Trends in Racial and Ethnic Disparities in COVID-19 Hospitalizations, by Region

United States, March-December 2020

Sebastian D. Romano, MPH; Anna J. Blackstock, PhD; Ethel V. Taylor, DVM; Suad El Burai Felix, MPH; Stacey Adjei, MPH; Christa-Marie Singleton, MD; Jennifer Fuld, PhD; Beau B. Bruce, MD, PhD; Tegan K. Boehmer, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(15):560-565. 

In This Article

Abstract and Introduction

Introduction

Persons from racial and ethnic minority groups are disproportionately affected by COVID-19, including experiencing increased risk for infection,[1] hospitalization,[2,3] and death.[4,5] Using administrative discharge data, CDC assessed monthly trends in the proportion of hospitalized patients with COVID-19 among racial and ethnic groups in the United States during March–December 2020 by U.S. Census region. Cumulative and monthly age-adjusted COVID-19 proportionate hospitalization ratios (aPHRs) were calculated for racial and ethnic minority patients relative to non-Hispanic White patients. Within each of the four U.S. Census regions, the cumulative aPHR was highest for Hispanic or Latino patients (range = 2.7–3.9). Racial and ethnic disparities in COVID-19 hospitalization were largest during May–July 2020; the peak monthly aPHR among Hispanic or Latino patients was >9.0 in the West and Midwest, >6.0 in the South, and >3.0 in the Northeast. The aPHRs declined for most racial and ethnic groups during July–November 2020 but increased for some racial and ethnic groups in some regions during December. Disparities in COVID-19 hospitalization by race/ethnicity varied by region and became less pronounced over the course of the pandemic, as COVID-19 hospitalizations increased among non-Hispanic White persons. Identification of specific social determinants of health that contribute to geographic and temporal differences in racial and ethnic disparities at the local level can help guide tailored public health prevention strategies and equitable allocation of resources, including COVID-19 vaccination, to address COVID-19–related health disparities and can inform approaches to achieve greater health equity during future public health threats.

Data were obtained from the Premier Healthcare Database Special COVID-19 Release (PHD-SR),* an all-payer, administrative database containing patient-level discharge records (including discharges ending in death) from more than 800 nongovernmental, community, and teaching hospitals across the United States. The database represents 20% of U.S. hospital admissions. Analyses were limited to 655 facilities that submitted data during March–December 2020 and did not have unusual race or ethnicity reporting patterns. COVID-19 hospitalizations were defined as having International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) discharge diagnosis code B97.29 (other coronavirus as the cause of disease classified elsewhere [recommended before the April 1, 2020 release of U07.1]) during March–April 2020 or code U07.1 (COVID-19, virus identified) during April–December 2020. Patient race and ethnicity variables were categorized as Hispanic or Latino of any race (Hispanic), non-Hispanic Asian (Asian), non-Hispanic Black (Black), non-Hispanic White (White), non-Hispanic all other races (other race),§ or race or ethnicity missing (unknown). Patients with unknown race/ethnicity were not included in the trend analyses.

The cumulative proportion (percentage) of hospitalized patients with COVID-19 was calculated as the number of patients with an index COVID-19 hospitalization during March–December 2020 divided by the total number of patients hospitalized during the same period for any reason, including COVID-19. Monthly proportions of hospitalized patients with COVID-19 were calculated as the number of patients with an index COVID-19 hospitalization during a given month divided by the number of patients with a first hospitalization for any reason during the same month. Proportions were stratified by patient race/ethnicity and by four U.S. Census regions** based on facility location. For each region, aPHRs were calculated for each racial and ethnic minority group compared with White patients using multivariable Poisson regression. Confidence intervals were calculated for the cumulative aPHRs using generalized estimating equations to account for clustering within facilities. Changes in the monthly aPHRs for each racial/ethnic group were examined qualitatively. The racial/ethnic distribution among all patients hospitalized in 2019 was compared with that among all non-COVID-19 patients hospitalized in 2020 to assess consistency of racial/ethnic proportions across pandemic and non-pandemic years. Analyses were conducted using SAS (version 9.4; SAS Institute) and R (version 4.0.2; The R Foundation). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.††

