[Skip to Content]
[Skip to Content Landing]

Variation in Clinical Treatment and Outcomes by Race Among US Veterans Hospitalized With COVID-19

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

Question  Are there differences in treatment and clinical outcomes of patients hospitalized with COVID-19 associated with race?

Findings  In this cohort study that included 43 222 adult veterans hospitalized with COVID-19, Black veterans had lower odds of receiving COVID-19–specific treatments, including steroids, immunomodulators, and antivirals.

Meaning  These findings suggest that variation in treatment contributes to differences in COVID-19 care between Black and White patients.


Importance  Patients from racially and ethnically minoritized populations, such as Black and Hispanic patients, may be less likely to receive evidence-based COVID-19 treatments than White patients, contributing to adverse clinical outcomes.

Objective  To determine whether clinical treatments and outcomes among patients hospitalized with COVID-19 were associated with race.

Design, Setting, and Participants  This retrospective cohort study was conducted in 130 Department of Veterans Affairs Medical Centers (VAMCs) between March 1, 2020, and February 28, 2022, with a 60-day follow-up period until May 1, 2022. Participants included veterans hospitalized with COVID-19. Data were analyzed from May 6 to June 2, 2022.

Exposures  Self-reported race.

Main Outcomes and Measures  Clinical care processes (eg, intensive care unit [ICU] admission; organ support measures, including invasive and noninvasive mechanical ventilation; prone position therapy, and COVID-19–specific medical treatments) were quantified. Clinical outcomes of interest included in-hospital mortality, 60-day mortality, and 30-day readmissions. Outcomes were assessed with multivariable random effects logistic regression models to estimate the association of race with outcomes not attributable to known mediators, such as socioeconomic status and age, while adjusting for potential confounding between outcomes and mediators.

Results  A total of 43 222 veterans (12 135 Black veterans [28.1%]; 31 087 White veterans [71.9%]; 40 717 [94.2%] men) with a median (IQR) age of 71 (62-77) years who were hospitalized with SARS-CoV-2 infection were included. Controlling for site of treatment, Black patients were equally likely to be admitted to the ICU (4806 Black patients [39.6%] vs 13 427 White patients [43.2%]; within-center adjusted odds ratio [aOR], 0.95; 95% CI, 0.88-1.02; P = .17). Two-thirds of patients treated with supplemental oxygen or noninvasive or invasive mechanical ventilation also received systemic steroids, but Black veterans were less likely to receive steroids (within-center aOR, 0.88; 95% CI, 0.80-0.96; P = .004; between-center aOR, 0.67; 95% CI, 0.48-0.96; P = .03). Similarly, Black patients were less likely to receive remdesivir (within-center aOR, 0.89; 95% CI, 0.83-0.95; P < .001; between-center aOR, 0.68; 95% CI, 0.47-0.99; P = .02) or treatment with immunomodulatory drugs (within-center aOR, 0.77; 95% CI, 0.67-0.87; P < .001). After adjusting for patient demographic characteristics, chronic health conditions, severity of acute illness, and receipt of COVID-19–specific treatments, there was no association of Black race with hospital mortality (within-center aOR, 0.98; 95% CI, 0.86-1.10; P = .71) or 30-day readmission (within-center aOR, 0.95; 95% CI, 0.88-1.04; P = .28).

Conclusions and Relevance  These findings suggest that Black veterans hospitalized with COVID-19 were less likely to be treated with evidence-based COVID-19 treatments, including systemic steroids, remdesivir, and immunomodulatory drugs.

Sign in to take quiz and track your certificates

Buy This Activity
Our websites may be periodically unavailable between 12:00am CT March 25, 2023 and 4:00pm CT March 26, 2023 for regularly scheduled maintenance.

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 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 11, 2022.

Published: October 25, 2022. doi:10.1001/jamanetworkopen.2022.38507

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Castro AD et al. JAMA Network Open.

Corresponding Author: Florian B. Mayr, MD, MPH, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240 (florian.mayr@pitt.edu).

Author Contributions: Drs Mayr and Butt 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. Mr Castro and Dr Mayr contributed equally.

Concept and design: Castro, Mayr, Shaikh, Yende, Butt.

Acquisition, analysis, or interpretation of data: Castro, Mayr, Talisa, Omer.

