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Is there any evidence looking at mortality in different races in Corona Virus Disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU)?

Comment by InpharmD Researcher

The most recent evidence indicates that race is not independently associated with in-hospital mortality after adjusting for differences in sociodemographic and clinical factors
Background

The current statistics according to the Centers for Disease Control and Prevention (CDC) state that black individuals have 2.6x more cases, 4.7x more hospitalizations, and 2.7x more deaths than white individuals affected by COVID-19. [1]

A review of the association between ethnicity, incidence, and outcomes of COVID-19 found minority patients had reduced lung function compared to white individuals. Additionally, there could be an association between COVID-19 and glucose-6-phosphate dehydrogenase (G6PD) deficiency, a deficiency seen more often in African, Asian, and Mediterranean patients. Furthermore, minority ethnicities in poorer socioeconomic circumstances are associated with more comorbidities, potentially leading to more COVID-19 cases. [2]

A review article assessing clinical characteristics and morbidity associated with COVID-19 in Detroit found that out of 463 patients, 334 (72.1%) were black. Male sex and older age were significantly associated with mortality, whereas African American race was not. [3]

According to a Centre of Evidence Based Medicine review, a higher mortality risk from COVID-19 is seen among Black, Asian and Minority Ethnic (BAME) groups, but deaths are not consistent across these groups. Similarly, adverse outcomes were seen for BAME patients in intensive care units and amongst medical staff and Health and Care Workers.[4]

The American Public Media (APM) Research Lab states that for each 100,000 Americans, about 88 Blacks have died from the coronavirus, the highest actual mortality rate of all groups—above Asians (36), Whites (40), Latinos (54), Pacific Islanders (64) and Indigenous people (73). If adjusted for age, Blacks are 3.6 times more likely to have died than Whites. [5]

References:

[1] COVID-19 Hospitalization and Death by Race/Ethnicity. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Accessed August 25, 2020.

[2] Abuelgasim E, Saw LJ, Shirke M, Zeinah M, Harky A. COVID-19: Unique public health issues facing Black, Asian and minority ethnic communities. Curr Probl Cardiol. 2020;45(8):100621. doi:10.1016/j.cpcardiol.2020.100621

[3] Suleyman G, Fadel RA, Malette KM, et al. Clinical Characteristics and Morbidity Associated With Coronavirus Disease 2019 in a Series of Patients in Metropolitan Detroit. JAMA Netw Open. 2020;3(6):e2012270. Published 2020 Jun 1. doi:10.1001/jamanetworkopen.2020.12270

[4] BAME COVID-19 DEATHS - What do we know? Rapid Data & Evidence Review. CEBM. https://www.cebm.net/covid-19/bame-covid-19-deaths-what-do-we-know-rapid-data-evidence-review/. Published May 20, 2020. Accessed August 25, 2020.

[5] COVID-19 deaths analyzed by race and ethnicity. APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. Published August 18, 2020. Accessed August 26, 2020.

Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

Is there any evidence looking at mortality in different races in Corona Virus Disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU)?

Please see Table 1 for your response.


Study Name

Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals

Design

Cohort Study

N= 11210

Objective

To evaluate the association of race, adjusting for sociodemographic and clinical factors, on all-cause, in-hospital mortality for patients with COVID-19

Methods

This cohort included patients with confirmed COVID-19, across 12 states and 92 hospitals. The researchers implemented protocols for COVID-19 screening, testing, and management across the sites of care. Patients sociodemographic characteristics, laboratory results, and health care utilization/insurance were collected and assembled into a uniform database. Race was self-reported and categorized as White, Black, and other.

 

Three models were used to assess the association of race with mortality; all models included the random effects term for hospital. Model 1 estimated HRs for patient characteristics, unadjusted for other factors. Model 2 included a priori patient characteristics of interest (race, age, sex, insurance, and ECI and NDI scores). Model 3 adjusted for the covariates in model 2 and specific chronic conditions if they were significant in univariable analyses at p < .05.

 

Study Groups/Patients

White (n= 4606)

Black (n= 4180)

Other or missing (n= 2424)

 

Duration

February 19, 2020 to June 25, 2020

 

Outcome Measures

Characteristics of patients admitted to the different care sites

 

Death during hospitalization

Results

Characteristics:

Characteristic

White

Black

Age

66

61

Women

49%

54.9%

Medicaid

13.3%

24.7%

Neighborhood Deprivation Index

(NDI) scores

-0.11

0.82

Elixhauser Comorbidity Index

(ECI) scores

21

22

Asthma

4.7%

8.8%

Cancer

3.2%

3.6%

Chronic Kidney Disease

12.9%

20.5%

Congestive Heart Failure

10.8%

12.5%

Diabetes Mellitus

23.0%

32.0%

Hypertension

25.0%

30.3%

Obesity

18.2%

32.2%

Solid Organ Transplantation

0.3%

0.5%

 

Death during hospitalization:

 

A total of 7139 patients were hospitalized

 

2866 patients admitted to intensive care unit (ICU)

2268 patients required ventilator

598 patients did not require ventilator

1404 patients discharged alive

864 patients died

467 patients discharged alive

131 patients died

Black

13.0%

Black

8.0%

Black

4.1%

Black

1.3%

White

14.0%

White

9.0%

White

4.0%

White

3.5%

Other

8.8%

Other

4.7%

Other

4.5%

Other

0.6%

 

4273 non-ICU care

3822 patients discharged alive

451 patients died

Black

27.7%

Black

2.5%

White

34.1%

White

5.4%

Other

28.7%

Other

2.1%

 

All-cause Mortality:

  White  Black
All-cause in-hospital mortality

23.1%

(724 of 3218 patients)

19.2%

(540 of 2812 patients)

 

Risk of mortality between Black and White patients:

hazards ratio: 0.93% – 95% Confidence Interval: 0.81 to 1.09

 

Study Author Conclusions

There was no statistically significant difference in all-cause, in-hospital mortality between White and Black patients after adjusting for other factors.

InpharmD Researcher Critique

Although other reports have suggested that Black patients have a higher share of COVID-19 infections and mortality, this study  showed that race was not independently associated with in-hospital mortality after adjusting for differences in sociodemographic and clinical factors.

Looking at patient characteristics, Black patients tended to be younger, more often female, and had more comorbidities compared to White individuals.

 

References:

Yehia BR, Winegar A, Fogel R, et al. Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals. JAMA Netw Open. 2020;3(8):e2018039. doi:10.1001/jamanetworkopen.2020.18039