Background There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. Methods and findings This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6–60.5) than Hispanic (52.7, 95% CI 52.1–53.4) and White individuals (38.6, 95% CI 38.4–38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85–2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74–1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80–1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73–1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41–2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11–1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. Conclusions In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities. Christopher Rentsch and colleagues study disparities in COVID-19 testing and mortality among veterans in the United States. Author summary Why was this study done? There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of morbidity and mortality from symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or coronavirus disease 2019 (COVID-19). Most studies investigating racial and ethnic disparities to date have focused on those who tested positive for SARS-CoV-2 or hospitalized patients. No single study to our knowledge has yet investigated racial and ethnic disparities in testing patterns (i.e., who received testing and who tested positive) as well as COVID-19 outcomes in a nationwide cohort with adequate adjustment for potential confounders. What did the researchers do and find? We used electronic health records from the largest integrated healthcare system in the US to investigate racial and ethnic disparities in testing and subsequent COVID-19 mortality. Non-Hispanic Black and Hispanic individuals were twice as likely as non-Hispanic White individuals to test positive for COVID-19, even after accounting for other demographics, geographic location, and underlying health conditions. The racial disparity between Black and White individuals in testing positive for COVID-19 slightly decreased over the study period, and was highest in the Midwest compared to all other regions. The ethnic disparity between Hispanic and White individuals in testing positive for COVID-19 was consistent across time, geographic region, and outbreak pattern; the disparity was consistently observed across all strata. Among those who tested positive for COVID-19, there was no observed difference in 30-day mortality by race/ethnicity group. What do these findings mean? Our findings highlight the urgent need for improved strategies to contain and prevent further outbreaks in racial and ethnic minority communities.
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