Racial and Ethnic Disparities in Excess Deaths Among Persons With Kidney Failure During the COVID-19 Pandemic, March-July 2020

Abstract

Studies of excess deaths during the coronavirus disease 2019 (COVID-19) pandemic suggest a 19%-21% increase in mortality in the US population from March to July 2020.1Woolf S.H. Chapman D.A. Sabo R.T. Weinberger D.M. Hill L. Excess deaths from COVID-19 and other causes, March-April 2020.JAMA. 2020; 324: 510-513Crossref PubMed Scopus (216) Google Scholar, 2Weinberger D.M. Chen J. Cohen T. et al.Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020.JAMA Intern Med. 2020; 180: 1336-1344Crossref PubMed Scopus (235) Google Scholar, 3Woolf S.H. Chapman D.A. Sabo R.T. Weinberger D.M. Hill L. Taylor D.D.H. Excess deaths from COVID-19 and other causes, March-July 2020.JAMA. 2020; 324: 1562-1564Crossref PubMed Scopus (190) Google Scholar Excess deaths (the difference between observed and expected deaths based on historical trends) capture those directly related to COVID-19 and those due to delayed or foregone medical care or economic disruption. COVID-19 has disproportionately impacted Black and Hispanic populations4Mackey K. Ayers C.K. Kondo K.K. et al.Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths: a systematic review.Ann Intern Med. 2021; 174: 362-373Crossref PubMed Scopus (382) Google Scholar; however, there is limited evidence about racial and ethnic disparities in excess deaths among high-risk populations, such as persons with kidney failure. This national study estimated excess deaths for the kidney failure population by race and ethnicity from March 1 through August 1, 2020. Data on deaths for the US kidney failure population (incident and prevalent dialysis patients and transplant patients) from January 2015 through August 2020 were obtained from the Centers for Medicare and Medicaid Services (CMS) ESRD Death Notification Form (CMS 2746). CMS requires completion of the form by the treating nephrologist within 2 weeks of death for all patients who survive until the 91st day of treatment initiation. Because the form does not list COVID-19 as a separate cause, the study outcome was all-cause mortality. Decedents’ race and ethnicity were identified from the ESRD Medical Evidence Report (CMS 2728). To estimate expected deaths, we applied a Poisson regression model to data pre-COVID (January 4, 2015 to February 29, 2020), adjusting for linear time trend, year fixed effects, and seasonality using Fourier terms (detailed methods in Item S1). We then predicted the expected deaths during the COVID period (March 1 to August 1, 2020) based on the estimated Poisson model (Table S1). We estimated weekly and cumulative excess deaths and the relative increase in excess deaths separately for non-Hispanic White, non-Hispanic Black, and Hispanic patients. Brown University’s Institutional Review Board approved the analyses with a waiver of informed consent. Fig 1A plots weekly numbers of observed, expected, and excess deaths from January 5 through August 1, 2020, showing an increase beginning March 1, with a peak in the week ending April 11. From March 1 through August 1, 2020, there were a total of 6,015 (95% CI, 5,236-6,778) excess deaths (Table 1). There were substantial disparities in excess deaths across racial and ethnic groups (Fig 1B and C ; Table 1), with the highest values observed among non-Hispanic Black patients (2,844 [95% CI, 2,581-3,103]), followed by Hispanic (1,482 [95% CI, 1,209-1,750]) and non-Hispanic White (1,227 [95% CI, 695-1,739]) patients. Black and Hispanic patients accounted for 47% and 25% of all excess deaths, respectively. The relative increase in deaths after March 1 was 28.3% (95% CI, 25.0%-31.7%), 27.1% (95% CI, 20.8%-33.5%), and 5.9% (95% CI, 3.2%-8.6%) for Black, Hispanic, and White patients, respectively. There were substantial state-level variations in the racial and ethnic disparities in excess deaths, with the disparity between Hispanic and White patients increasing over time (Fig S1). Overall, states with larger increases in per capita COVID-19 rates experienced greater increases in excess deaths (Fig S2).Table 1Excess Deaths From March 1 to August 1, 2020, by Race/EthnicityNo. of Observed DeathsNo. of Expected DeathsNo. of Excess DeathsPercent Excess DeathsAll patients44,56738,552 (37,789-39,331)6,015 (5,236-6,778)15.6% (13.3%-17.9%)White, non-Hispanic22,01020,783 (20,271-21,315)1,227 (695-1,739)5.9% (3.2%-8.6%)Black, non-Hispanic12,88410,040 (9,781-10,303)2,844 (2,581-3,103)28.3% (25.0%-31.7%)Hispanic6,9425,460 (5,129-5,733)1,482 (1,209-1,750)27.1% (20.8%-33.5%)Observed deaths are the weekly number of deaths from March 1 to August 1, 2020; expected deaths are estimated as described in the text based on data from January 4, 2015 to February 29, 2020 and are projected forward until August 1, 2020; number