Underlying chronic conditions, public insurance, and low income appear to exacerbate susceptibility

A retrospective cohort study from Ochsner Health in Louisiana underscores the racial disparity of the Covid-19 pandemic. While black people comprise 31% of the health system’s population, 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died were black, according to a study published in the New England Journal of Medicine.

However, after adjusting for sociodemographic and clinical characteristics, in-hospital death did not differ between the black and white population.

Nonetheless, the differences in baseline characteristics were notable, Eboni G. Price-Haywood, MD, MPH from the Ochsner Health Center and Outcomes and Health Services Research, in New Orleans, and colleagues reported, with black patients having a higher prevalence of obesity, diabetes, hypertension, and chronic kidney disease than white patients.

“A higher percentage of blacks than whites presented with elevated levels of creatinine, AST, or inflammatory markers,” Price-Haywood and colleagues wrote. “Among the patients who received critical care or mechanical ventilation, approximately 80% were black. Black race, increasing age, a higher score on the Charlson Comorbidity Index, public insurance (Medicare or Medicaid), and residence in a low income area were associated with increased odds of hospital admission.”

Price-Haywood and colleagues noted that there are likely many reasons for the racial differences of those contracting Covid-19 — for example, an increased community exposure due to the type of employment, as service jobs are predominantly held by minority groups.

Underlying chronic conditions also highlight the racial disparity and a higher susceptibility to contracting severe illness.

“According to a 2018 Health Report Card, Louisiana ranked 45th of 50 states for obesity, 46th for heart disease or strokes, and 47th for diabetes,” the study authors wrote. “The report further showed that the incidences of obesity and diabetes were higher in the black population than in the white population. The incidences of these conditions are also higher among persons with lower education and low-income levels across all race groups.”

In their study, Price-Haywood and colleagues culled data on patients with laboratory-confirmed SARS-Cov-2 seen in the Ochsner Health system from March 1 to April 11. The primary outcomes of the study were hospitalization and in-hospital death. These were assessed with unadjusted and multivariable models.

Of 3,626 patients who tested positive for Covid-19, 145 were excluded because of missing data on race or ethnicity or because they were Hispanic, Asian, or another ethnic group, leaving 3,481 patients included in the analysis. Most of these patients (60%) were female, the mean age of the participants was 54 years old, and most (70.4%) were black, non-Hispanic. The black patients were three times more likely to have Medicaid insurance as non-Hispanic white patients and were nearly twice as likely to live in low-income areas.

Along with having a higher incidence of obesity, diabetes, hypertension, and chronic kidney disease than white patients, the black patients “were also more likely than white patients to present with fever, cough, or dyspnea at the time of Covid-19 testing,” the study authors wrote. More black patients (65.3%) than white (38.0%) were tested for Covid-19 in the ED (1,992 patients in total were tested in the ED).

Highlights of the study results include:

  • 39.7% (1,382 patients) who tested positive for Covid-19 were hospitalized, and 76.9% were black.
  • More black patients than white had fever on admission.
  • More white than black patients presented with low white-cell, lymphocyte, or platelet counts, low sodium levels, or elevated levels of brain-type natriuretic peptide.
  • More black patients than white presented with elevated levels of creatinine, AST, procalcitonin, and C-reactive protein.
  • Common among all patients at any time during their hospital stay were hypoxic respiratory failure and pneumonia co-infection.
  • 15.3% of black patients had acute renal failure compared with 10.7% of white.
  • Of the 474 patients admitted to the hospital, 80.2% of the black patients received ICU care.
  • There were 354 patients on mechanical ventilation of whom 81.6% were black
  • 326 patients died in the hospital — 230 (70.6%) were black
  • Most of those patients who died had been on mechanical ventilation — 73.9% were black, 36.5% were white.
  • 30.1% of white patients and 21.6% of black patients comprised the unadjusted case fatality rate.
  • The median length of stay did not differ significantly by race.

“In adjusted time-to-event analyses, variables that were associated with higher in-hospital mortality were increasing age and presentation with an elevated respiratory rate; elevated levels of venous lactate, creatinine, or procalcitonin; or low platelet or lymphocyte counts,” the study authors pointed out. “However, black race was not independently associated with higher mortality (hazard ratio for death versus white race, 0.89; 95% confidence interval, 0.68 to 1.17).”

Limitations of the study include that it was conducted at one health system and may not be generalizable outside of that setting. The study authors also noted that not all laboratory studies were performed in all patients — most likely a reflection of the rapidly evolving pandemic and ongoing changes in clinical management — and finally that the data were culled from the electronic medical record, which might not be complete or totally accurate.

  1. While blacks comprise 31% of the Ochsner Health system’s population, 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died were black.

  2. Be aware that after adjusting for sociodemographic and clinical characteristics, in-hospital death did not differ between the black and white population.

Candace Hoffmann, Managing Editor, BreakingMED™

Price-Haywood reports non-financial support from Sanofi-Aventis and non-financial support from Pfizer outside the submitted work.

Cat ID: 190

Topic ID: 79,190,254,930,287,585,728,791,932,570,730,933,190,520,926,192,927,151,928,925,934