Black patients may be at increased risk of COVID-19 hospitalization and death
EBM Focus - Volume 15, Issue 22
Reference: N Engl J Med. 2020 May 27
Disparities in health outcomes and healthcare quality related to patient skin color, particularly among non-Hispanic black patients, have been well-documented. COVID-19 has also been reported to disproportionately affect black patients. A recent retrospective cohort study included 3,481 patients (mean age 54 years) with confirmed COVID-19 receiving care in an integrated-delivery health system (Ochsner Health) in New Orleans, Louisiana. Of these patients, 70.4% were non-Hispanic black and 29.6% were non-Hispanic white. Notably, black patients make up only 31% of the patients routinely cared for by Ochsner Health. The study excluded patients with COVID-19 who were not black or white or who did not have race/ethnicity data available.
The primary outcomes analyzed were hospitalization and in-hospital mortality. Black patients had an increased risk of hospitalization in an analysis adjusted for other factors associated with increased odds of hospitalization, including older age, male sex, obesity, residence in a low-income area, and insurance with Medicare or Medicaid (adjusted odds ratio 1.96, 95% CI 1.62-2.37). Among all COVID-19 cases, 70.4% occurred in black patients, and among all patients dying from COVID-19, 70.6% were black. Black patients were not at a higher risk of death after adjustment for age and sex (adjusted hazard ratio vs. white patients 0.89, 95% CI 0.68-1.17). Among deceased patients, black patients were twice as likely to have been treated with mechanical ventilation (73.9% vs. 36.5%).
Several analyses presented in this study suggest that black patients may have been sicker at presentation and had a lower socioeconomic status. More black than white patients presented with fever, cough, and dyspnea, and with higher creatinine, aspartate aminotransferase, or inflammatory marker levels at the time of COVID-19 testing. Black patients were also more likely than white patients to be diagnosed with COVID-19 in an emergency department (65.3% vs. 38%). Black patients were more likely to have obesity (53.9% vs. 39.5%), hypertension (33.8% vs. 23.9%), diabetes (18.5% vs. 10.9%), and chronic kidney disease (9.4% vs. 4.6%). Compared with white patients, black patients were three times as likely to have Medicaid (15% vs. 5%), were less likely to have commercial insurance (47.1% vs. 57.3%), and were almost twice as likely to live in a low-income area (56.9% vs. 29%). Nevertheless, these differences did not entirely explain the disparity in hospitalization between black and white patients.
These results indicate that black patients are more likely to contract COVID-19, which leads to higher rates of hospitalization and death due to COVID-19. While the rates of death among black and white patients with COVID-19 were similar to the rates of infection, black patients were significantly overrepresented among those who were infected. These results are echoed by studies conducted in Georgia, Northern California, Ohio, and the UK. Several factors beyond those considered in this study could account for the significantly higher infection rate in the black population. There is a higher proportion of black individuals in service industry jobs, including working in hospitals, long-term care facilities, or grocery stores, many of which are classified as essential and carry an increased risk of exposure. Additionally, a lower percentage of black employees are able to work from home, thereby limiting their ability to socially distance. Black individuals may also be more likely to live in areas characterized by higher levels of air pollution and a higher proportion of households with crowded living conditions. Additional work is required to elucidate all of the reasons for this glaring disparity in COVID-19 hospitalization and death. However, based on these data, clinicians should bear in mind that black patients are likely at higher risk of COVID-19 infection, and that this leads to a higher risk for COVID-19 hospitalization and mortality.
For more information, see the topic COVID-19 (Novel Coronavirus) in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Terri Levine, PhD, Senior Medical Writer in Obstetrics and Gynecology at DynaMed. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.