Drafting of the manuscript: Castro, Mayr.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mayr, Talisa.

Obtained funding: Mayr.

Administrative, technical, or material support: Butt.

Supervision: Mayr, Yende, Butt.

Conflict of Interest Disclosures: Dr. Mayr reported receiving personal fees from Baxter for serving on a racial disparities advisory board outside the submitted work. Dr Butt reported receiving grants to the institution from Gilead Sciences and Merck outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Mayr was supported by grant No. K23GM132688 from the National Institute of General Medical Sciences of the National Institutes of Health. This study was supported by data created by the VA COVID-19 Shared Data Resource and resources and facilities of the Department of Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Health Services Research and Development Service grant No. RES 13-457. This work is also supported by resources and the use of facilities at the VA Pittsburgh Healthcare System and the central data repositories maintained by the VA Information Resource Center, including the Corporate Data Warehouse.

Role of the Funder/Sponsor: The funders 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.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Mackey  K , Ayers  CK , Kondo  KK ,  et al.  Racial and ethnic disparities in COVID-19–related infections, hospitalizations, and deaths: a systematic review.   Ann Intern Med. 2021;174(3):362-373. doi:10.7326/M20-6306 PubMedGoogle ScholarCrossref
Ioannou  GN , Ferguson  JM , O’Hare  AM ,  et al.  Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: a population-based cohort study.   PLoS Med. 2021;18(10):e1003807. doi:10.1371/journal.pmed.1003807 PubMedGoogle ScholarCrossref
Bailey  ZD , Krieger  N , Agénor  M , Graves  J , Linos  N , Bassett  MT .  Structural racism and health inequities in the USA: evidence and interventions.   Lancet. 2017;389(10077):1453-1463. doi:10.1016/S0140-6736(17)30569-X PubMedGoogle ScholarCrossref
Gershengorn  HB , Patel  S , Shukla  B ,  et al.  Association of race and ethnicity with COVID-19 test positivity and hospitalization is mediated by socioeconomic factors.   Ann Am Thorac Soc. 2021;18(8):1326-1334. doi:10.1513/AnnalsATS.202011-1448OC PubMedGoogle ScholarCrossref
Escobar  GJ , Adams  AS , Liu  VX ,  et al.  Racial disparities in COVID-19 testing and outcomes: retrospective cohort study in an integrated health system.   Ann Intern Med. 2021;174(6):786-793. doi:10.7326/M20-6979 PubMedGoogle ScholarCrossref
Localio  AR , Berlin  JA , Ten Have  TR , Kimmel  SE .  Adjustments for center in multicenter studies: an overview.   Ann Intern Med. 2001;135(2):112-123. doi:10.7326/0003-4819-135-2-200107170-00012 PubMedGoogle ScholarCrossref
Uppal  A , Silvestri  DM , Siegler  M ,  et al.  Critical care and emergency department response at the epicenter of the COVID-19 pandemic.   Health Aff (Millwood). 2020;39(8):1443-1449. doi:10.1377/hlthaff.2020.00901 PubMedGoogle ScholarCrossref
French  G , Hulse  M , Nguyen  D ,  et al.  Impact of hospital strain on excess deaths during the COVID-19 pandemic—United States, July 2020-July 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(46):1613-1616. doi:10.15585/mmwr.mm7046a5 PubMedGoogle ScholarCrossref
Kvasnovsky  CL , Shi  Y , Rich  BS ,  et al.  Limiting hospital resources for acute appendicitis in children: lessons learned from the U.S. epicenter of the COVID-19 pandemic.   J Pediatr Surg. 2021;56(5):900-904. doi:10.1016/j.jpedsurg.2020.06.024 PubMedGoogle ScholarCrossref
