COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data

Summary

This analysis builds on a continually growing body of research on racial disparities in COVID-19 by examining testing, infection, hospitalization, and death by race and ethnicity among patients in the Epic health record system. It contributes to the research in this area by providing insight into the experiences of a large patient population across a range of states and health systems, examining variation in the level of care patients required at the time they tested positive for COVID-19 by race and ethnicity, and assessing the extent to which underlying sociodemographic characteristics and health conditions explain racial disparities in hospitalization and death. Overall, it shows that, despite being at increased risk of exposure to the virus, people of color did not have markedly higher testing rates compared to White patients and were more likely to be positive when tested and to require a higher level of care at the time they tested positive. Moreover, it builds on previous research showing people of color have higher rates of hospitalization and death due to COVID-19 by finding that these disparities persist after controlling for sociodemographic characteristics and underlying health conditions. Key findings include:

• Differences in testing rates by race and ethnicity were small, but people of color were more likely, compared to White patients, to be positive when tested and to require a higher level of care at the time they tested positive for COVID-19. Although there were not large differences in testing by race and ethnicity, among those tested, Hispanic patients were over two and a half times more likely to have a positive result (311 per 1,000) and Black and Asian patients were nearly twice as likely to test positive (219 and 220 per 1,000, respectively) compared to White patients (113 per 1,000). Further, larger shares of Black, Hispanic, and Asian patients were in an inpatient setting when they tested positive for COVID-19 compared to White patients, and they also were more likely to require oxygen or ventilation at the time of diagnosis.
• Black, Hispanic, and Asian patients had significantly higher rates of infection, hospitalization, and death compared to their White counterparts. The infection rate for Hispanic patients was over three times higher than the rate in White patients (143 vs. 46 per 10,000), and the rate among Black patients was over two times as high (107 per 10,000). The hospitalization rate for Hispanic patients was more than four times as high as the rate in White patients (30.4 vs. 7.4 per 10,000), and the rate in Black patients was over three times as high (24.6 per 10,000). Death rates for both groups were over twice as high as the rate for White patients (5.6 and 5.6 compared to 2.3 per 10,000). Asian patients also faced significant disparities in these measures.
• Racial disparities in hospitalization and death persisted among positive patients even after controlling for certain sociodemographic factors and underlying differences in health, with Asian patients exhibiting the highest relative risk. Among patients who tested positive for COVID-19, Black, Hispanic, and Asian patients remained at higher risk for hospitalization and death compared to White patients with similar sociodemographic characteristics and underlying health conditions. Asian patients were at the highest risk relative to White patients, followed by Hispanic and Black patients.

As previously documented, the higher infection rate among people of color likely reflects their increased risk of exposure to coronavirus due to their work, living, and transportation situations. They are more likely to be working in low-income jobs that cannot be done from home, to be living in larger households in densely populated areas, and to utilize public or shared modes of transportation. Despite being at increased risk of exposure to the virus, people of color did not have markedly higher testing rates compared to White patients and were more likely to be positive when tested and to require a higher level of care at the time they tested positive for COVID-19. These findings suggest that people of color may face increased barriers to testing that contribute to delays in them obtaining testing until they are in more serious condition.

The higher hospitalization and death rates among patients of color, in part, reflect higher infection rates and higher rates of underlying health conditions as well as social and economic inequities and barriers to care. However, the persistence of disparities after controlling for COVID-19 infection, certain sociodemographic factors, and underlying health conditions show that differences in these underlying factors do not fully explain the disparities in hospitalization and death. This finding suggests that other factors, including racism and discrimination, are negatively affecting their health outcomes through additional avenues.

Together, the findings point to the importance of considering health equity in COVID-19 response and relief efforts and health care more broadly, and, in particular, improving access to testing before individuals develop severe illness in order to slow the spread of infections. They also illustrate the importance of considering a wide array of factors both within and beyond the health care system and addressing structural and systemic racism and discrimination as root causes as part of efforts to address health disparities. These efforts will be key for narrowing the disparate effects of COVID-19, ensuring equitable distribution of treatments and a vaccine as they are developed, and preventing widening disparities in health care more broadly looking forward.