Racial/Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed COVID-19: A Retrospective Cohort Study

Joseph, Nicholos P.; Reid, Nicholas J.; Som, Avik; Li, Matthew D; Hyle, Emily P.; Dugdale, Caitlin M.; Lang, Min; Betancourt, Joseph R.; Deng, Francis; Mendoza, Dexter P.; Little, Brent P.; Narayan, Anand K.; Flores, Efren J.

BACKGROUND: Disease severity on chest radiographs (CXR) has been associated with higher risk of disease progression and adverse outcomes from COVID-19. Few studies have evaluated COVID-19-related racial/ethnic disparities in radiology. PURPOSE: To evaluate whether Non-White minority patients hospitalized with confirmed COVID-19 infection presented with increased severity on admission CXR compared with White/Non-Hispanic patients. METHODS: Single-institution, retrospective cohort study approved by the IRB. Patients hospitalized with confirmed COVID-19 infection (3/27/20-4/10/20) were identified using the electronic medical record (EMR) (n=326, mean age: 59 years (SD: 17 years), M:F (188:138). Primary outcome was severity of lung disease on admission CXR, measured by modified Radiographic Assessment of Lung Edema (mRALE) score. Secondary outcome was a composite adverse clinical outcome of intubation, ICU admission, or death. Primary exposure was racial/ethnic category: White/Non-Hispanic versus Non-White [i.e., Hispanic, Black, Asian, Other]. Multivariable linear regression analyses were performed to evaluate the association between mRALE scores and race/ethnicity. RESULTS: Non-White patients had significantly higher mRALE scores (median 6.1, 95% CI 5.4–6.7) compared with White/Non-Hispanic patients (median 4.2, 95% CI 3.6–4.9) (unadjusted average difference 1.8, 95% CI 0.9–2.8, p<0.01). For both White (Adjusted HR, 1.3, 95%CI 1.2-1.4, p<0.001) and Non-White patients (Adjusted HR 1.2, 95%CI 1.1-1.3, p<0.001), increasing mRALE scores were associated with a higher likelihood of experiencing composite adverse outcome with no evidence of interaction (p = 0.16). Multivariable linear regression analyses demonstrated that Non-White patients presented with higher mRALE scores on admission CXR versus White/Non-Hispanic patients (adjusted average difference 1.6, 95% CI 0.5–2.7, p<0.01). Adjustment for hypothesized mediators revealed that the association between race/ethnicity and mRALE scores was mediated by limited English proficiency (p<0.01). CONCLUSION: Non-White patients hospitalized with COVID-19 infection were more likely to present with higher severity of disease on admission CXR than White/Non-Hispanic patients, and increased severity was associated with worse outcomes for all patients.