COVID‐19 Disproportionately Impacts More Vulnerable Rural Hospitals and Communities

RESEARCH OBJECTIVE: We sought to identify the degree to which COVID‐19 burden varied by the risk of financial distress of the hospital and community vulnerability. STUDY DESIGN: Community burden of COVID‐19 was assessed using three per‐capita measures calculated from the New York Times GitHub using data through 12/31/2020 – cumulative identified cases and cumulative deaths measure the cumulative burden on the community and peak case date. Hospital burden was measured using occupancy measures calculated from the US HHS data on COVID‐19 Reported Patient Impact and Hospital Capacity by Facility. The Financial Distress Index (FDI) is an algorithm that uses historical data about hospital financial performance, government reimbursement, organizational characteristics, and market characteristics to predict the current risk of financial distress. The model assigns every rural hospital to one of four financial risk categories: high, mid‐high, mid‐low, or low. Rural hospitals were characterized by their 2020 risk of financial distress level. The Centers for Disease Control and Prevention Social Vulnerability Index (SVI) indicates US counties' relative vulnerability based on 15 social factors covering economy, infrastructure, and community composition. POPULATION STUDIED: We include all rural hospitals defined by the Federal Office of Rural Health Policy. PRINCIPAL FINDINGS: The analytical dataset included 2266 rural hospitals with financial distress, including High (N = 228, 10.1%), Mid‐High (N = 399, 17.6%), Mid‐Low (N = 997, 44.0%) and Low (N = 642, 28.3%). While there were no significant differences in cumulative or peak cases among communities with low or high financial distress hospitals, communities with hospitals in high financial distress had higher death rates per capita (13.4 deaths per 10,000 for High distress vs. 10.6 deaths for Low distress (p < 0.0001). During the last week of December, more distressed hospitals had a higher percent of occupied beds with COVID‐19 patients and lower reported occupancy (both p < 0.01). In regression analyses, more vulnerable communities, as measured by the SVI, had higher death rates (p < 0.001) and lower peak rates (p < 0.001) but no significant difference in cumulative cases per capita. CONCLUSIONS: More vulnerable rural counties have faced a higher COVID‐19 burden in terms of deaths per capita, and they were also more likely to have financially stressed hospitals. IMPLICATIONS FOR POLICY OR PRACTICE: Financially stressed hospitals serving vulnerable communities may need additional support to provide services to their populations, which have been the most burdened by COVID‐19 deaths.