Objectives: Health inequalities were often exacerbated during the emerging epidemic. This study examined urban-rural inequalities among COVID-19 patients aged 65 or above in US Florida from March 2 to May 27, 2020.

Methods: A retrospective cohort study was conducted using individual patient records. Multivariable Poisson and logistic models were used to calculate adjusted incidence of COVID-19 and the associated rates of emergency department (ED) visits, hospitalizations and deaths.

Results: As of May 27, 2020, there were 13,659 elderly COVID-19 patients (people aged 65 or above) in Florida and 14.9% of them died. Elderly people living in small metropolitan areas were less likely to be diagnosed with COVID-19 than those living in large metropolitan areas. There were significant decreasing trends of ED visit and hospitalization rates across metropolitan statuses for both men and women. Those patients living in small metropolitan or rural areas were less likely to be hospitalized than those living in large metropolitan areas (35% and 34% vs. 41%). Elderly women aged 75 or above living in rural areas had 113% higher adjusted incidence of COVID-19 than those living in large metropolitan areas, and the rates of hospitalizations were 29% compared with 46% among those living in large metropolitan areas (OR: 0.37 [0.25-0.54]; p <0.001).

Conclusions: In US Florida, elderly people living in small metropolitan or rural areas suffered heavier burden of COVID-19 than those living in large metropolitan areas.