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Racial Disparities in Incidence and Outcomes Among Patients With COVID-19

Educational Objective
To understand the racial disparities in incidence and outcomes among patients with COVID-19
1 Credit CME
Key Points

Question  Is there an association between race and coronavirus disease 2019 (COVID-19) after controlling for age, sex, socioeconomic status, and comorbidities?

Findings  In this cross-sectional study of 2595 patients, positive COVID-19 tests were associated with Black race, male sex, and age 60 years or older. Black race and poverty were associated with hospitalization, but only poverty was associated with intensive care unit admission.

Meaning  The results of this study indicate that in the first weeks of the COVID-19 pandemic in Milwaukee, Wisconsin, Black race was associated with a positive COVID-19 test and the subsequent need for hospitalization, but only poverty was associated with intensive care unit admission.


Importance  Initial public health data show that Black race may be a risk factor for worse outcomes of coronavirus disease 2019 (COVID-19).

Objective  To characterize the association of race with incidence and outcomes of COVID-19, while controlling for age, sex, socioeconomic status, and comorbidities.

Design, Setting, and Participants  This cross-sectional study included 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020, at Froedtert Health and Medical College of Wisconsin (Milwaukee), the largest academic system in Wisconsin, with 879 inpatient beds (of which 128 are intensive care unit beds).

Exposures  Race (Black vs White, Native Hawaiian or Pacific Islander, Native American or Alaska Native, Asian, or unknown).

Main Outcomes and Measures  Main outcomes included COVID-19 positivity, hospitalization, intensive care unit admission, mechanical ventilation, and death. Additional independent variables measured and tested included socioeconomic status, sex, and comorbidities. Reverse transcription polymerase chain reaction assay was used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Results  A total of 2595 patients were included. The mean (SD) age was 53.8 (17.5) years, 978 (37.7%) were men, and 785 (30.2%) were African American patients. Of the 369 patients (14.2%) who tested positive for COVID-19, 170 (46.1%) were men, 148 (40.1%) were aged 60 years or older, and 218 (59.1%) were African American individuals. Positive tests were associated with Black race (odds ratio [OR], 5.37; 95% CI, 3.94-7.29; P = .001), male sex (OR, 1.55; 95% CI, 1.21-2.00; P = .001), and age 60 years or older (OR, 2.04; 95% CI, 1.53-2.73; P = .001). Zip code of residence explained 79% of the overall variance in COVID-19 positivity in the cohort (ρ = 0.79; 95% CI, 0.58-0.91). Adjusting for zip code of residence, Black race (OR, 1.85; 95% CI, 1.00-3.65; P = .04) and poverty (OR, 3.84; 95% CI, 1.20-12.30; P = .02) were associated with hospitalization. Poverty (OR, 3.58; 95% CI, 1.08-11.80; P = .04) but not Black race (OR, 1.52; 95% CI, 0.75-3.07; P = .24) was associated with intensive care unit admission. Overall, 20 (17.2%) deaths associated with COVID-19 were reported. Shortness of breath at presentation (OR, 10.67; 95% CI, 1.52-25.54; P = .02), higher body mass index (OR per unit of body mass index, 1.19; 95% CI, 1.05-1.35; P = .006), and age 60 years or older (OR, 22.79; 95% CI, 3.38-53.81; P = .001) were associated with an increased likelihood of death.

Conclusions and Relevance  In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. These findings can be helpful in targeting mitigation strategies for racial disparities in the incidence and outcomes of COVID-19.

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Article Information

Accepted for Publication: August 14, 2020.

Published: September 25, 2020. doi:10.1001/jamanetworkopen.2020.21892

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Muñoz-Price LS et al. JAMA Network Open.

Corresponding Author: L. Silvia Muñoz-Price, MD, PhD, Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 (smunozprice@mcw.edu).

Author Contributions: Drs Muñoz-Price and Pezzin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Muñoz-Price, Nattinger, Rivera, Singh, Buchan, Pezzin.

Acquisition, analysis, or interpretation of data: Muñoz-Price, Hanson, Gmehlin, Perez, Singh, Ledeboer, Pezzin.

Drafting of the manuscript: Muñoz-Price, Rivera, Gmehlin, Pezzin.

Critical revision of the manuscript for important intellectual content: Muñoz-Price, Nattinger, Hanson, Perez, Singh, Buchan, Ledeboer, Pezzin.

Statistical analysis: Muñoz-Price, Hanson, Pezzin.

Administrative, technical, or material support: Muñoz-Price, Singh, Ledeboer.

Supervision: Muñoz-Price, Buchan.

Conflict of Interest Disclosures: Dr Nattinger reported receiving grants from the National Institutes of Health and the Advancing Healthier Wisconsin Endowment outside the submitted work. Dr Singh reported receiving consulting fees from Astra Zeneca outside the submitted work. Dr Buchan reported receiving grants and personal fees from BioFire Diagnostics outside the submitted work. No other disclosures were reported.

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