During March–December 2020, PHD-SR identified 3,780,251 total unique hospitalized patients, including 298,066 (7.9%) unique patients with a COVID-19 diagnosis. The racial/ethnic distributions of non-COVID-19 patient populations were similar in 2019 and 2020 (Supplementary Table https://stacks.cdc.gov/view/cdc/104959). The racial/ethnic distribution of hospitalized COVID-19 patients differed among U.S. Census regions (Table). In every region, Hispanic patients represented the highest cumulative proportion of hospitalized patients with COVID-19 and highest cumulative aPHR relative to White patients. The monthly patterns in proportions of hospitalized patients with COVID-19 by race and ethnicity varied by U.S. Census region early in the pandemic, but all regions showed increasing proportions of patients hospitalized among all racial/ethnic groups later in 2020 (Figure 1). In the Northeast, the proportion peaked in April and was high for all racial and ethnic minority groups. In the Midwest, the proportion was high among several racial and ethnic minority groups during April–May and peaked in November for all groups. In the South, the proportion among Hispanic and Black patients peaked in July. In the West, the proportion among Hispanic patients was high in July and increased more than that in other racial/ethnic groups during November–December, peaking in December.

Figure 1.

Monthly proportion (percentage) of hospitalized patients with COVID-19, by race/ethnicity* and U.S. Census region — United States, March–December 2020§
*Hispanic persons could be of any race; Asian, Black, White, and Other race persons were non-Hispanic. Other group includes persons who were a race other than Asian, Black, or White, including American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiple races.
Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
§Data from subset of 655 hospitals in Premier Healthcare Database Special COVID-19 Release.

Racial and ethnic disparities in the proportion of hospitalized patients with COVID-19, as measured by aPHRs, were most pronounced early in the pandemic (Figure 2). In the Northeast, relative to White patients, aPHRs were highest for most racial and ethnic minority groups in April, and remained high for Hispanic patients through July, followed by a decrease among all racial and ethnic minority groups through December. In the Midwest, relative to White patients, the aPHR for Black patients was highest in March, and the aPHRs for Asian and Hispanic patients were highest during May–June; aPHRs decreased through November, with slight increases for Black patients and patients of other race in December. In the South, aPHRs for all racial and ethnic minority groups were highest during May–June and decreased through November, except for an increase among Asian patients during September–December. In the West, aPHRs were highest for Hispanic and Black patients in June and for Asian patients and patients of other races in August; aPHRs decreased through November, with slight increases among Hispanic and Asian patients in December.

Figure 2.

Monthly age-adjusted* COVID-19 proportionate hospitalization ratios comparing racial and ethnic minority patients with White patients, by U.S. Census region§ — United States, March–December 2020
*Adjusted for age group using Poisson regression. Age groups were: <18, 18–39, 40–54, 55–64, 65–74, and ≥75 years.
Hispanic persons could be of any race; Asian, Black, White, and Other race persons were non-Hispanic. Other group includes persons who were a race other than Asian, Black, or White, including American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiple races.
§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
Data from subset of 655 hospitals in Premier Healthcare Database Special COVID-19 Release.

*Data in PHD-SR, formerly known as the PHD COVID-19 Database, are released every 2 weeks; release date March 2, 2021; access date March 3, 2021. http://offers.premierinc.com/rs/381-NBB-525/images/PHD_COVID-19_White_Paper.pdf
Facilities were excluded if they reported only one category of race (e.g., all unknown or all White) for all hospitalized patients or only one category of ethnicity (e.g., all unknown) for all hospitalized patients during the analytic period of March–December 2020 (n = 99).
§The other races group includes persons who reported non-Hispanic ethnicity and a race other than Asian, Black, or White, including American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiple races.
Index COVID-19 hospitalization was defined a patient's first hospitalization with a discharge diagnosis of COVID-19 (code B97.29 during March–April or U07.1 during April–December) within the March–December study period.
**Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
††45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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