of excess deaths is the difference between observed and expected deaths; 95% confidence interval (95% CI) indicated in parentheses. Percent excess deaths equals excess deaths divided by expected deaths; 95% CI estimated using the Delta method (Item S1). Open table in a new tab Observed deaths are the weekly number of deaths from March 1 to August 1, 2020; expected deaths are estimated as described in the text based on data from January 4, 2015 to February 29, 2020 and are projected forward until August 1, 2020; number of excess deaths is the difference between observed and expected deaths; 95% confidence interval (95% CI) indicated in parentheses. Percent excess deaths equals excess deaths divided by expected deaths; 95% CI estimated using the Delta method (Item S1). Among the US kidney failure population, the number of excess deaths from March 1 through August 1, 2020 was 16% higher than expected, similar to reports for the general population.1Woolf S.H. Chapman D.A. Sabo R.T. Weinberger D.M. Hill L. Excess deaths from COVID-19 and other causes, March-April 2020.JAMA. 2020; 324: 510-513Crossref PubMed Scopus (216) Google Scholar, 2Weinberger D.M. Chen J. Cohen T. et al.Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020.JAMA Intern Med. 2020; 180: 1336-1344Crossref PubMed Scopus (235) Google Scholar, 3Woolf S.H. Chapman D.A. Sabo R.T. Weinberger D.M. Hill L. Taylor D.D.H. Excess deaths from COVID-19 and other causes, March-July 2020.JAMA. 2020; 324: 1562-1564Crossref PubMed Scopus (190) Google Scholar However, our results showed stark racial and ethnic disparities in excess deaths: 72% of all excess deaths occurred among Black and Hispanic patients, and the relative increase in deaths among Black and Hispanic patients was more than 4-fold higher than that observed among White patients. The magnitude of these disparities was larger than corresponding relative ratios reported among COVID-19–associated deaths in the general population, reported by Gross et al5Gross C.P. Essien U.R. Pasha S. Gross J.R. Wang S.Y. Nunez-Smith M. Racial and ethnic disparities in population-level Covid-19 mortality.J Gen Intern Med. 2020; 35: 3097-3099Crossref PubMed Scopus (173) Google Scholar to be 3.6 for Black persons and 1.9 for Hispanic persons, and by Bassett et al6Bassett M.T. Chen J.T. Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study.PLoS Med. 2020; 17e1003402Crossref PubMed Scopus (138) Google Scholar to be 3.6 and 2.8, respectively.6Bassett M.T. Chen J.T. Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study.PLoS Med. 2020; 17e1003402Crossref PubMed Scopus (138) Google Scholar The mortality disparities we observed align with the disparities in hospitalization rates reported in the US Renal Data System.7Johansen KL, Chertow GM, Foley RN, et al. US Renal Data System 2020 Annual Data Report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2021;77(4)(suppl 1):Svii-Sviii, S1-S597.Google Scholar Our findings on racial and ethnic disparities in excess deaths are likely explained by inequities in social determinants of health.8Webb Hooper M. Napoles A.M. Perez-Stable E.J. COVID-19 and racial/ethnic disparities.JAMA. 2020; 323: 2466-2467Crossref PubMed Scopus (1212) Google Scholar These determinants include income, living conditions, access to health care, and structural racism, the historical and contemporary societal structures that systematically disadvantage racial/ethnic minorities. Our data do not capture deaths in the first 90 days following treatment initiation, and alternative modeling assumptions may yield different estimates. Further, our data cannot distinguish deaths directly related to COVID-19 from those arising indirectly from the pandemic (eg, delayed or disrupted care). Public health interventions to mitigate the pandemic’s impact on persons with kidney failure must consider the stark racial/ethnic disparities in excess deaths in this population and address the underlying social determinants that generate these disparities. Research idea and study design: DK, ANT; data acquisition: YL; data analysis/interpretation: DK, YL, RT, KHN, SS, MR-H, ANT; statistical analysis: DK; supervision or mentorship: ANT. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual’s own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate. This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under grant R01DK113298-02 and by the Agency for Healthcare Research and Quality under grant R01HS28285. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The authors declare that they have no relevant financial interests. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. Received December 10, 2020. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form February 2, 2021. Download .pdf (.66 MB) Help with pdf files Supplementary File (PDF)Figures S1-S2; Item S1; Table S1