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Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study

. 2020 Sep 22;17(9):e1003379. doi: 10.1371/journal.pmed.1003379. eCollection 2020 Sep. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study Farah Kidwai-Khan^{1 3}, Janet P Tate^{1 3}, Lesley S Park⁴, Joseph T King Jr^{1 5}, Melissa Skanderson¹, Ronald G Hauser^{1 6}, Anna Schultze², Christopher I Jarvis², Mark Holodniy^{7 8}, Vincent Lo Re 3rd^{9 10}, Kathleen M Akgün^{1 3}, Kristina Crothers^{11 12}, Tamar H Taddei^{1 3}, Matthew S Freiberg^{13 14}, Amy C Justice^{1 3 15}

Affiliations

¹ VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America.
² Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
³ Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁴ Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America.
⁵ Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁶ Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁷ VA Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California, United States of America.
⁸ Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
⁹ Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
¹⁰ Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
¹¹ VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington, United States of America.
¹² Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America.
¹³ Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee, United States of America.
¹⁴ Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
¹⁵ Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, United States of America.

PMID: 32960880
PMCID: PMC7508372
DOI: 10.1371/journal.pmed.1003379

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Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study

Christopher T Rentsch et al. PLoS Med. 2020.

. 2020 Sep 22;17(9):e1003379. doi: 10.1371/journal.pmed.1003379. eCollection 2020 Sep. Authors Christopher T Rentsch^{1 2}, Farah Kidwai-Khan^{1 3}, Janet P Tate^{1 3}, Lesley S Park⁴, Joseph T King Jr^{1 5}, Melissa Skanderson¹, Ronald G Hauser^{1 6}, Anna Schultze², Christopher I Jarvis², Mark Holodniy^{7 8}, Vincent Lo Re 3rd^{9 10}, Kathleen M Akgün^{1 3}, Kristina Crothers^{11 12}, Tamar H Taddei^{1 3}, Matthew S Freiberg^{13 14}, Amy C Justice^{1 3 15} Affiliations

¹ VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America.
² Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
³ Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁴ Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America.
⁵ Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁶ Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
⁷ VA Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California, United States of America.
⁸ Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
⁹ Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
¹⁰ Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
¹¹ VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington, United States of America.
¹² Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America.
¹³ Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee, United States of America.
¹⁴ Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
¹⁵ Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, United States of America.

PMID: 32960880
PMCID: PMC7508372
DOI: 10.1371/journal.pmed.1003379

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Abstract

Background: There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States.

Methods and findings: This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health.

Conclusions: In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures
Fig 1. Distribution of 16,317 laboratory-confirmed COVID-19…

Fig 1. Distribution of 16,317 laboratory-confirmed COVID-19 cases in the US Department of Veterans Affairs…
Fig 1. Distribution of 16,317 laboratory-confirmed COVID-19 cases in the US Department of Veterans Affairs as of July 22, 2020.

(a) Distribution of all COVID-19 laboratory-confirmed cases in the US Department of Veterans Affairs between February 8 and July 22, 2020, included in the current study. (b) Proportion of positive COVID-19 test results by the proportion of Black individuals in care by site. Map created using R library USMAP (v0.5.0) and RStudio (v3.6.3). COVID-19, coronavirus disease 2019.

Fig 2. Adjusted associations of demographic characteristics…

Fig 2. Adjusted associations of demographic characteristics with testing positive for COVID-19 and subsequent 30-day…
Fig 2. Adjusted associations of demographic characteristics with testing positive for COVID-19 and subsequent 30-day mortality as of July 22, 2020.

(a) Positive test result among tested; (b) 30-day mortality among cases. Both models were conditioned on site of care and adjusted for baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), and medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker). *Low number of mortality events in age groups 20–39 and 40–49 thus grouped with 50–59. CI, confidence interval; COVID-19, coronavirus disease 2019; OR, odds ratio.

Fig 3. Racial and ethnic disparities in…

Fig 3. Racial and ethnic disparities in testing positive for COVID-19, by calendar time, region,…
Fig 3. Racial and ethnic disparities in testing positive for COVID-19, by calendar time, region, and outbreak pattern.

(a) Black versus White individuals; (b) Hispanic versus White individuals. All p < 0.001. Region based on US Census groupings. Outbreak pattern based on site-level percentage of positive tests per month among sites with at least 100 positive COVID-19 tests: early (≥10% in March or April), late (≥10% in June or July), resurgent (≥10% in March or April and June or July), steady (<10% in all months), other (sites with <100 positive tests). Models were conditioned on site of care and adjusted for baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), and medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker). CI, confidence interval; COVID-19, coronavirus disease 2019; OR, odds ratio.

Update of

Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans. Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Re VL 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Rentsch CT, et al. medRxiv [Preprint]. 2020 May 18:2020.05.12.20099135. doi: 10.1101/2020.05.12.20099135. medRxiv. 2020. PMID: 32511524 Free PMC article. Updated. Preprint.
Covid-19 Testing, Hospital Admission, and Intensive Care Among 2,026,227 United States Veterans Aged 54-75 Years. Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Re VL 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Rentsch CT, et al. medRxiv [Preprint]. 2020 Apr 14:2020.04.09.20059964. doi: 10.1101/2020.04.09.20059964. medRxiv. 2020. PMID: 32511595 Free PMC article. Updated. Preprint.