Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study

Abstract

Objective: To describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including frailty and inflammatory markers.

Setting: Five acute National Health Service Hospitals in east London.

Design: Prospectively defined observational study using registry data.

Participants: 1737 patients aged 16 years or over admitted to hospital with confirmed COVID-19 infection between 1 January and 13 May 2020.

Main outcome measures: The primary outcome was 30-day mortality from time of first hospital admission with COVID-19 diagnosis during or prior to admission. Secondary outcomes were 90-day mortality, intensive care unit (ICU) admission, ICU and hospital length of stay and type and duration of organ support. Multivariable survival analyses were adjusted for potential confounders.

Results: 1737 were included in our analysis of whom 511 had died by day 30 (29%). 538 (31%) were from Asian, 340 (20%) black and 707 (40%) white backgrounds. Compared with white patients, those from minority ethnic backgrounds were younger, with differing comorbidity profiles and less frailty. Asian and black patients were more likely to be admitted to ICU and to receive invasive ventilation (OR 1.54, (95% CI 1.06 to 2.23); p=0.023 and OR 1.80 (95% CI 1.20 to 2.71); p=0.005, respectively). After adjustment for age and sex, patients from Asian (HR 1.49 (95% CI 1.19 to 1.86); p<0.001) and black (HR 1.30 (95% CI 1.02 to 1.65); p=0.036) backgrounds were more likely to die. These findings persisted across a range of risk factor-adjusted analyses accounting for major comorbidities, obesity, smoking, frailty and ABO blood group.

Conclusions: Patients from Asian and black backgrounds had higher mortality from COVID-19 infection despite controlling for all previously identified confounders and frailty. Higher rates of invasive ventilation indicate greater acute disease severity. Our analyses suggest that patients of Asian and black backgrounds suffered disproportionate rates of premature death from COVID-19.

Keywords: adult intensive & critical care; epidemiology; public health; respiratory infections.

Figure 1

Heat map of prognostic factors in COVID-19 hospital admissions by age and ethnic background showing proportions within each ethnic group for each age group. Asian and black patients differed from those of white background in the presence of risk factors and their age distribution, however, differences were also apparent between different black and minority ethnic groups at different ages. Proportions are of those with data (see table 1). BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HT, hypertension.

Figure 2

Forest plot showing HRs of mortality to 30 days comparing ethnic groups, age and sex corrected, on log scale.

Figure 3

Survival curve to 30 days comparing predicted survival of Asian, black and white ethnic groups (mixed and other group omitted for clarity), in an age and sex adjusted Cox hazard analysis. Survival curves adjusted to median age 65 years and male sex.

Figure 4

Forest plot showing HRs of mortality to 30 days comparing ethnic groups, age and sex corrected, on log scale. Additional variables included Index of Multiple Deprivation (IMD) quintile (five least deprived), smoking, body mass index ≥30 kg/m², diabetes. CKD, chronic kidney disease; HTN, hypertension.

Figure 5

Survival curve to 30 days from multivariable analysis comparing Asian, black and white ethnic groups. Survival modelled for median age 65 years and male sex, Index of Multiple Deprivation (IMD) least deprived quintile, no history of baseline risk factors defined as non-smoking, BMI <30 kg/m² and no diabetes, hypertension or chronic kidney disease. Statistically significant difference in survival between Asian group and white group persists after adjustment for age, sex, social deprivation and major COVID-19 risk factors. BMI, body mass index.