Racial and Ethnic Disparities in Hospitalization Outcomes Among Medicare Beneficiaries During the COVID-19 Pandemic

Abstract

Importance: The COVID-19 pandemic has disproportionately affected racial and ethnic minority populations. However, racial and ethnic disparities in hospitalization outcomes during the pandemic-for both COVID-19 and non-COVID-19 hospitalizations-are poorly understood, especially among older populations.

Objective: To assess racial and ethnic differences in hospitalization outcomes during the COVID-19 pandemic among Medicare beneficiaries.

Design setting and participants: In the 100% traditional Medicare inpatient data, there were 31 771 054 unique beneficiaries in cross-section just before the pandemic (February 2020), among whom 26 225 623 were non-Hispanic White, 2 797 462 were Black, 692 994 were Hispanic, and 2 054 975 belonged to other racial and ethnic minority groups. There were 14 021 285 hospitalizations from January 2019 through February 2021, of which 11 353 581 were among non-Hispanic White beneficiaries, 1 656 856 among Black beneficiaries, 321 090 among Hispanic beneficiaries, and 689 758 among beneficiaries of other racial and ethnic minority groups. Sensitivity analyses tested expanded definitions of mortality and alternative model specifications.

Exposures: Race and ethnicity in Medicare claims from the Social Security Administration.

Main outcomes and measures: In-hospital mortality and mortality inclusive of discharges to hospice, deaths during 30-day readmissions, and 30-day all-cause mortality. Secondary outcomes included discharges to hospice and discharges to postacute care.

Results: The decline in non-COVID-19 and emergence of COVID-19 hospitalizations were qualitatively similar among beneficiaries of different racial and ethnic minority groups through February 2021. In-hospital COVID-19 mortality was not significantly different among Black patients relative to White patients, but was 3.5 percentage points higher among Hispanic patients (95% CI, 2.9-4.1; P < .001) and other racial and ethnic minority patients relative to White counterparts (95% CI, 3.0-4.1; P < .001). For non-COVID-19 hospitalizations, in-hospital mortality among Black patients increased by 0.5 percentage points more than it increased among White patients (95% CI, 0.3-0.6; P < .001), a 17.5% differential increase relative to the prepandemic baseline. This gap was robust to expanded definitions of mortality. Hispanic patients had similar differential increases in expanded definitions of mortality and model specification. Disparities in discharges to hospice and postacute care were evident. In aggregate across COVID-19 and non-COVID-19 hospitalizations, mortality differentially increased among racial and ethnic minority populations during the pandemic.

Conclusions and relevance: In this cohort study, racial and ethnic disparities in mortality were evident among COVID-19 hospitalizations and widened among non-COVID-19 hospitalizations, motivating greater attention to health equity.

Figure 1.. Total Medicare Hospitalizations and Share of Hospitalizations for Patients With COVID-19^a

^aThe rate of COVID-19 and non–COVID-19 hospitalizations for Black, Hispanic, and other racial and ethnic minority groups, and non-Hispanic White traditional Medicare beneficiaries are shown in the shaded regions (left vertical axis). The share of total hospitalizations representing COVID-19 hospitalizations is represented by the line plot (right vertical axis). Other racial and ethnic minority group members included Asian, North American Native, and beneficiaries of “unknown” or “other” race as reported by the Medicare beneficiary race variable from the Social Security Administration. COVID-19 hospitalizations comprise patients who had a diagnosis of COVID-19 during the hospitalization, whether or not COVID-19 was the chief reason for hospitalization. The vertical line denotes February 2020, the last prepandemic month.

Figure 2.. In-Hospital Mortality Among COVID-19 and All Other Hospitalizations^a

^aIn-hospital mortality reflects a discharge status of death and is shown among COVID-19 and non-COVID hospitalizations for Black, Hispanic, other racial and ethnic minority groups, and non-Hispanic White beneficiaries. Other racial and ethnic minority group members included Asian, North American Native, and beneficiaries of “unknown” or “other” race as reported by the Medicare beneficiary race variable from the Social Security Administration. The COVID-19 category comprises all hospitalizations of patients who had a diagnosis of COVID-19, whether or not COVID-19 was the chief reason for hospitalization. The vertical line denotes February 2020, the last prepandemic month.