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Disparities in COVID-19 Outcomes by Race, Ethnicity, and Socioeconomic StatusA Systematic Review and Meta-analysis

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are race and ethnicity–based COVID-19 outcome disparities in the United States associated with socioeconomic characteristics?

Findings  In this systematic review and meta-analysis of 4.3 million patients from 68 studies, African American, Hispanic, and Asian American individuals had a higher risk of COVID-19 positivity and ICU admission than White individuals. Socioeconomic disparity and clinical care quality were associated with COVID-19 mortality and incidence in racial and ethnic minority groups.

Meaning  In this study, members of racial and ethnic minority groups had higher rates of COVID-19 positivity and disease severity than White populations; these findings are important for informing public health decisions, particularly for individuals living in socioeconomically deprived communities.


Importance  COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear.

Objective  To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants.

Data Sources  A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021.

Study Selection  Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria.

Data Extraction and Synthesis  Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model.

Main Outcomes and Measures  The main measures were RRs, ORs, and combined prevalence values.

Results  A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P < .001). The area deprivation index was associated with mortality rates in Asian American and Hispanic individuals (P < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals (P < .001) and African American individuals (P < .001).

Conclusions and Relevance  In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.

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Article Information

Accepted for Publication: September 12, 2021.

Published: November 11, 2021. doi:10.1001/jamanetworkopen.2021.34147

Correction: This article was corrected on December 21, 2021, to fix errors in Figures 1 and 2, and on February 24, 2022, to remove the interpretation of mortality risk estimates from unadjusted regression models.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Magesh S et al. JAMA Network Open.

Corresponding Author: Weg M. Ongkeko, MD, PhD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093 (rongkeko@health.ucsd.edu).

Author Contributions: Dr Ongkeko had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ms Magesh, Mr John, and Mr W. Li contributed equally and are co–first authors.

Concept and design: Magesh, John, W. Li, Mattingly-app, Ongkeko.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Magesh, John, Mattingly-app, Ongkeko.

Critical revision of the manuscript for important intellectual content: Magesh, John, W. Li, Y. Li, Jain, Chang, Ongkeko.

Statistical analysis: Magesh, John, W. Li, Y. Li, Mattingly-app.

Obtained funding: Chang, Ongkeko.

Administrative, technical, or material support: W. Li, Y. Li, Jain, Ongkeko.

Supervision: W. Li, Ongkeko.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant R00RG2369 from the University of California, Office of the President/Tobacco-Related Disease Research Program Emergency COVID-19 Research Seed Funding to Dr Ongkeko.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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