Black Rural Patients Experience Higher Mortality Risk for Health Care-Associated Infection
Investigators also find that the proportion of patients that were admitted to the intensive care unit after hospital admission was much higher for Black rural patients.
Structural racism and disinvestment in rural communities could influence individual health care-associated infection (HAIs) risk and outcomes, according to results of a study published in JAMA Network Open. Investigators note that future work should address structural factors via policy and process challenges to eliminate inequities in health care.1
The Affordable Care Act was put into place to help reduce these inequities, though they still persist in insurance coverage, health care cost, and quality of care. | Image Credit: VILevi | stock.adobe.com
This is not the first time structural racism has been shown to effect health outcomes. Recently, the American Heart Association released data published in Hypertension that linked gender-based racism through microaggression with higher postpartum blood pressure. In the analysis, more than one third of individuals reported at least 1 gendered racial microaggression during their care, with those experiences being associated with a 3-month average systolic and diastolic blood pressure of 2.12 mm Hg and 1.43 mm Hg higher than those who did not experience microaggressions. Furthermore, in the analysis, the highest 3-month average blood pressures were related to individuals who experience microaggressions and lived in areas with higher levels of structural racism.2
In addition to cardiovascular findings, the COVID-19 pandemic further highlighted the inequities of racial and ethnic minority groups, especially with structural racism. In a review published by Health Affairs, the authors define structural racism as operating “through laws and policies that allocate resources in ways that disempower and devalue members of racial and ethnic minority groups, resulting in inequitable access to high-quality care.” The Affordable Care Act was put into place to help reduce these inequities, though they still persist in insurance coverage, health care cost, and quality of care.3
In the current JAMA study, the investigators evaluated the association between these structural factors and HAIs as well as adverse outcomes of HAIs for patient race and urban/rural residence. There were 3 network hospitals included in the study: 1 urban, and 2 suburban. Individuals included in the study were 18 years and older, were admitted for 48 hours or long from January 1, 2017, to August 31, 2020, and were either White or Black. Patients who were in psychiatric, rehabilitation, obstetrics and/or gynecology, and hospice were excluded. Patient race and rurality were the only 2 social determinants of health that were included in the study as they relate most to structural racism and disinvestment in rural communities.1
The final cohort included a total of 214,955 patients with a median age of 63 years and were 50.6% female. Approximately 33.2% were Black urban patients, 0.5% were Black rural patients, 50.4% were White urban patients, and 15.9% were White rural patients. There were 6699 HAIs, including 1572 blood infections, 2497 respiratory infections, and 3146 urine infections, which were not mutually exclusive. HAIs that developed during admission occurred in 1955 Black urban patients, 45 among Black rural patients, 3368 in White urban patients, and 1331 in White rural patients.1
In the study, the authors reported a decreased risk of HAI among Black urban patients and an increased risk among White rural patients when compared with White urban patients. Black rural patients also had a risk similar to White urban patients. There were also no differences in admissions among patients with Medicaid and those from the lowest income neighborhoods. However, investigators also found that the proportion of patients that were admitted to the intensive care unit (ICU) after hospital admission was much higher for Black rural patients (7 admissions [50.0%]) compared with Black urban patients (171 admissions [19.4%]), White urban patients (343 admissions [20.0%]) and for White rural patients (132 admissions [23.0%]).1
Within the multivariable analysis, the investigators noted that Black rural patients had an increased risk of ICU admission and Black urban and White rural patients had similar outcomes to White urban patients. Medicaid and neighborhood income were not associated with ICU admission. Additionally, approximately 17.5% of those with HAI died during admission. For Black rural patients, the proportion was 37.8% (17 patients), 17.2% (337 patients) for Black urban patients, 17.4% (585 patients) for White urban patients, and 17.4% (231 patients) for White rural patients. In the multivariable analysis, Black rural patients had an increased risk of in-hospital death when compared with White urban patients, and White rural and Black urban patients had similar outcomes to White urban patients. There were no significant outcomes in mortality for Medicaid or neighborhood income.1
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