COVID-19 Inequities Across Multiple Racial and Ethnic Groups: Results From an Integrated Health Care Organization
Authors: Claudia Nau, Katia Bruxvoort, Ronald A. Navarro, Shari G. Chevez, Tiffany A. Hogan, Kristen R. Ironside, Stacey M. Ludwig, Quyen Ngo-Metzger, Natalie R. Mourra, Deborah Rohm Young, Navdeep Sangha, Branden P. Turner, Iona (Xia) Li, Ariadna Padilla, Aiyu Chen, Vennis Hong, Vincent Yau, Sara Tartof
Journal: Annals of Internal Medicine (2021)

Letters20 April 2021COVID-19 Inequities Across Multiple Racial and Ethnic Groups: Results From an Integrated Health Care OrganizationFREEClaudia Nau, PhD, Katia Bruxvoort, PhD, MPH, Ronald A. Navarro, MD, Shari G. Chevez, MD, Tiffany A. Hogan, MD, Kristen R. Ironside, MA, Stacey M. Ludwig, MD, MPH, Quyen Ngo-Metzger, MD, MPH, Natalie R. Mourra, MD, Deborah Rohm Young, PhD, Navdeep Sangha, MD, Branden P. Turner, MD, Iona (Xia) Li, MS, Ariadna Padilla, MBA, Aiyu Chen, MPH, Vennis Hong, MPH, Vincent Yau, PhD, and Sara Tartof, PhD, MPHClaudia Nau, PhDKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Katia Bruxvoort, PhD, MPHKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Ronald A. Navarro, MDSouth Bay Medical Center, Kaiser Permanente Southern California, Harbor City, CaliforniaSearch for more papers by this author, Shari G. Chevez, MDKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Tiffany A. Hogan, MDLos Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaSearch for more papers by this author, Kristen R. Ironside, MALos Angeles Medical Center, Kaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Stacey M. Ludwig, MD, MPHLos Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaSearch for more papers by this author, Quyen Ngo-Metzger, MD, MPHKaiser Permanente School of Medicine, Pasadena, CaliforniaSearch for more papers by this author, Natalie R. Mourra, MDLos Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaSearch for more papers by this author, Deborah Rohm Young, PhDKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Navdeep Sangha, MDLos Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaSearch for more papers by this author, Branden P. Turner, MDWest Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaSearch for more papers by this author, Iona (Xia) Li, MSKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Ariadna Padilla, MBAKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Aiyu Chen, MPHKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Vennis Hong, MPHKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this author, Vincent Yau, PhDGenentech, South San Francisco, CaliforniaSearch for more papers by this author, and Sara Tartof, PhD, MPHKaiser Permanente Southern California, Pasadena, CaliforniaSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-8283 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Coronavirus disease 2019, the illness caused by SARS-CoV-2, has shown stark health inequities, including by race/ethnicity (1). Prior research has often been limited by small, nondiverse samples or lack of reliable clinical data to provide a detailed picture of COVID-19–related inequities across multiple racial/ethnic groups in the same population. Some studies suggest that racial/ethnic disparities in comorbidities and obesity may be major drivers of racial inequities in COVID-19 outcomes (2, 3). Comprehensive health equity assessments of COVID-19 testing and outcomes are needed to support an equitable pandemic response and vaccination efforts.Objective: To compare age- and sex-adjusted relative risk (RR) of COVID-19 testing, cases, hospitalizations, and intensive-level care among Hispanic, Black or African American, Asian, and Pacific Islander populations versus White populations before and after adjusting for comorbidities and body weight status.Methods: We conducted a retrospective cohort study using electronic health record data from Kaiser Permanente Southern California (KPSC), a large, integrated health care system that serves 10 Southern California counties and has a membership that approximately represents the population in its service region (4). We identified 47 974 COVID-19 cases via diagnoses and positive COVID-19 test results during 1 March to 31 July 2020. The sample was restricted to members who were at least 18 years old, had 12 months of membership, and had a single race/ethnicity category available (93.4% of eligible members). Race/ethnicity was identified using an algorithm that relies on several data sources, including membership data, birth certificates, encounter-based race/ethnicity data, and language preferences. This approach was concordant with self-reported race/ethnicity in 91% of cases for major race/ethnicity categories in previous, unpublished validation studies.Robust Poisson regression was used to estimate 2 sets of models that adjust for age and sex and for age, sex, body mass index categories, Elixhauser Comorbidity Index, and 5 comorbidity categories (Table) (2). For each race/ethnicity, we estimated the RR of an event occurring, with being White as the reference category. We also provide the adjusted marginal probability of each outcome, expressed as percentages for ease of interpretation. This research was approved by the KPSC Institutional Review Board.Table Sample Characteristics by COVID-19 Status and Outcomes Among KPSC Members, 1 March to 31 July 2020Findings: We identified 47 974 COVID-19 cases; 4517 (9.42%) required hospitalization and 1498 (3.12%) required intensive-level care (Table). Patients who required hospitalization and intensive-level care were on average