Higher hospitalization and mortality rates among SARS‐CoV‐2‐infected persons in rural America

  1. Alfred Jerrod Anzalone
  2. Ronald Horswell
  3. Brian M. Hendricks
  4. San Chu
  5. William B. Hillegass
  6. William H. Beasley
  7. Jeremy R. Harper
  8. Wesley Kimble
  9. Clifford J. Rosen
  10. Lucio Miele
  11. James C. McClay
  12. Susan L. Santangelo
  13. Sally L. Hodder
  14. National COVID Cohort Collaborative (N3C) Consortium

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Abstract

Purpose

Rural communities are among the most underserved and resource‐scarce populations in the United States. However, there are limited data on COVID‐19 outcomes in rural America. This study aims to compare hospitalization rates and inpatient mortality among SARS‐CoV‐2‐infected persons stratified by residential rurality.

Methods

This retrospective cohort study from the National COVID Cohort Collaborative (N3C) assesses 1,033,229 patients from 44 US hospital systems diagnosed with SARS‐CoV‐2 infection between January 2020 and June 2021. Primary outcomes were hospitalization and all‐cause inpatient mortality. Secondary outcomes were utilization of supplemental oxygen, invasive mechanical ventilation, vasopressor support, extracorporeal membrane oxygenation, and incidence of major adverse cardiovascular events or hospital readmission. The analytic approach estimates 90‐day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient adverse events while controlling for major risk factors using Kaplan‐Meier survival estimates and mixed‐effects logistic regression.

Findings

Of 1,033,229 diagnosed COVID‐19 patients included, 186,882 required hospitalization. After adjusting for demographic differences and comorbidities, urban‐adjacent and nonurban‐adjacent rural dwellers with COVID‐19 were more likely to be hospitalized (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI], 1.16‐1.21 and aOR 1.29, CI 1.24‐1.1.34) and to die or be transferred to hospice (aOR 1.36, CI 1.29‐1.43 and 1.37, CI 1.26‐1.50), respectively. All secondary outcomes were more likely among rural patients.

Conclusions

Hospitalization, inpatient mortality, and other adverse outcomes are higher among rural persons with COVID‐19, even after adjusting for demographic differences and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.

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  1. Version published to 10.1111/jrh.12689
  2. ScreenIT

    SciScore for 10.1101/2021.10.05.21264543: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: This retrospective cohort study received Institutional Review Board approval from each investigator’s institution and was reviewed and approved by the N3C Data Access Committee.
    Field Sample Permit: This study followed the Enhancing the Quality and Transparency of Health Research (EQUATOR) reporting guidelines, Reporting of Studies Conducted Using Observational Routinely Collected Health Data (
    Sex as a biological variablenot detected.
    RandomizationThe only specification change identified was the need to include the data provider organization as a fixed or random effect, with the choice of effect type (fixed versus random) found to be irrelevant.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    RECORD).
    RECORD
    suggested: (RECORD, RRID:SCR_009097)
    Concept sets28 contain standardized terminology corresponding to clinical domains (e.g., LOINC, SNOMED CT, ICD-10, RxNorm)
    RxNorm
    suggested: (RxNorm, RRID:SCR_006645)

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: N3C is an observational registry compiling data from multiple diverse participating sites. Therefore, some information may be entirely or partially and non-randomly missing from the database in rural versus urban residents. In our C19 positive cohort, we report incidence of comorbidities in more than two-thirds of our study population, which is similar to those reported in a COVID-19 study across OCHIN, a network of 396 community health centers across 14 states.49 Nonetheless, we examined the possibility that estimated rural effects stemmed from rural and urban patients differing in extent of pre-COVID comorbidity information and found this not to be the case. To some degree, such potential bias can be partly assessed by future analyses, which would include data based on all diagnosed C19+ populations in geographic areas, rather than data limited to C19 patients who received care at N3C collaborating provider systems.50 A second potential confounder is that rural residents with C19 may have been diagnosed later in their disease course than urban residents, leading to a greater risk of serious complications. Additionally, healthcare organizations contributing data to N3C may have cared for more severely ill patients, providing a potential source of bias. Other limitations of the N3C data source include data aggregated from different health systems with different local practices, regulations, and data models, resulting in potential reporting differences, despite ou...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2021.10.05.21264543v1 on medRxiv