Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study

Abstract

Background: There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States.

Methods and findings: This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health.

Conclusions: In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.

Fig 1. Distribution of 16,317 laboratory-confirmed COVID-19 cases in the US Department of Veterans Affairs as of July 22, 2020.

(a) Distribution of all COVID-19 laboratory-confirmed cases in the US Department of Veterans Affairs between February 8 and July 22, 2020, included in the current study. (b) Proportion of positive COVID-19 test results by the proportion of Black individuals in care by site. Map created using R library USMAP (v0.5.0) and RStudio (v3.6.3). COVID-19, coronavirus disease 2019.

Fig 2. Adjusted associations of demographic characteristics with testing positive for COVID-19 and subsequent 30-day mortality as of July 22, 2020.

(a) Positive test result among tested; (b) 30-day mortality among cases. Both models were conditioned on site of care and adjusted for baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), and medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker). *Low number of mortality events in age groups 20–39 and 40–49 thus grouped with 50–59. CI, confidence interval; COVID-19, coronavirus disease 2019; OR, odds ratio.

Fig 3. Racial and ethnic disparities in testing positive for COVID-19, by calendar time, region, and outbreak pattern.

(a) Black versus White individuals; (b) Hispanic versus White individuals. All p < 0.001. Region based on US Census groupings. Outbreak pattern based on site-level percentage of positive tests per month among sites with at least 100 positive COVID-19 tests: early (≥10% in March or April), late (≥10% in June or July), resurgent (≥10% in March or April and June or July), steady (<10% in all months), other (sites with <100 positive tests). Models were conditioned on site of care and adjusted for baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), and medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker). CI, confidence interval; COVID-19, coronavirus disease 2019; OR, odds ratio.