J Korean Med Sci.  2021 Apr;36(13):e100. 10.3346/jkms.2021.36.e100.

Interaction Effects between COVID-19 Outbreak and Community Income Levels on Excess Mortality among Patients Visiting Emergency Departments

  • 1Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
  • 2National Emergency Medical Center, National Medical Center, Seoul, Korea
  • 3Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
  • 4Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, Korea


The objective of this study was to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on excess in-hospital mortality among patients who visited emergency departments (EDs) and to assess whether the excess mortality during the COVID-19 pandemic varies by community income level.
This is a cross-sectional study using the National Emergency Department Information System (NEDIS) database in Korea. The study population was defined as patients who visited all 402 EDs with medical conditions other than injuries between January 27 and May 31, 2020 (after-COVID) and for the corresponding time period in 2019 (before-COVID). The primary outcome was in-hospital mortality. The main exposure was the COVID-19 outbreak, and the interaction variable was county per capita income tax. We calculated the risk-adjusted in-hospital mortality rates by COVID-19 outbreak, as well as the difference-in-difference of risk-adjusted rates between the before-COVID and after-COVID groups according to the county income tax using a multilevel linear regression model with the interaction term.
A total of 11,662,167 patients (6,765,717 in before-COVID and 4,896,450 in afterCOVID) were included in the study with a 1.6% crude in-hospital mortality rate. The riskadjusted mortality rate in the after-COVID group was higher than that in the before-COVID group (1.82% vs. 1.50%, difference: 0.31% [0.30 to 0.33]; adjusted odds ratio: 1.22 [1.18 to 1.25]). The excess in-hospital mortality rate of the after-COVID in the lowest quartile group of county income tax was significantly higher than that in the highest quartile group (difference-in-difference: 0.18% (0.14 to 0.23); P-for-interaction: < 0.01).
During the COVID-19 pandemic, there was excess in-hospital mortality among patients who visited EDs, and there were disparities in excess mortality depending on community socioeconomic positions.


COVID-19; Excess Mortality; Socioeconomic Position
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