Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor.
Rogel Cancer Center, University of Michigan Medicine, Ann Arbor.
JAMA Netw Open. 2020 Oct 1;3(10):e2025197. doi: 10.1001/jamanetworkopen.2020.25197.
Black patients are overrepresented in the number of COVID-19 infections, hospitalizations, and deaths in the US. Reasons for this disparity may be due to underlying comorbidities or sociodemographic factors that require further exploration.
To systematically determine patient characteristics associated with racial/ethnic disparities in COVID-19 outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used comparative groups of patients tested or treated for COVID-19 at the University of Michigan from March 10, 2020, to April 22, 2020, with an outcome update through July 28, 2020. A group of randomly selected untested individuals were included for comparison. Examined factors included race/ethnicity, age, smoking, alcohol consumption, comorbidities, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and residential-level socioeconomic characteristics.
In-house polymerase chain reaction (PCR) tests, commercial antibody tests, nasopharynx or oropharynx PCR deployed by the Michigan Department of Health and Human Services and reverse transcription-PCR tests performed in external labs.
The main outcomes were being tested for COVID-19, having test results positive for COVID-19 or being diagnosed with COVID-19, being hospitalized for COVID-19, requiring intensive care unit (ICU) admission for COVID-19, and COVID-19-related mortality (including inpatient and outpatient). Medical comorbidities were defined from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes and were aggregated into a comorbidity score. Associations with COVID-19 outcomes were examined using odds ratios (ORs).
Of 5698 patients tested for COVID-19 (mean [SD] age, 47.4 [20.9] years; 2167 [38.0%] men; mean [SD] BMI, 30.0 [8.0]), most were non-Hispanic White (3740 patients [65.6%]) or non-Hispanic Black (1058 patients [18.6%]). The comparison group included 7168 individuals who were not tested (mean [SD] age, 43.1 [24.1] years; 3257 [45.4%] men; mean [SD] BMI, 28.5 [7.1]). Among 1139 patients diagnosed with COVID-19, 492 (43.2%) were White and 442 (38.8%) were Black; 523 (45.9%) were hospitalized, 283 (24.7%) were admitted to the ICU, and 88 (7.7%) died. Adjusting for age, sex, socioeconomic status, and comorbidity score, Black patients were more likely to be hospitalized compared with White patients (OR, 1.72 [95% CI, 1.15-2.58]; P = .009). In addition to older age, male sex, and obesity, living in densely populated areas was associated with increased risk of hospitalization (OR, 1.10 [95% CI, 1.01-1.19]; P = .02). In the overall population, higher risk of hospitalization was also observed in patients with preexisting type 2 diabetes (OR, 1.82 [95% CI, 1.25-2.64]; P = .02) and kidney disease (OR, 2.87 [95% CI, 1.87-4.42]; P < .001). Compared with White patients, obesity was associated with higher risk of having test results positive for COVID-19 among Black patients (White: OR, 1.37 [95% CI, 1.01-1.84]; P = .04. Black: OR, 3.11 [95% CI, 1.64-5.90]; P < .001; P for interaction = .02). Having any cancer was associated with higher risk of positive COVID-19 test results for Black patients (OR, 1.82 [95% CI, 1.19-2.78]; P = .005) but not White patients (OR, 1.08 [95% CI, 0.84-1.40]; P = .53; P for interaction = .04). Overall comorbidity burden was associated with higher risk of hospitalization in White patients (OR, 1.30 [95% CI, 1.11-1.53]; P = .001) but not in Black patients (OR, 0.99 [95% CI, 0.83-1.17]; P = .88; P for interaction = .02), as was type 2 diabetes (White: OR, 2.59 [95% CI, 1.49-4.48]; P < .001; Black: OR, 1.17 [95% CI, 0.66-2.06]; P = .59; P for interaction = .046). No statistically significant racial differences were found in ICU admission and mortality based on adjusted analysis.
These findings suggest that preexisting type 2 diabetes or kidney diseases and living in high-population density areas were associated with higher risk for COVID-19 hospitalization. Associations of risk factors with COVID-19 outcomes differed by race.
