Racial/Ethnic Disparities in COVID Treatment/Hospitalization: Social Determinants & Special Populations
Publisher: name: integrated Translational Health Research Institute of Virginia, University of Virginia
Year: 2022
Subjects: translational science
health equity
COVID-19
Social Determinants of Health

description: Background: The COVID-19 pandemic has exposed long-standing inequities in health, both in access to healthcare and allocation of treatments1,2. These Social Determinants of Health (SDoH)3,4 have reignited questions on whether ones’ ZIP code of residence yields greater impact than their genetic code as a predictor of their health5. 
Objective: Our main question looked at an overall cohort of COVID+ individuals, determining whether there is health equity in the decision to hospitalize a patient who presents to the emergency department (ED) and, once hospitalized, equity in assigning treatment across race/ethnicity, controlling for county-level social determinants of health (SDoH) as ecological predictors6, age, sex, and comorbidities. 
Methods: We conducted exploratory and descriptive analyses with other special populations, such as patients with dementia and patients who are pregnant, with particular focus on those experiencing housing instability. This study leverages prior research establishing racial/ethnic disparities in health access/treatment using individual-level factors (age, sex, race/ethnicity, and medical comorbidities). We utilized the National Covid Cohort Collaborative (N3C)7, one of the largest national repositories of harmonized clinical data, to study patterns in big health data.
Results: Our overall cohort was split into an ED group (808,956 individuals) and hospitalized group (253,805 individuals). From this initial cohort, we derived a cohort where patient-level SDoH is known (ED: 627,854 individuals, Hospitalized: 195,544 individuals) and a cohort where Housing Instability (HI) were reported (ED: 10,235 individuals, Hospitalized: 3,634 individuals). Across all three cohorts, significant factors in likelihood of hospitalization consistently included chronic lung disease (OR No SDoH = 2.18, p<.0001; OR SDoH = 2.03, p<.0001; ORHI = 1.51, p=0.0004) and obesity (OR No SDoH = 1.25, p<.0001; OR SDoH = 1.1, p<.0001; ORHI = 0.74, p=0.0002). These same comorbidities were significant in whether Remdesivir was received. Across all three cohorts, Black and African-Americans consistently have lower likelihood of hospitalization after an ED visit (OR No SDoH = 0.78, p<.0001; OR SDoH = 0.77, p<.0001; OR HI = 0.66, p=0.00005). When SDoH is not considered, race/ethnicity plays a significant role in likelihood of hospitalization and receiving Remdesivir. After including SDoH factors, race/ethnicity remains significant in likelihood of hospitalization but non-significant in receiving treatment once hospitalized. SDoH factors remain significant factor in both likelihood of hospitalization and receiving Remdesivir. The housing instability cohort generally follows a similar pattern to the larger COVID+ cohort. 
Conclusion: This study sheds light on how some health inequity may be the result of clinical care decisions made in the ED and treatment decisions made during the hospital stay. 
 
 
 
References
1. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 — Implications for the Health Care System. New England Journal of Medicine. 2020;383(15):1483-1488. doi:10.1056/NEJMsb2021088
2. Douglas JA, Subica AM. COVID-19 treatment resource disparities and social disadvantage in New York City. Prev Med. 2020;141:106282. doi:10.1016/j.ypmed.2020.106282
3. Braveman P, Egerter S, Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Public Health. 2011;32(1):381-398. doi:10.1146/annurev-publhealth-031210-101218
4. Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep. 2014;129(1_suppl2):19-31.doi:10.1177/00333549141291S206
5. Amy Roeder. Zip code better predictor of health than genetic code. Harvard T.H. Chan: School of Public Health - News. Published August 4, 2014. Accessed July 26, 2022.
https://www.hsph.harvard.edu/news/features/zip-code-better-predictor-of-health-than-genetic-code/
6. Sharecare Community Well-Being Index Methodology. Sharecare. Accessed July 26, 2022. https://wellbeingindex.sharecare.com/research/community-well-being-index-methods/
7. National COVID Cohort Collaborative (N3C). National Center for Advancing Translational Sciences. Published May 12, 2020. Accessed July 21, 2022. https://ncats.nih.gov/n3c