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Are Comorbidities a Greater Concern Than Race in ICU COVID-19 Deaths?

  • Authors: News Author: Neil Osterweil; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 12/3/2021
  • Valid for credit through: 12/3/2022
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, infectious disease specialists, critical care specialists, nurses, pharmacists, and other members of the healthcare team who care for patients with COVID-19.

The goal of this activity is to assess any difference in the length of stay in intensive care units (ICUs) according to race/ethnicity.

Upon completion of this activity, participants will:

  • Compare rates of hospital admission and in-hospital mortality among Black and White patients with COVID-19
  • Assess any difference in length of stay in the ICU according to race/ethnicity among adults with COVID-19
  • Outline implications for the healthcare team


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News Author

  • Neil Osterweil

    Freelance writer, Medscape


    Disclosure: Neil Osterweil has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

  • Esther Nyarko, PharmD

    Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

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Are Comorbidities a Greater Concern Than Race in ICU COVID-19 Deaths?

Authors: News Author: Neil Osterweil; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 12/3/2021

Valid for credit through: 12/3/2022


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

The COVID-19 pandemic has been particularly hard on communities of color, where less opportunity to shelter safely at home and higher rates of chronic illness have potentiated the negative effects of SARS-CoV-2. A previous study by Price-Haywood and colleagues, which was published in the June 25, 2020 issue of the New England Journal of Medicine,[1]used a retrospective cohort design to compare outcomes of Black and White patients with COVID-19 in one large health system in Louisiana.

The analysis included 3481 patients: 70.4% of patients with COVID-19 were Black non-Hispanic, and 29.6% were non-Hispanic White. Black race was associated with higher rates of obesity, diabetes, hypertension, and chronic kidney disease compared with White patients. Black race, older age, and increasing levels of chronic illness were associated with a higher risk for hospitalization for COVID-19. In-hospital mortality was significantly associated with older age and multiple metabolic parameters, but Black race did not appear to be an independent predictor of mortality.

There are less data regarding how race/ethnicity affects hospital length of stay data. The current study by Kumar and colleagues addresses this issue.

Study Synopsis and Perspective

Racial/ethnic disparities in COVID-19 mortality rates may be related more to comorbidities than to demographics, suggest authors of a new study.

Researchers compared the length of stay in intensive care units (ICUs) in 2 suburban hospitals for patients with severe SARS-CoV-2 infections. Their study shows that although the incidence of comorbidities and rates of use of mechanical ventilation and death were higher among Black patients than among patients of other races, length of stay in the ICU was generally similar for patients of all races. The study was conducted by Tripti Kumar, DO, from Lankenau Medical Center, Wynnewood, Pennsylvania, and colleagues.

"Racial disparities are observed in the United States concerning COVID-19, and studies have discovered that minority populations are at ongoing risk for health inequity," Kumar said in a narrated e-poster presented during the American College of Chest Physicians' 2021 annual meeting (CHEST 2021) and published in a supplemental issue of CHEST on October 1, 2021.[2]

"Primary prevention initiatives should take precedence in mitigating the effect that comorbidities have on these vulnerable populations to help reduce necessity for mechanical ventilation, hospital length of stay, and overall mortality," she added.

Higher Death Rates for Black Persons

At the time the study was conducted, the COVID-19 death rate in the United States had topped 500,000 (as of this writing, it stands at approximately 744,000[3]). Of those individuals who died, 22.4% were Black, 18.1% were Hispanic, and 3.6% were of Asian descent. The numbers of COVID-19 diagnoses and deaths were significantly higher in US counties where the proportions of Black residents were higher, the authors noted.

To see whether differences in COVID-19 outcomes were reflected in ICU length of stay, the researchers conducted a retrospective chart review of data on 162 patients admitted to ICUs at Paoli Hospital and Lankenau Medical Center, both in suburban Philadelphia. All patients were diagnosed with COVID-19 from March through June 2020.

In all, 60% of the study population were Black, 35% were White, 3% were Asian, and 2% were Hispanic. Women composed 46% of the sample.

The average length of ICU stay, which was the primary endpoint, was similar among Black patients (15.4 days), White patients (15.5 days), and Asians (16 days). The shortest average hospital stay was among Hispanic patients, at 11.3 days.

The investigators determined that among all races, the prevalence of type 2 diabetes, obesity, hypertension, and smoking was highest among Black patients.

Overall, nearly 85% of patients required mechanical ventilation. Among the patients who required it, 86% were Black, 84% were White, 66% were Hispanic, and 75% were Asian.

Overall mortality was 62%. It was higher among Black patients, at 60%, than among White patients, at 33%. The investigators did not report mortality rates for Hispanic or Asian patients.

Missing Data

Demondes Haynes, MD, FCCP, professor of medicine in the division of pulmonary and critical care and associate dean for admissions at the University of Mississippi Medical Center and School of Medicine, Jackson, Mississippi, who was not involved in the study, told Medscape Medical News that there are some gaps in the study that make it difficult to draw strong conclusions about the findings.

"For sure, comorbidities contribute a great deal to mortality, but is there something else going on? I think this poster is incomplete in that it cannot answer that question," he said in an interview.

He noted that the use of retrospective rather than prospective data makes it hard to account for potential confounders.

"I agree that these findings show the potential contribution of comorbidities, but to me, this is a little incomplete to make that a definitive statement," he said. "I can't argue with their recommendation for primary prevention -- we definitely want to do primary prevention to decrease comorbidities. Would it decrease overall mortality? It might, it sure might, for just COVID-19 I'd say no, we need more information."

No funding source for the study was reported. Kumar and colleagues and Haynes reported no relevant financial relationships.

Study Highlights

  • The study was conducted as a retrospective chart review of 162 patients admitted to 2 ICUs near Philadelphia, Pennsylvania. The study period was March to June 2020.
  • The main study outcome was the length of stay in the ICU.
  • 46% of patients were female. The breakdown of the race/ethnicity of the cohort was as follows:
    • Black -- 60%
    • White -- 35%
    • Asian -- 3%
    • Hispanic -- 2%
  • The average lengths of stay in the ICU (in days) for these racial/ethnic groups were as follows:
    • Black -- 15.4
    • White -- 15.5
    • Asian -- 16
    • Hispanic -- 11.3
  • Black patients had the highest rates of obesity, hypertension, type 2 diabetes, and smoking cigarettes among the racial/ethnic groups studied.
  • Nearly 85% of all patients required mechanical ventilation, with the highest rates among Black (86%) and White (84%) patients.
  • The overall mortality rate in the study cohort was 62%. The respective mortality rates among Black and White patients were 60% and 33%, respectively.

Clinical Implications

  • A previous study by Price-Haywood found that although most patients who were admitted to hospital and subsequently died of COVID-19 were Black, Black race was not an independent risk factor for in-hospital mortality.
  • Although Black race was associated with a higher rate of mortality among inpatients with COVID-19 in the current study by Kumar and colleagues, length of stay in the ICU was not affected by race.
  • Implications for the healthcare team: The healthcare team should continue to prioritize COVID-19 vaccination among Black patients and practice equitable care for patients with COVID-19.


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