Weiner-Lastinger  LM , Pattabiraman  V , Konnor  RY ,  et al.  The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.   Infect Control Hosp Epidemiol. 2022;43(1):12-25. doi:10.1017/ice.2021.362 PubMedGoogle ScholarCrossref
Fakih  MG , Bufalino  A , Sturm  L ,  et al.  Coronavirus disease 2019 (COVID-19) pandemic, central-line–associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts.   Infect Control Hosp Epidemiol. 2022;43(1):26-31. doi:10.1017/ice.2021.70 PubMedGoogle ScholarCrossref
Baker  MA , Sands  KE , Huang  SS ,  et al; CDC Prevention Epicenters Program.  The impact of COVID-19 on healthcare-associated infections.   Clin Infect Dis. 2022;74(10):1748-1754. doi:10.1093/cid/ciab688 PubMedGoogle ScholarCrossref
Baden  LR , El Sahly  HM , Essink  B ,  et al; COVE Study Group.  Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine.   N Engl J Med. 2021;384(5):403-416. doi:10.1056/NEJMoa2035389 PubMedGoogle ScholarCrossref
Horby  P , Lim  WS , Emberson  JR ,  et al; RECOVERY Collaborative Group.  Dexamethasone in hospitalized patients with COVID-19.   N Engl J Med. 2021;384(8):693-704. doi:10.1056/NEJMoa2021436 PubMedGoogle ScholarCrossref
Gordon  AC , Mouncey  PR , Al-Beidh  F ,  et al; REMAP-CAP Investigators.  Interleukin-6 receptor antagonists in critically ill patients with COVID-19.   N Engl J Med. 2021;384(16):1491-1502. doi:10.1056/NEJMoa2100433 PubMedGoogle ScholarCrossref
Beigel  JH , Tomashek  KM , Dodd  LE ,  et al; ACTT-1 Study Group Members.  Remdesivir for the treatment of COVID-19—final report.   N Engl J Med. 2020;383(19):1813-1826. doi:10.1056/NEJMoa2007764 PubMedGoogle ScholarCrossref
Ioannou  GN , O’Hare  AM , Berry  K ,  et al.  Trends over time in the risk of adverse outcomes among patients with severe acute respiratory syndrome coronavirus 2 infection.   Clin Infect Dis. 2022;74(3):416-426. doi:10.1093/cid/ciab419 PubMedGoogle ScholarCrossref
Tobin  MJ , Laghi  F , Jubran  A .  Caution about early intubation and mechanical ventilation in COVID-19.   Ann Intensive Care. 2020;10(1):78. doi:10.1186/s13613-020-00692-6 PubMedGoogle ScholarCrossref
Wiltz  JL , Feehan  AK , Molinari  NM ,  et al.  Racial and ethnic disparities in receipt of medications for treatment of COVID-19—United States, March 2020-August 2021.   MMWR Morb Mortal Wkly Rep. 2022;71(3):96-102. doi:10.15585/mmwr.mm7103e1 PubMedGoogle ScholarCrossref
Mayr  FB , Talisa  VB , Shaikh  O , Yende  S , Butt  AA .  Effectiveness of homologous or heterologous COVID-19 boosters in veterans.   N Engl J Med. 2022;386(14):1375-1377. doi:10.1056/NEJMc2200415 PubMedGoogle ScholarCrossref
Butt  AA , Omer  SB , Yan  P , Shaikh  OS , Mayr  FB .  SARS-CoV-2 vaccine effectiveness in a high-risk national population in a real-world setting.   Ann Intern Med. 2021;174(10):1404-1408. doi:10.7326/M21-1577 PubMedGoogle ScholarCrossref
Butt  AA , Yan  P , Shaikh  OS , Mayr  FB , Omer  SB .  Rate and risk factors for severe/critical disease among fully vaccinated persons with breakthrough SARS-CoV-2 infection in a high-risk national population.   Clin Infect Dis. 2022;75(1):e849-e856. doi:10.1093/cid/ciab1023 PubMedGoogle ScholarCrossref
Agrawal  U , Katikireddi  SV , McCowan  C ,  et al.  COVID-19 hospital admissions and deaths after BNT162b2 and ChAdOx1 nCoV-19 vaccinations in 2.57 million people in Scotland (EAVE II): a prospective cohort study.   Lancet Respir Med. 2021;9(12):1439-1449. doi:10.1016/S2213-2600(21)00380-5 PubMedGoogle ScholarCrossref
Butt  AA , Talisa  VB , Yan  P , Shaikh  OS , Omer  SB , Mayr  FB .  Vaccine effectiveness of 3 versus 2 doses of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines in a high-risk national population.   Clin Infect Dis. 2022;75(1):e579-e584. doi:10.1093/cid/ciac178 PubMedGoogle ScholarCrossref
