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Key Points Question Are the higher in-hospital mortality rates for COVID-19 among American Indian and Alaska Native patients compared with other racial groups associated with differences in comorbidity burden? Findings In this cross-sectional study of 18 731 US adults hospitalized with COVID-19 in 2020, American Indian and Alaska Native patients had a lower mean comorbidity risk score compared with the overall patient population, yet they were significantly more likely than patients of all other races to die in the hospital. Increased COVID-19 in-hospital deaths among American Indian and Alaska Native adults were not associated with increased comorbidity experiences in all populations. Meaning These findings suggest that alternative factors contributing to disparate in-hospital mortality rates among Indigenous communities must be investigated further.

Background Long-standing health disparities experienced by American Indians (AIs) are associated with increased all-cause mortality rates and shortened life expectancies when compared to other races and ethnicities. Nationally, these disparities have persisted with the COVID-19 pandemic as AIs are more likely than all other races to be infected, hospitalized, or die from SARS-CoV-2. The Mississippi Band of Choctaw Indians, the only federally recognized American Indian tribe in the state, has been one of the hardest hit in the nation. Methods Using de-identified data from the University of Mississippi Medical Center’s COVID-19 Research Registry, a retrospective cohort study was conducted to assess COVID-19 inpatient mortality outcomes among adults (≥ age 18) admitted at the state’s safety net hospital in 2020. Results Exactly 41% ( n = 25) of American Indian adults admitted with a deemed diagnosis of COVID-19 died while in hospital, in comparison to 19% ( n = 153) of blacks and 23% ( n = 65) of whites. Racial disparities persisted even when controlling for those risk factors the CDC reported put adults at greatest risk of severe outcomes from the disease. The adjusted probability of inpatient mortality among American Indians was 46% ( p < 0.00) in comparison to 19% among blacks and 20% among whites. Conclusion Although comorbidities were commonly observed among COVID-19 + American Indian inpatients, only one was associated with inpatient mortality. This challenges commonly cited theories attributing disparate COVID-19 mortality experiences among indigenous populations to disparate comorbidity experiences. Expanded studies are needed to further investigate these associations.