Higher Hospitalization and Mortality Rates Among SARS-CoV-2 infected Persons in Rural America

Anzalone, A. J.; Horswell, R.; Hendricks, B.; Chu, S.; Hillegass, W.; Beasley, W.; Harper, J.; Rosen, C.; Miele, L.; McClay, J.; Santangelo, S.; Hodder, S.; Consortium, N3C

IMPORTANCE: Rural communities are among the most underserved and resource-scarce populations in the United States (US), yet there are limited data on COVID-19 mortality in rural America. Furthermore, rural data are rarely centralized, precluding comparability across urban and rural regions. OBJECTIVE: The purpose of this study is to assess hospitalization rates and all-cause inpatient mortality among persons with definitive COVID-19 diagnoses residing in rural and urban areas. DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective cohort study from the National COVID Cohort Collaborative (N3C) examines a cohort of 573,018 patients from 27 US hospital systems presenting with SARS-CoV-2 infection between January 2020 and March 2021, of whom 117,897 were hospitalized. A sample of 450,725 hospitalized persons without COVID-19 diagnoses was identified for comparison. EXPOSURES: ZIP Codes provided by source hospital systems were classified by urban-rural gradient through a crosswalk to the US Department of Agriculture Rural-Urban Commuting Area Codes. MAIN OUTCOMES AND MEASURES: Primary outcomes were hospitalization and all-cause mortality among hospitalized patients. Kaplan-Meier analysis and mixed effects logistic regression were used to estimate 30-day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient mortality while controlling for major risk factors. RESULTS: Rural patients were more likely to be older, white, have higher body mass index, and diagnosed with SARS-CoV-2 later in the pandemic compared with their urban counterparts. Rural compared with urban inhabitants had higher rates of hospitalization (23% vs. 19%) and all-cause mortality among hospitalized patients (16% vs. 11%). After adjustment for demographic and baseline differences, rural residents (both urban adjacent and non-adjacent) with COVID-19 were more likely to be hospitalized (Adjusted Odds Ratio (AOR) 1.41, 95% Confidence Interval (CI), 1.37-1.45 and AOR 1.42, CI 1.35-1.50) and to die or be transferred to hospice (AOR 1.62, CI 1.30-1.49 and 1.38, CI 1.30-1.49), respectively. Similar differences in mortality were noted for hospitalized patients without SARS-CoV-2 infection. CONCLUSIONS: Hospitalization and inpatient mortality are higher among rural compared with urban persons with COVID-19, even after adjusting for several factors, including age and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.