Previous research and anecdotal evidence show that in the United States, some populations, including people who are Black, Asian, or mixed race, are more likely to develop COVID-19.
However, after controlling for underlying conditions and average neighborhood income, new research from NYU Langone Health shows that, once hospitalized, Black patients may be less likely to die than white patients.
These findings suggest Black and Hispanic patients are not inherently more likely to experience poor COVID-19 outcomes than other populations. In the study, Black patients’ outcomes were also the same as or better than those of white patients once hospitalized.
If accurate, these findings support the idea that pervasive structural determinants of health in Black and Hispanic communities might account for a disproportionately higher rate of out-of-hospital COVID-19 deaths in these communities.
“We know that Black and Hispanic populations account for a disproportionate share of COVID-19-related deaths relative to their population size in New York and major cities across the country,” says Dr. Gbenga Ogedegbe, Dr. Adolph and Margaret Berger Professor of Medicine and Population Health at NYU Langone Health and the study’s lead author.
“We were, however, surprised to find that Black and Hispanic patients were no more likely to be hospitalized across NYU Langone than white patients, which means we need to look at other structural factors at play that are negatively affecting outcomes in these communities,” says Dr. Ogedegbe, who also directs NYU Langone’s Institute for Excellence in Health Equity.
The study appears in JAMA Network Open.
Studies from across the U.S. show that Black and Hispanic communities are experiencing higher rates of the new coronavirus infection and related hospitalizations and deaths than white populations.
According to the Centers for Disease Control and Prevention (CDC), Black and African American persons are 1.4 times more likely than white persons to develop COVID-19, 3.7 times more likely to be hospitalized with it, and 2.8 times more likely to die from it.
According to the same statistics, Hispanic people are 1.7 times more likely to develop COVID-19 than white people, 4.1 times more likely to be hospitalized with it, and 2.8 times more likely to die from it.
The exact reason for these discrepancies in disease rates and outcomes remains unclear. However, several factors may contribute to it, especially socioeconomic ones.
For example, higher disease rates may be related to difficulty maintaining social distance due to crowding in housing, at work, or while commuting. Frontline and essential workers, for example, are also more likely to be exposed to the novel coronavirus because of their occupation.
Reduced or delayed access to healthcare may also heavily impact disease severity and progression. The rate of underlying conditions that can worsen COVID-19 outcomes, such as hypertension, obesity, diabetes, and chronic kidney disease, is also higher among Black and Hispanic populations.
According to the authors, currently only one study explores the role of comorbidity, or the presence of multiple medical conditions or factors, in relation to ethnic and racial differences in COVID-19 hospitalization and death rates.
The researchers examined data from NYU Langone Health’s electronic health record of patients tested for COVID-19 in 260 outpatient locations and four acute care hospitals in Manhattan, Long Island, and Brooklyn, New York City (NYC), NY. Out of the 9,722 patients, 4,843 patients tested positive for SARS-CoV-2.
Data were collected between March 1, 2020, and April 8, 2020. Researchers followed case details and outcomes through May 13, 2020. Patients self-reported information about their race and ethnicity.
For patients with a SARS-CoV-2 infection, the researchers also recorded each patient’s age, sex, body mass index, smoking history, and comorbidity. Specific conditions included were diabetes, hypertension, coronary artery disease, high cholesterol, chronic kidney disease, heart failure, asthma, chronic obstructive pulmonary disease, and cancer.
Researchers also collected neighborhood socioeconomic status (SES) data.
They calculated neighborhood SES by geocoding patients’ home addresses and zip codes and then matching the resulting geocodes to census tracts using computer software. Geocoding transforms text-based addresses into geographical coordinates.
The Agency for Healthcare Research and Quality (AHRQ) SES index was then calculated using American Community Survey data, which assign each patient an SES score. The AHRQ SES index is weighted with seven indicators:
- percentage of population within a patient’s census tract in the labor force who are unemployed
- median household income
- median value of owner-occupied dwellings
- percentage of people living below poverty level
- percentage of residents aged 25 years or older with less than 12th grade education
- percentage of residents aged 25 years or older completing 4 or more years of college
- percentage of households that average one or more persons per room
The researchers used this data to compare racial and ethnic differences in the risk of testing positive for COVID-19, being hospitalized with it, developing critical disease, and dying from it. They also used it to assess whether differences in outcomes were related to age, sex, comorbidity, insurance, and neighborhood SES.
After controlling for coexisting medical conditions and neighborhood income, the researchers found that, compared with white patients, Black patients were less likely to develop a severe disease, be discharged to a hospice, or die.
The findings also showed that Black and Hispanic patients were not hospitalized more often than white patients. In adjusted models, Asian patients were more likely to be hospitalized than white patients.
Among hospitalized patients, Black patients were also less likely to develop a critical disease or die compared with their white counterparts. Hispanic and Asian patients had similar odds of developing a critical disease and dying compared with white patients.
Dr. Joseph Ravenell, associate professor in the Department of Population Health and associate dean for Diversity Affairs and Inclusion at NYU Langone, says:
“Our findings provide more evidence that the social determinants of health play a critical role in determining patient outcomes, particularly for Black patients, before they ever get to the hospital.”
“However, we do see a bit of a paradox,” he adds. “In keeping with other research, we have found that once Black patients with COVID-19 make it to the hospital — despite coming from lower income neighborhoods — their odds of dying are similar to or lower than white patients. Meanwhile, we also know that Black and Hispanic people are disproportionately contracting and dying of COVID-19 across the country.”
According to Dr. Ogedegbe and Dr. Ravenell, this phenomenon may be explained by socioeconomic factors. For example, Black populations are less likely to be well insured than white populations, which could mean that Black patients are more likely to die at home than in the hospital.
The authors note several shortcomings of their study. For example, not enough information was available to assess the role of occupation.
Male sex is also a positive predictor of poor outcomes for patients hospitalized with COVID-19. Additionally, 62% of Black hospitalized patients in the study were female, potentially accounting for better outcomes. The study population may also not be representative of the NYC population overall.
The authors claim this is one of the first studies to explore the impact of comorbid conditions and neighborhood SES on patients hospitalized for COVID-19 who are Black, Hispanic, or Asian.
According to study senior author Dr. Leora Horwitz, an associate professor in the Departments of Population Health and Medicine and director of the Center for Healthcare Innovation and Delivery Science at NYU Langone, future studies must examine how structural inequities directly impact racial and ethnic disparities in COVID-19-related rates of hospitalization, disease severeness, and death.
“These factors include poor housing conditions, unequal access to healthcare, differential employment opportunities, and poverty — and they must be addressed.”
– Dr. Gbenga Ogedegbe