that we've made this front and center," said Rodriguez, who was part of the writing committee for the AHA advisory statement. "The reason it hasn't been previously addressed is that it's daunting to think of the many things we all need to be doing in our different silos but that's the necessary solution to address these disparities, not just for COVID-19, but for chronic disease in general."

Rodriguez reported event adjudication for NovoNordisk; serving on advisory boards for Janssen and The Medicines Company; consulting for Novartis; and equity in HealthPals.

American Heart Association 2020 Scientific Sessions. Presented November 17, 2020.

Circulation. Published online November 17, 2020. Abstract

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