older, more likely to be obese, and more likely to have a higher Elixhauser Comorbidity Index than those with COVID-19 who did not experience these events (Table). The COVID-19 outcomes also varied by race/ethnicity.We observed disparities across race/ethnicity for all outcomes before and after adjustment for age, sex, comorbidities, and body mass index. Patients of color were slightly more likely to be tested and to test positive or be diagnosed with COVID-19 than White patients but were substantially more likely to be hospitalized and to receive intensive-level care (Figure). Hispanic patients had the highest RRs of being tested and testing positive or being diagnosed with COVID-19 compared with White patients; however, Pacific Islander, Black or African American, and Asian patients had higher RRs for severe COVID-19 outcomes than White patients (Figure).Figure. Relative risks and adjusted marginal percentages of COVID-19 testing, hospitalizations, and receipt of intensive-level care, by race/ethnicity.All relative risks and adjusted marginal percentages were estimated using robust Poisson regression and included the log of follow-up days as offset to account for differential follow-up (<5% were lost to follow-up). Analyses were done using SAS, version 9.4 (SAS Institute). The fully adjusted model adjusted for age, sex, comorbidity categories, Elixhauser Comorbidity Index (count of comorbidities documented within past 12 mo), and body mass index categories. No collinearity issues were observed when using the Elixhauser Comorbidity Index along with the 5 broad comorbidity categories that adjust for the independent effects of each respective disease category. KP = Kaiser Permanente. Download figure Download PowerPoint Discussion: Our results confirm findings from earlier in the pandemic that suggest that COVID-19 affects Hispanic, Black or African American, and Asian persons disproportionately (2). We further provide evidence of the disproportionate effect of COVID-19 on Pacific Islanders. We show that even after adjustment for known COVID-19 risk factors, such as comorbidities and body mass index, persons of color continue to have a substantially higher risk for hospitalization and requiring intensive-level care than White persons (1–3).A limitation of this study is that some KPSC members may have been tested outside the KPSC system, particularly early in the pandemic. We have no information on these results. We are, however, able to identify patients seeking COVID-19–related care after an outside test. These patients were given a COVID-19 diagnosis by their provider, often without receiving a second confirmatory test at KPSC. We could not identify COVID-19–related intensive-level care that was delivered outside KPSC. Similar to other research on COVID-19 using KP data, we used only data from encounters within the KP system (2). Inequities in deaths were not analyzed because some racial/ethnic groups had fewer than 10 cases.Inequities in COVID-19 outcomes are a call to action for a culturally appropriate pandemic response and vaccination strategies that go beyond addressing comorbidities and account for factors like distrust in the medical system, resource constraints, language proficiency, and health literacy.References1. Lopez L 3rd, Hart LH 3rd, Katz MH. Racial and ethnic health disparities related to COVID-19. JAMA. 2021;325:719-720. [PMID: 33480972] doi:10.1001/jama.2020.26443 CrossrefMedlineGoogle Scholar2. Escobar GJ, Adams AS, Liu VX, et al. Racial disparities in COVID-19 testing and outcomes: retrospective cohort study in an integrated health system. Ann Intern Med. 2021;174:786-793. [PMID: 33556278] doi:10.7326/M20-6979 LinkGoogle Scholar3. Tartof SY, Qian L, Hong V, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Ann Intern Med. 2020;173:773-781. [PMID: 32783686] doi:10.7326/M20-3742 LinkGoogle Scholar4. Koebnick C, Langer-Gould AM, Gould MK, et al. Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data. Perm J. 2012;16:37-41. [PMID: 23012597] CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Claudia Nau, PhD; Katia Bruxvoort, PhD, MPH; Ronald A. Navarro, MD; Shari G. Chevez, MD; Tiffany A. Hogan, MD; Kristen R. Ironside, MA; Stacey M. Ludwig, MD, MPH; Quyen Ngo-Metzger, MD, MPH; Natalie R. Mourra, MD; Deborah Rohm Young, PhD; Navdeep Sangha, MD; Branden P. Turner, MD; Iona (Xia) Li, MS; Ariadna Padilla, MBA; Aiyu Chen, MPH; Vennis Hong, MPH; Vincent Yau, PhD; Sara Tartof, PhD, MPHAffiliations: Kaiser Permanente Southern California, Pasadena, CaliforniaSouth Bay Medical Center, Kaiser Permanente Southern California, Harbor City, CaliforniaLos Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaLos Angeles Medical Center, Kaiser Permanente Southern California, Pasadena, CaliforniaKaiser Permanente School of Medicine, Pasadena, CaliforniaWest Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CaliforniaGenentech, South San Francisco, CaliforniaFinancial Support: By Roche–Genentech. However, the study was solely done at KPSC. The funder did not contribute to the design, conduct, or analysis of this study or to manuscript development, writing, or review.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-8283.Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Nau (e-mail, claudia.l.nau@kp.org). Data set: Not available.Corresponding Author: Claudia Nau, PhD, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 2nd Floor, Pasadena, CA 91101; e-mail, claudia.l.nau@kp.org.This article was published at Annals.org on 20 April 2021. 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