Association Between Race and COVID-19 Outcomes During the Pre-Vaccination Period in the United States (2020–2021)

Objective: To determine the association between race, a proxy for social determinants of health, and COVID-19 outcomes adjusted for demographic, clinical, and socioeconomic differences. Methods: We conducted a retrospective cohort study using administrative claims data in the Sentinel Distributed Database. We identified 841,628 individuals diagnosed with COVID-19; and separately, 133,773 individuals hospitalized with COVID-19 between April 1, 2020, and March 31, 2021, in the US. Eligible individuals required at least 6 months of enrollment in a health plan prior to cohort entry. Crude and adjusted associations between self-reported race (Asian, Black or African American, American Indian or Alaska Native [AIAN], Native Hawaiian or Other Pacific Islander [NHOPI], White, or Unknown) and COVID-19 outcomes (hospitalization with COVID-19; critical COVID; 30-day all-cause inpatient mortality) were determined using multivariable logistic regression. Results: Of the 841,628 individuals with COVID-19, 45.5% were White, 42.1% were of Unknown race, 9.5% Black or African American, 2% Asian, 0.5% NHOPI, and 0.3% AIAN. All subpopulations had increased odds of hospitalization compared to White population (AIAN, adjusted Odds Ratio 1.45 [95% confidence interval 1.11– 1.90]; Asian population 1.58 [1.38– 1.80]; Black or African American population 1.58 [1.40– 1.78]; NHOPI 1.32 [1.22– 1.42]). There were 133,773 individuals hospitalized with COVID-19, 56.2% of whom were White, 23.4% of Unknown race, 17.6% Black or African American, 1.5% Asian, 0.9% NHOPI, and 0.4% AIAN. Over half of all hospitalized individuals progressed to critical COVID (58%) and 14.2% died within 30 days. Progression to critical COVID was significantly higher in NHOPI population compared to White population (1.17 [1.03– 1.32]). AIAN population (1.52 [1.20– 1.91]), Asian population (1.30 [1.13– 1.49]), and NHOPI population (1.24 [1.06– 1.45]) had significantly higher odds of 30-day inpatient mortality compared to White population. Conclusion: We identified significant differences in COVID-19 outcomes in different subgroups within a diverse US population.