Racial Disparities in Incidence and Outcomes Among Patients With COVID-19 | Health Disparities | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

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.

Abstract

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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

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.

References
1.
World Health Organization. Report of the WHO-China Joint Mission on coronavirus disease 2019 (COVID-19). Accessed April 10, 2020. https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
2.
The Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Coronavirus COVID-19 global cases. Accessed April 10, 2020. https://coronavirus.jhu.edu/map.html
3.
McMichael  TM , Currie  DW , Clark  S ,  et al; Public Health–Seattle and King County, EvergreenHealth, and CDC COVID-19 Investigation Team.  Epidemiology of COVID-19 in a long-term care facility in King County, Washington.   N Engl J Med. 2020;382(21):2005-2011. doi:10.1056/NEJMoa2005412PubMedGoogle ScholarCrossref
4.
Wang  D , Hu  B , Hu  C ,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.   JAMA. 2020;323(11):1061-1069. doi:10.1001/jama.2020.1585PubMedGoogle ScholarCrossref
5.
Zhou  F , Yu  T , Du  R ,  et al.  Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.   Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3PubMedGoogle ScholarCrossref
6.
Yancy  CW .  COVID-19 and African Americans.   JAMA. 2020;323(19):1891-1892. doi:10.1001/jama.2020.6548PubMedGoogle ScholarCrossref
7.
Milwaukee County. Coronavirus disease (COVID-19). Accessed April 10, 2020. https://county.milwaukee.gov/EN/COVID-19
8.
Wu  Z , McGoogan  JM .  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648PubMedGoogle ScholarCrossref
9.
Burroughs  VJ , Nonas  C , Sweeney  CT ,  et al.  Self-reported comorbidities among self-described overweight African-American and Hispanic adults in the United States: results of a national survey.   Obesity (Silver Spring). 2008;16(6):1400-1406. doi:10.1038/oby.2008.61PubMedGoogle ScholarCrossref
10.
Paeratakul  S , Lovejoy  JC , Ryan  DH , Bray  GA .  The relation of gender, race and socioeconomic status to obesity and obesity comorbidities in a sample of US adults.   Int J Obes Relat Metab Disord. 2002;26(9):1205-1210. doi:10.1038/sj.ijo.0802026PubMedGoogle ScholarCrossref
11.
Nelson  A .  Unequal treatment: confronting racial and ethnic disparities in health care.   J Natl Med Assoc. 2002;94(8):666-668.PubMedGoogle Scholar
12.
US Census Bureau. Health insurance coverage in the United States: 2018. Published November 8, 2019. Accessed April 16, 2020. https://www.census.gov/library/publications/2019/demo/p60-267.html
13.
Richardson  S , Hirsch  JS , Narasimhan  M ,  et al; and the Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
14.
Bajgain  KT , Badal  S , Bajgain  BB , Santana  MJ .  Prevalence of comorbidities among individuals with COVID-19: A rapid review of current literature.   Am J Infect Control. Published online July 10, 2020. doi:10.1016/j.ajic.2020.06.213PubMedGoogle Scholar
15.
Zhou  Y , Yang  Q , Chi  J ,  et al.  Comorbidities and the risk of severe or fatal outcomes associated with coronavirus disease 2019: a systematic review and meta-analysis.   Int J Infect Dis. Published online July 25, 2020. doi:10.1016/j.ijid.2020.07.029PubMedGoogle Scholar
16.
Price-Haywood  EG , Burton  J , Fort  D , Seoane  L .  Hospitalization and mortality among Black patients and White patients with COVID-19.   N Engl J Med. 2020;382(26):2534-2543. doi:10.1056/NEJMsa2011686PubMedGoogle ScholarCrossref
17.
US Census Bureau. Educational attainment. Accessed August 3, 2020. https://www.census.gov/topics/education/educational-attainment.html
18.
US Census Bureau. Income and poverty in the United States: 2018. Published September 10, 2019. Accessed August 3, 2020. https://www.census.gov/library/publications/2019/demo/p60-266.html
19.
Bump  P. Wealthy cities have more coronavirus cases—but, in New York, poorer communities are more affected. The Washington Post. Published April 2, 2020. Accessed April 8, 2020. https://www.washingtonpost.com/politics/2020/04/02/wealthy-cities-have-more-coronavirus-cases-new-york-poorer-communities-are-more-affected/
20.
Cuebiq. Mobility Insights. Accessed April 10, 2020. https://www.cuebiq.com/visitation-insights-covid19/
21.
Kind  AJH , Buckingham  WR .  Making neighborhood-disadvantage metrics accessible—the Neighborhood Atlas.   N Engl J Med. 2018;378(26):2456-2458. doi:10.1056/NEJMp1802313PubMedGoogle ScholarCrossref
22.
University of Wisconsin–Madison. Neighborhood Atlas. Accessed April 18, 2020. https://www.neighborhoodatlas.medicine.wisc.edu/
23.
STROBE Statement. STROBE checklists. Accessed August 7, 2020. https://www.strobe-statement.org/?id=available-checklists
24.
US Centers for Disease Control and Prevention. Information for laboratories about coronavirus (COVID-19). Accessed April 25, 2020. https://www.cdc.gov/coronavirus/2019-ncov/lab/index.html
25.
Pan  W .  Akaike’s information criterion in generalized estimating equations.   Biometrics. 2001;57(1):120-125. doi:10.1111/j.0006-341X.2001.00120.xPubMedGoogle ScholarCrossref
26.
Goyal  P , Choi  JJ , Pinheiro  LC ,  et al.  Clinical characteristics of COVID-19 in New York City.   N Engl J Med. 2020;382(24):2372-2374. doi:10.1056/NEJMc2010419PubMedGoogle ScholarCrossref
27.
US Census Bureau. Housing vacancies and homeownership. Accessed April 28, 2020. https://www.census.gov/housing/hvs/index.html
28.
Beyer  KMM , Laud  PW , Zhou  Y , Nattinger  AB .  Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas.   Cancer. 2019;125(21):3818-3827. doi:10.1002/cncr.32358PubMedGoogle ScholarCrossref
29.
Khazanchi  R , Beiter  ER , Gondi  S , Beckman  AL , Bilinski  A , Ganguli  I .  County-level association of social vulnerability with COVID-19 cases and deaths in the USA.   J Gen Intern Med. 2020;1-4.PubMedGoogle Scholar
30.
The Lancet.  The plight of essential workers during the COVID-19 pandemic.   Lancet. 2020;395(10237):1587. doi:10.1016/S0140-6736(20)31200-9PubMedGoogle ScholarCrossref
31.
Garfield  R , Rudowitz  R , Orgera  K , Damico  A . Understanding the intersection of Medicaid and work: what does the data say? Published August 8, 2019. Accessed August 5, 2020. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/
32.
State of Wisconsin, Department of Health Services. Emergency order #12: safer at home order. Accessed April 20, 2020. https://evers.wi.gov/Documents/COVID19/EMO12-SaferAtHome.pdf
33.
Chowkwanyun  M , Reed  AL  Jr .  Racial health disparities and COVID-19—caution and context.   N Engl J Med. 2020;383(3):201-203. doi:10.1056/NEJMp2012910PubMedGoogle ScholarCrossref
34.
Yudell  M , Roberts  D , DeSalle  R , Tishkoff  S .  Science and society: taking race out of human genetics.   Science. 2016;351(6273):564-565. doi:10.1126/science.aac4951PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close