Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department

Background There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults. Methods This was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19–related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs). Results In the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6–42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1–47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7–23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9–36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19. Conclusions These preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.


Introduction
Since the first case of coronavirus disease 2019 (COVID- 19) was reported in December 2019, the virus has rapidly spread worldwide, resulting in a pandemic and public health emergency. The United States currently leads the world with 20,558,489 cases and 350,664 deaths as of January 4, 2020 ( 1 ). California is one of the states most affected by COVID-19, reporting 2,391,261 cases and 26,538 deaths to date ( 1 ). Older patients and those with comorbidities (e.g., cardiovascular disease and diabetes) have been found to experience worse outcomes, such as hospitalization, death, and acute respiratory distress syndrome (2)(3)(4)(5)(6)(7)(8)(9)(10). Furthermore, emerging evidence suggests racial and ethnic differences in COVID-19 disease burden. In particular, Hispanic patients are overrepresented in the number of COVID-19 infections and appear to have worse outcomes than other racial and ethnic groups. As of January 4, 2020, there have been 1,684,586 cases of COVID-19 and 26,333 deaths due to this disease among individuals of Hispanic ethnicity in the United States ( 11 ). The overall COVID-19 disease burden among individuals of Hispanic ethnicity (21.6%) in the United States is higher than that observed among other minorities, including those of Black (12.6%), Asian (3.4%), and American Indian or Alaskan Native (1.3%) race and ethnicity, as of January 4, 2020 ( 11 ). In addition, a recent report showed higher rates of hospitalization among Hispanic (46.5%) relative to Black (39.5%) and non-Hispanic White (34.4%) patients with COVID-19 ( 12 ). Studies examining ethnic disparities in clinical presentation and outcomes from COVID-19 are urgently needed. However, there is a dearth of epidemiological data on ethnic differences among patients with COVID-19, especially among adults 65 years and older.
To date, no study has examined the clinical features or outcomes from COVID-19 among older patients presenting to a geriatric emergency department (GED). Common features of GEDs include staff with training in geriatric medicine, evidence-based protocols for geriatric care, and physical modifications to accommodate functional limitations ( 13 , 14 ). GEDs have been shown to improve health outcomes in older adults, such as lowering risk of hospital admission and readmission and reducing length of stay (15)(16)(17)(18)(19)(20). To better inform the emergency care of diverse populations of older adults with COVID-19, we examined clinical characteristics and outcomes from COVID-19 among older U.S. patients aged 65 years and older presenting to two GEDs at a large academic health system. Importantly, nearly half of the older patients with COVID-19 were Hispanic, allowing us to evaluate ethnic differences in clinical presentation and outcomes.

Study Design, Setting, and Population
This was a retrospective cohort study among older U.S. patients with COVID-19 presenting to two GEDs within a single academic health system, University of California (UC) San Diego Health, between March 10, 2020 and August 9, 2020. One GED is located in an urban teaching hospital with a level I trauma center, with an annual census of approximately 50,000 patients per year. The second GED is located in a suburban, communitybased hospital with an annual census of approximately 35,000 patients per year. The suburban hospital consists of an accredited GED with a dedicated space to provide emergency care to adults 65 years and older. The urban ED functions as a GED, but does not have a separate space for older adults. The two GEDs have a shared electronic medical record system. The suburban GED received level I GED accreditation by the American College of Emergency Physicians (the highest level), which is awarded to GEDs that are guided by 20 best practices in education, staffing, policies, protocols, quality improvement, outcome measures, equipment, and physical environment. The urban GED is currently undergoing review for accreditation. The present study was approved by the Human Research Protections Program of University of California, San Diego.
This study included all patients 65 years and older presenting to the GED who tested positive for COVID-19 while in the GED or within 2 h of their triage temperature if admitted and tested after leaving the GED. Two rapid diagnostic tests were used to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the Abbott ID Now COVID-19 assay (Abbott Inc., Chicago, IL), which uses a nasal, nasopharyngeal, or throat swab to detect viral RNA, and the ePLex SARS-CoV-2 (GenMark Diagnostics Inc., Carlsbad, CA), which uses a nasopharyngeal swab to detect virus particles Tests were performed at our health system's clinical laboratory according to U.S. Food and Drug Administration Emergency Use Authorization guidelines.
The following major clinical outcomes after COVID-19 diagnosis, which have been reported previously in studies of patients with COVID-19, were queried: acute medical conditions, including pneumonia (ICD-10 codes J10-J18), acute respiratory distress syndrome (ICD-10 code J80), respiratory failure (ICD-10 code J96), sepsis (ICD-10 code A41), acute kidney failure (ICD-10 code N17), and electrolyte disturbance (ICD-10 code E87); hospitalization; hospital length of stay; intensive care unit (ICU) admission; and death ( 2-10 ). Many patients with COVID-19 with complex care needs were transferred to the intermediate unit, where they received a high level of care, were carefully monitored, and received treatment, or the telemetry unit, where they received cardiac monitoring. In general, only patients with COVID-19 who required a higher level of oxygen support or a ventilator were transferred to the ICU. Here, we report only on ICU admissions (either following the ED or during inpatient stay), because they are of greater clinical interest. We also queried 30-day return visits to the GED after GED or hospital discharge and 30-day hospital readmissions, which have not yet been widely reported in patients with COVID-19. Use of Remdesivir, the antiviral medication approved by the U.S. Food and Drug Administration for treatment of cases of COVID-19 requiring hospitalization, was also collected.

