B16-05 Rural Disparities in Outcomes Among Medicare Beneficiaries Experiencing Severe Acute Exacerbation of COPD Across the COVID-19 Pandemic

Abstract Rationale The COVID-19 pandemic caused major disruptions in healthcare delivery, adversely affecting patients with acute, non-COVID-19 illnesses. However, the impact of the pandemic on the management and outcomes of severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) - and whether these effects differed between urban and rural populations - remains unclear. Therefore, we aimed to characterize the epidemiologic trends and rural-urban disparities in severe AECOPD before, during, and after the COVID-19 pandemic. Methods We performed a retrospective cohort study of all episodes of severe AECOPD among fee-for-service Medicare beneficiaries between January 2018 and December 2023, categorized as pre-pandemic (2018-2019), pandemic (2020-2021), and post-pandemic (2022-2023) periods. Severe AECOPD was defined as an emergency department (ED) visit or hospitalization with a principal diagnosis of COPD or secondary diagnoses including AECOPD and acute respiratory failure. The primary outcome was death within 90 days of admission. Secondary outcomes included receipt of invasive and non-invasive mechanical ventilation (IMV or NIMV), in-hospital death, and ED visits or rehospitalizations within 90 days. We used generalized estimating equations, clustering on hospitals and adjusting for beneficiary characteristics, to compare outcomes between time periods and between urban and rural beneficiaries. Results We identified 5,561,048 episodes of severe AECOPD from 2018-2023; 27.9% occurred among rural beneficiaries. A principal diagnosis of COVID-19 was coded among 7.3% of episodes during the pandemic and 6.0% of episodes post-pandemic. Overall, 90-day mortality increased during the pandemic (adjusted odds ratio aOR 1.21; 95% confidence interval CI 1.20-1.22) and decreased below baseline post-pandemic (aOR 0.96 0.96-0.97) (Figure). In-hospital mortality was higher in both the pandemic (aOR 1.36 1.35-1.37) and post-pandemic (aOR 1.02 1.01-1.03) periods. The odds of receiving IMV did not change during the pandemic but were lower post-pandemic (aOR 0.71 0.70-0.72). In contrast, the odds of receiving NIMV were lower during the pandemic (aOR 0.96 0.94-0.98) and returned to baseline post-pandemic. Mortality did not differ by rurality during the pandemic; however, post-pandemic, rural beneficiaries had significantly greater odds of 90-day and in-hospital mortality compared to urban beneficiaries (P 0.0001 for both interactions). Conclusions Overall, Medicare beneficiaries who experienced severe AECOPD during the pandemic had higher mortality compared to the pre-pandemic baseline. While the odds of mortality improved overall in the post-pandemic period, rural beneficiaries had significantly higher odds of 90-day and in-hospital mortality relative to urban beneficiaries. Further work is needed to identify the mediators of disparate mortality among rural beneficiaries. This abstract is funded by: National Institute of Nursing Research