在美国，黑人群体的 COVID-19 感染率、住院率和死亡率均偏高。造成这一差异的原因可能是由于潜在的合并症或社会人口因素，这些因素需要进一步研究。
系统地确定与 COVID-19 结局相关的种族/族裔差异患者特征。
设计、地点和参与者：本回顾性队列研究使用了 2020 年 3 月 10 日至 4 月 22 日在密歇根大学接受 COVID-19 检测或治疗的患者的比较组，结果更新至 2020 年 7 月 28 日。还纳入了一组随机选择的未接受检测的个体作为比较。研究的因素包括种族/族裔、年龄、吸烟、饮酒、合并症、体重指数（BMI；体重以千克为单位除以身高以米为单位的平方）和住宅级别的社会经济特征。
内部聚合酶链反应（PCR）检测、商业抗体检测、密歇根州卫生与公众服务部部署的鼻咽或口咽 PCR 以及外部实验室进行的逆转录 PCR 检测。
主要结果是接受 COVID-19 检测、COVID-19 检测结果呈阳性或被诊断为 COVID-19、因 COVID-19 住院、因 COVID-19 入住重症监护病房（ICU）以及 COVID-19 相关死亡（包括住院和门诊）。医疗合并症根据国际疾病分类第 9 版和第 10 版代码定义，并汇总为合并症评分。使用优势比（OR）检查与 COVID-19 结局的关联。
在 5698 名接受 COVID-19 检测的患者中（平均[SD]年龄为 47.4[20.9]岁；2167[38.0%]为男性；平均[SD]BMI 为 30.0[8.0]），大多数为非西班牙裔白人（3740 例[65.6%]）或非西班牙裔黑人（1058 例[18.6%]）。对照组包括 7168 名未接受检测的个体（平均[SD]年龄为 43.1[24.1]岁；3257[45.4%]为男性；平均[SD]BMI 为 28.5[7.1]）。在 1139 名被诊断为 COVID-19 的患者中，492 名（43.2%）为白人，442 名（38.8%）为黑人；523 名（45.9%）住院，283 名（24.7%）入住 ICU，88 名（7.7%）死亡。在调整年龄、性别、社会经济地位和合并症评分后，与白人患者相比，黑人患者更有可能住院（OR，1.72[95%CI，1.15-2.58]；P=0.009）。除了年龄较大、男性和肥胖外，居住在人口稠密地区也与住院风险增加相关（OR，1.10[95%CI，1.01-1.19]；P=0.02）。在总体人群中，患有 2 型糖尿病（OR，1.82[95%CI，1.25-2.64]；P=0.02）和肾脏疾病（OR，2.87[95%CI，1.87-4.42]；P<0.001）的患者也有更高的住院风险。与白人患者相比，肥胖与黑人患者 COVID-19 检测结果阳性的风险更高相关（白人：OR，1.37[95%CI，1.01-1.84]；P=0.04。黑人：OR，3.11[95%CI，1.64-5.90]；P<0.001；P 交互作用=0.02）。任何癌症都与黑人患者 COVID-19 检测结果阳性的风险增加相关（OR，1.82[95%CI，1.19-2.78]；P=0.005），但与白人患者无关（OR，1.08[95%CI，0.84-1.40]；P=0.53；P 交互作用=0.04）。总体合并症负担与白人患者住院风险增加相关（OR，1.30[95%CI，1.11-1.53]；P=0.001），但与黑人患者无关（OR，0.99[95%CI，0.83-1.17]；P=0.88；P 交互作用=0.02），2 型糖尿病也是如此（白人：OR，2.59[95%CI，1.49-4.48]；P<0.001；黑人：OR，1.17[95%CI，0.66-2.06]；P=0.59；P 交互作用=0.046）。基于调整分析，未发现 ICU 入院和死亡率存在统计学上显著的种族差异。
这些发现表明，患有 2 型糖尿病或肾脏疾病以及居住在人口密度较高的地区与 COVID-19 住院风险增加相关。风险因素与 COVID-19 结局的关联因种族而异。
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