Statistical Analysis
We report the distribution of clinical characteristics and outcomes overall and by ethnicity (Hispanic vs. non-Hispanic). Findings are presented as means and standard deviations for continuous variables, and frequencies and proportions for categorical variables. We also report differences in proportions and mean differences with associated 95% confidence intervals (CIs). Analyses were conducted using SPSS for Windows, Version 25.0 (IBM Corp, Armonk, NY).

Discussion
In a sample of 100 adults 65 years and older who presented with COVID-19 to a GED at a large academic health system, Hispanic patients with COVID-19, who represented 46.0% of the sample, had higher percentage of shortness of breath, pneumonia, acute respiratory distress syndrome, and acute kidney failure relative to non-Hispanic patients with COVID-19. However, rates of     ‡ Represents the mean difference. § Among patients who were admitted to the hospital from the GED (n = 54; n = 24 non-Hispanics; n = 30 Hispanics). Number represents those who returned to the GED within 30 days of hospital discharge. Denominator excludes those who died during hospitalization (n = 18) or were transferred or discharged to continued inpatient care (n = 7). || Among patients who were admitted to the hospital from the GED (n = 54; n = 24 non-Hispanics; n = 30 Hispanics). Number represents those who returned to the GED within 30 days and were again admitted to the hospital. Denominator excludes those who died during hospitalization (n = 18) or were transferred or discharged to continued inpatient care (n = 7).
other poor outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death, were not significantly different between Hispanic and non-Hispanic patients with COVID-19.
Although individuals from underrepresented groups may have higher risk of acquiring COVID-19 than White individuals, not all studies have shown higher rates of severe outcomes from COVID-19 in underrepresented populations ( 22 , 23 ). Similar to our study, in a cohort of 5902 patients with COVID-19 with a median age of 58 years at a large, urban academic medical center, Hispanic patients and non-Hispanic Black patients did not experience worse survival than White patients ( 24 ). A study among 369 patients with COVID-19, among whom 40% were 60 years or older, found an increased risk of hospitalization among Black patients but observed no racial differences in ICU admission, mechanical ventilation, or death ( 23 ). A study in 2729 patients with COVID-19 from Boston Medical Center, in which one-third of patients were 60 years or older, reported higher hospitalization but lower likelihood of death in Hispanic compared with non-Hispanic patients with COVID-19 ( 12 ). That study also observed that Hispanic patients were more likely to be male and have underlying health conditions, including diabetes and obesity, but were less likely to have hypertension than non-Hispanic Whites ( 12 ). A study among 116 patients with COVID-19 with a mean age of 52.6 years who presented to a large urban ED, found that Hispanic patients were more likely to be hospitalized than discharged (54.5% vs. 24.1%), whereas Black, White, and individuals from other races were more likely to be discharged ( 25 ). However, the latter two studies did not report racial or ethnic differences in comorbidities, symptoms, vital signs, critical illnesses, or other clinical outcomes from COVID-19. Our findings extend prior studies by suggesting potential ethnic differences in a few COVID-19-related symptoms (e.g., shortness of breath) and critical conditions (e.g, pneumonia), but also suggest that rates of many poor outcomes, including hospitalization, ICU admission, or death, may not vary by ethnicity.
Ethnic differences in clinical presentation and outcomes from COVID-19 may be due to several factors. It is possible that older Hispanic patients wait longer than non-Hispanic patients to seek care for their infection, which may result in more severe illness on presentation to the health care setting. Prior studies have shown that older patients with COVID-19 with comorbidities, such as cardiovascular disease, chronic kidney disease, or obesity, experience more severe outcomes from COVID-19 ( 21 , 26-28 ). It is possible that ethnic differences in clinical presentation from COVID-19 in our study may be explained in part by higher prevalence of obesity in older Hispanic compared with non-Hispanic patients with COVID-19. In the United States, individuals of Hispanic ethnicity have a 23% higher percentage of obesity than non-Hispanic Whites, placing them at increased risk of severe COVID-19 outcomes ( 29 ). Furthermore, individuals of Hispanic ethnicity are more likely to be employed in essential work settings, such as grocery stories, farms, factories, and transportation, and have low-paying and less stable jobs that lack adequate paid leave benefits ( 30 ). This may force individuals of Hispanic ethnicity in these occupations to continue working when sick, leading to a more serious clinical presentation when visiting the GED.

Limitations
Our study has several limitations. The study design was retrospective and data were extracted from electronic medical records. Our study was limited to a single academic health system and to patients 65 years and older who visited a GED. Thus, findings may not necessarily translate to younger patients with COVID-19 or those seen in other health care settings. We focused on presenting descriptive statistics, given the modest sample size, and thus did not present associations of risk factors with clinical outcomes. However, our preliminary findings highlight important ethnic differences that warrant further examination in larger studies of older patients. Strengths of this study include the ethnically diverse sample with information on a large number of clinical characteristics and outcomes.

Conclusions
We observed ethnic disparities in COVID-19 among adults 65 years and older in this preliminary and initial analysis of patients presenting to two GEDs at a large academic health system. Older Hispanic patients relative to non-Hispanic patients with COVID-19 had a higher percentage of shortness of breath and acute medical conditions, including pneumonia, acute respiratory distress syndrome, and acute kidney failure. However, rates of other poor outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death, did not differ by ethnicity. These preliminary findings suggest that not all poor outcomes among older patients with COVID-19 may differ by ethnicity. Prospective studies are needed to evaluate ethnic disparities in clinical presentation and outcomes from COVID-19 in larger populations of ethnically diverse older patients presenting to the GED. Further studies are also needed to compare our findings with clinical outcomes among patients with COVID-19 presenting to EDs that do not function as GEDs.