Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs

In the US, New York City has emerged as the epicenter of the coronavirus disease 2019 (COVID-19) outbreak.¹ As of April 25, 2020, more than 150 000 cases had been reported, which is approximately 17% of total cases in the US.^2,3 New York City is composed of 5 boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), each with unique demographic, socioeconomic, and community characteristics.

Prior analyses have shown health inequities across these boroughs, but whether similar patterns have also emerged amid the COVID-19 pandemic is unknown.⁴ Understanding the patterns could inform public health and policy strategies to mitigate the ongoing spread of COVID-19, and future approaches to address a possible resurgence of the disease. Therefore, in this study, we aimed to examine population characteristics and hospital bed capacities across the 5 boroughs and evaluate whether differences in the rates of COVID-19 testing, hospitalizations, and deaths have emerged in these communities.

The 2018 American Community Survey, an annual nationwide audit conducted by the US Census Bureau, was used to describe the population characteristics of the 5 New York City boroughs. Hospitals and their bed capacities were identified using the American Hospital Association 2016 file and a manual search of hospital websites.

The cumulative number of COVID-19 tests performed, the number of patients with COVID-19 who were hospitalized, and the number of deaths related to COVID-19 according to borough of residence for each patient were obtained using data from the New York City Department of Health and Mental Hygiene and last updated on April 25, 2020.² Both laboratory-confirmed and probable COVID-19 deaths were examined.

Descriptive statistical analyses were performed to calculate the total number of COVID-19 tests, hospitalizations, and deaths per 100 000 persons using the population of each borough as a denominator. Institutional review board approval was not sought due to the use of publicly available, deidentified data, per usual institutional policy.

The total population of New York City was 8 398 748. Across the 5 boroughs, the population density ranged from 8112 per square mile in Staten Island to 71 434 per square mile in Manhattan (Table). The proportion of older adults (aged ≥65 years) was lowest in the Bronx (12.8%) and highest in Manhattan (16.5%), whereas the proportion of black or African American persons was highest in the Bronx (38.3%) and lowest in Staten Island (11.5%).

Household median income was lowest in the Bronx ($38 467) as was the proportion of persons with a bachelor’s degree or higher (20.7%). There were 48 short-term acute care hospitals. The number of hospitals per borough ranged from 2 in Staten Island to 16 in Manhattan. The number of hospital beds per 100 000 population was lowest in Queens (144 beds) and highest in the Bronx (336 beds) and in Manhattan (534 beds).

Among New York City boroughs, there was variation in the number of COVID-19 tests performed per 100 000 population (4599 in the Bronx; 2970 in Brooklyn; 2844 in Manhattan; 3800 in Queens; and 5603 in Staten Island). The number of patients with COVID-19 who were hospitalized per 100 000 population was highest in the Bronx (634) and lowest in Manhattan (331). The number of deaths related to COVID-19 per 100 000 population was also highest in the Bronx (224) and lowest in Manhattan (122) (Figure).

The substantial variation in the rates for COVID-19 hospitalizations and deaths across the New York City boroughs is concerning. The Bronx, which has the highest proportion of racial/ethnic minorities, the most persons living in poverty, and the lowest levels of educational attainment had higher rates of hospitalization and death related to COVID-19 than the other 4 boroughs.

In contrast, the rates for hospitalizations and deaths were lowest among residents of the most affluent borough, Manhattan, which is composed of a predominately white population. Manhattan and the Bronx have the highest number of per capita hospital beds, and Manhattan has the highest population density, indicating that other factors, such as underlying comorbid illnesses, occupational exposures, socioeconomic determinants, and race-based structural inequities may explain the disparate outcomes among the boroughs.^5,6

This study has limitations, including an ecological design and limited follow-up through April 25, 2020. Demographic characteristics for patients who died were not available by borough of residence. The rate of COVID-19 cases was not evaluated given significant variability in testing.

Further studies are needed to examine whether the disproportionate burden of COVID-19 is being borne by lower income and minority communities in other regions of the US.

Accepted for Publication: April 20, 2020.

Corresponding Author: Rishi K. Wadhera, MD, MPP, MPhil, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Ave, Boston, MA 02215 (rwadhera@bidmc.harvard.edu).

Published Online: April 29, 2020. doi:10.1001/jama.2020.7197

Author Contributions: Drs R. Wadhera and Shen had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Yeh and Shen contributed equally.

Concept and design: R. Wadhera, P. Wadhera, Gaba, Figueroa, Yeh, Shen.

Acquisition, analysis, or interpretation of data: R. Wadhera, Figueroa, Joynt Maddox, Shen.

Drafting of the manuscript: R. Wadhera, Figueroa.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: R. Wadhera, Gaba, Shen.

Administrative, technical, or material support: R. Wadhera.

Supervision: P. Wadhera, Yeh.

Conflict of Interest Disclosures: Dr R. Wadhera reported receiving research support from the National Heart, Lung, and Blood Institute (grant K23HL148525-1) and previously serving as a consultant for Regeneron. Dr Figueroa reported receiving research support from the National Center for Advancing Translational Sciences (grant KL2 TR002542) and the Commonwealth Fund. Dr Joynt Maddox reported receiving research support from the National Heart, Lung, and Blood Institute (grant R01HL143421) and the National Institute on Aging (grant R01AG060935); receiving grant support from the Commonwealth Fund; and having prior contract work with the Office of the Assistant Secretary for Planning and Evaluation. Dr Yeh reported receiving research support from the National Heart, Lung, and Blood Institute (grant R01HL136708); serving as a consultant to Biosense Webster; and serving as a consultant to and receiving grants from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic. No other disclosures were reported.

Funding/Support: This work was supported by the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

Role of the Funder/Sponsor: The funder/sponsor 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.

Disclaimer: Dr Joynt Maddox is Associate Editor of JAMA, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.