Clinical, behavioural and social factors associated with racial disparities in COVID-19 patients from an integrated healthcare system in Georgia: a retrospective cohort study
Dr Felipe Lobelo, Alan Bienvenida, Serena Leung, Armand Mbanya, Elizabeth Leslie, Kate Koplan, Sangmin Ryan Shin
BMJ Open, doi:10.1136/bmjopen-2020-044052
Objectives To identify sociodemographic, clinical and behavioural drivers of racial disparities and their association with clinical outcomes among Kaiser Permanente Georgia (KPGA) members with COVID-19. Design Retrospective cohort of patients with COVID-19 seen from 3 March to 29 October 2020. We described the distribution of underlying comorbidities, quality of care metrics, demographic and social determinants of health (SDOH) indicators across race groups. We also described clinical outcomes in hospitalised patients including length of stay, intensive care unit (ICU) admission, readmission and mortality. We performed multivariable analyses for hospitalisation risk among all patients with COVID-19 and stratifyied by race and sex. Setting KPGA, an integrated healthcare system. Participants 5712 patients who all had laboratoryconfirmed COVID-19. Of them, 57.8% were female, 58.4% black, 29.5% white, 8.5% Hispanic and 3.6% Asian. Results Black patients had the highest proportions of living in neighborhoods under the federal poverty line (12.4%) and in more deprived locations (neighbourhood deprivation index=0.4). Overall, 14.4% (n=827) of this cohort was hospitalised. Asian patients had the highest rates of ICU admission (53.1%) and mechanical ventilation (21.9%). Among all patients, Hispanics (adjusted 1.60, 95% CI (1.08, 2.37)), blacks (1.43 (1.13, 1.83)), age in years (1.03 (1.02, 1.04)) and living in a zip code with high unemployment (1.08 (1.03, 1.13)) were associated with higher odds of hospitalisation. COVID-19 patients with chronic obstructive pulmonary disease ( 2 .59 (1.67, 4.02)), chronic heart failure (1.79 (1.31, 2.45)), immunocompromised (1.77 (1.16, 2.70)), with glycated haemoglobin >8% (1.68 (1.19, 2.38)), depression (1.60 (1.24, 2.06)), hypertension (1.5 (1.21, 1.87)) and physical inactivity (1.25 (1.03, 1.51)) had higher odds of hospitalisation. Conclusions Black and Hispanic KPGA patients were at higher odds of hospitalisation, but not mortality, compared with other race groups. Beyond previously reported sociodemographics and comorbidities, factors such as quality of care, lifestyle behaviours and SDOH indicators should be considered when designing and implementing interventions to reduce COVID-19 racial disparities. ► To our knowledge, this is the first COVID-19 retrospective cohort study to incorporate multiple individual and community-level social determinants of health indicators, pre-pandemic lifestyle behaviours and comorbidity management metrics as drivers of COVID-19 racial disparities.
Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research. Patient consent for publication Not required.
Ethics approval The KPGA institutional review board approved this study with a waiver of informed consent. Provenance and peer review Not commissioned; externally peer reviewed.
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'abstract': '<jats:sec><jats:title>Objectives</jats:title><jats:p>To identify sociodemographic, clinical '
'and behavioural drivers of racial disparities and their association with clinical outcomes '
'among Kaiser Permanente Georgia (KPGA) members with '
'COVID-19.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Retrospective '
'cohort of patients with COVID-19 seen from 3 March to 29 October 2020. We described the '
'distribution of underlying comorbidities, quality of care metrics, demographic and social '
'determinants of health (SDOH) indicators across race groups. We also described clinical '
'outcomes in hospitalised patients including length of stay, intensive care unit (ICU) '
'admission, readmission and mortality. We performed multivariable analyses for hospitalisation '
'risk among all patients with COVID-19 and stratifyied by race and '
'sex.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>KPGA, an integrated '
'healthcare '
'system.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>5712 '
'patients who all had laboratory-confirmed COVID-19. Of them, 57.8% were female, 58.4% black, '
'29.5% white, 8.5% Hispanic and 3.6% '
'Asian.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Black patients '
'had the highest proportions of living in neighborhoods under the federal poverty line (12.4%) '
'and in more deprived locations (neighbourhood deprivation index=0.4). Overall, 14.4% (n=827) '
'of this cohort was hospitalised. Asian patients had the highest rates of ICU admission '
'(53.1%) and mechanical ventilation (21.9%). Among all patients, Hispanics (adjusted 1.60, '
'95%\u2009CI (1.08, 2.37)), blacks (1.43 (1.13, 1.83)), age in years (1.03 (1.02, 1.04)) and '
'living in a zip code with high unemployment (1.08 (1.03, 1.13)) were associated with higher '
'odds of hospitalisation. COVID-19 patients with chronic obstructive pulmonary disease (2.59 '
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'2.70)), with glycated haemoglobin >8% (1.68 (1.19, 2.38)), depression (1.60 (1.24, 2.06)), '
'hypertension (1.5 (1.21, 1.87)) and physical inactivity (1.25 (1.03, 1.51)) had higher odds '
'of '
'hospitalisation.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Black '
'and Hispanic KPGA patients were at higher odds of hospitalisation, but not mortality, '
'compared with other race groups. Beyond previously reported sociodemographics and '
'comorbidities, factors such as quality of care, lifestyle behaviours and SDOH indicators '
'should be considered when designing and implementing interventions to reduce COVID-19 racial '
'disparities.</jats:p></jats:sec>',
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