Goldstein  LB , Samsa  GP , Matchar  DB , Horner  RD .  Charlson Index comorbidity adjustment for ischemic stroke outcome studies.   Stroke. 2004;35(8):1941-1945. doi:10.1161/01.STR.0000135225.80898.1cPubMedGoogle ScholarCrossref
K C  M , Oral  E , Straif-Bourgeois  S , Rung  AL , Peters  ES ; C. MK.  The effect of area deprivation on COVID-19 risk in Louisiana.   PLoS One. 2020;15(12):e0243028. doi:10.1371/journal.pone.0243028 PubMedGoogle ScholarCrossref
Berlin  JA , Kimmel  SE , Ten Have  TR , Sammel  MD .  An empirical comparison of several clustered data approaches under confounding due to cluster effects in the analysis of complications of coronary angioplasty.   Biometrics. 1999;55(2):470-476. doi:10.1111/j.0006-341X.1999.00470.x PubMedGoogle ScholarCrossref
Azar  KMJ , Shen  Z , Romanelli  RJ ,  et al.  Disparities In outcomes among COVID-19 patients in a large health care system in California.   Health Aff (Millwood). 2020;39(7):1253-1262. doi:10.1377/hlthaff.2020.00598 PubMedGoogle ScholarCrossref
Gordon  AC , Mouncey  PR , Al-Beidh  F ,  et al; REMAP-CAP Investigators.  Interleukin-6 receptor antagonists in critically ill patients with COVID-19.   N Engl J Med. 2021;384(16):1491-1502. doi:10.1056/NEJMoa2100433 PubMedGoogle ScholarCrossref
Rosas  IO , Bräu  N , Waters  M ,  et al.  Tocilizumab in hospitalized patients with severe COVID-19 pneumonia.   N Engl J Med. 2021;384(16):1503-1516. doi:10.1056/NEJMoa2028700 PubMedGoogle ScholarCrossref
Ader  F , Bouscambert-Duchamp  M , Hites  M ,  et al; DisCoVeRy Study Group.  Remdesivir plus standard of care versus standard of care alone for the treatment of patients admitted to hospital with COVID-19 (DISCOVERY): a phase 3, randomised, controlled, open-label trial.   Lancet Infect Dis. 2022;22(2):209-221. doi:10.1016/S1473-3099(21)00485-0 PubMedGoogle ScholarCrossref
Consortium  WST ; WHO Solidarity Trial Consortium.  Remdesivir and three other drugs for hospitalised patients with COVID-19: final results of the WHO Solidarity randomised trial and updated meta-analyses.   Lancet. 2022;399(10339):1941-1953. doi:10.1016/S0140-6736(22)00519-0 PubMedGoogle ScholarCrossref
Mayr  FB , Yende  S , D’Angelo  G ,  et al.  Do hospitals provide lower quality of care to Black patients for pneumonia?   Crit Care Med. 2010;38(3):759-765. doi:10.1097/CCM.0b013e3181c8fd58 PubMedGoogle ScholarCrossref
Valbuena  VSM , Seelye  S , Sjoding  MW ,  et al.  Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study.   BMJ. 2022;378:e069775. doi:10.1136/bmj-2021-069775 PubMedGoogle ScholarCrossref
Sjoding  MW , Dickson  RP , Iwashyna  TJ , Gay  SE , Valley  TS .  Racial bias in pulse oximetry measurement.   N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240 PubMedGoogle ScholarCrossref
Fawzy  A , Wu  TD , Wang  K ,  et al.  Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19.   JAMA Intern Med. 2022;182(7):730-738. doi:10.1001/jamainternmed.2022.1906 PubMedGoogle ScholarCrossref
Department of Veterans Affairs. COVID-19 response plan. Updated March 23, 2020. Accessed August 12, 2022. https://www.va.gov/opa/docs/VHA_COVID_19_03232020_vF_1.pdf
Gangopadhyaya  A . Do Black and White patients experience similar rates of adverse safety events at the same hospital? Urban Institute. July 2021. Accessed September 21, 2022. https://www.urban.org/sites/default/files/publication/104559/do-black-and-white-patients-experience-similar-rates-of-adverse-safety-events-at-the-same-hospital_0.pdf
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
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

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.