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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.

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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.

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 credit toward the CME of the American Board of Surgery’s Continuous Certification program

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

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