Ethnicity and risk of death in patients hospitalised for COVID-19 infection in the UK: an observational cohort study in an urban catchment area

  1. Elizabeth Sapey
  2. Suzy Gallier
  3. Chris Mainey
  4. Peter Nightingale
  5. David McNulty
  6. Hannah Crothers
  7. Felicity Evison
  8. Katharine Reeves
  9. Domenico Pagano
  10. Alastair K Denniston
  11. Krishnarajah Nirantharakumar
  12. Peter Diggle
  13. Simon Ball

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Abstract

Studies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that outcomes would be poorer for those of South Asian ethnicity hospitalised from a confirmed SARS-CoV-2 infection, once confounding factors, health-seeking behaviours and community demographics were considered, and that this might reflect a more aggressive disease course in these patients.

Methods

Patients with confirmed SARS-CoV-2 infection requiring admission to University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK between 10 March 2020 and 17 April 2020 were included. Standardised admission ratio (SAR) and standardised mortality ratio (SMR) were calculated using observed COVID-19 admissions/deaths and 2011 census data. Adjusted HR for mortality was estimated using Cox proportional hazard model adjusting and propensity score matching.

Results

All patients admitted to UHB with COVID-19 during the study period were included (2217 in total). 58% were male, 69.5% were white and the majority (80.2%) had comorbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger and have no comorbidities, but twice the prevalence of diabetes than white patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted and they were more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death, both by Cox regression (HR 1.4, 95% CI 1.2 to 1.8), after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching, matching for the same factors but categorising ethnicity into South Asian or not (HR 1.3, 95% CI 1.0 to 1.6).

Conclusions

Those of South Asian ethnicity appear at risk of worse COVID-19 outcomes. Further studies need to establish the underlying mechanistic pathways.

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  1. Version published to 10.1136/bmjresp-2020-000644
  2. ScreenIT

    SciScore for 10.1101/2020.05.05.20092296: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    The limitations in our overall analysis need to be considered, specifically that 5% of patients remain in hospital at the time of the data lock and more patients have been admitted, so our findings will evolve. Since the proportion of patients presenting from different ethnic groups was stable across the course of data collection, any consequence for our main conclusion on the mortality risk in South Asians admitted to hospital is likely to be small. Data on the admission severity scoring did not include all patients, which is a limitation. This limitation reflects the real-world response within a global pandemic which includes designing a score to inform care escalation decisions and updating the UHB electronic health record to capture this information during the first wave of patient admissions. However, these data suggest further exploration of severity of disease at presentation is warranted. It is also important to acknowledge that standardised admission and mortality ratios from Birmingham and Solihull use the most recent census data, but that these are from 2011. Estimates of the contemporary age structure do not however suggest a need to significantly qualify these findings. The UK has not undertaken widespread screening or diagnosis of patients in the community, we are therefore unable to comment upon the natural history of COVID-19 prior to admission to secondary care, irrespective of ethnic group. This testing regime is likely to evolve with the development of capa...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.05.05.20092296 on medRxiv