Racial and ethnic minority patients show more severe cases on chest X-ray, fueled by socioeconomic factors.
Patients who come from racial and ethnic minority groups are experiencing more severe COVID-19 disease than their white and non-Hispanic counterparts – and the differences are not coming from any biological risk factors, new research has revealed.
As a virus that has shown no true predilection for patients with any over-arching risk factors, striking patient of all ages, races, and health statuses, COVID-19 could be viewed as an equalizer among all populations. Yet, emerging data continues to paint a picture of a greater burden being felt by patients who come from racial or ethnic minority groups – most of whom are under-represented and under-served.
In a study published recently in Radiology, a team of investigators from Massachusetts General Hospital (MGH) led by Efren J. Flores, M.D., MGH radiologist and radiology instructor at Harvard Medical School, examined the underlying factors that are contributing to the higher rate of severe disease patients in these groups are experiencing.
Sparked by the larger number of COVID-19-positive patients with worse cases presenting the an MGH respiratory clinic in Chelsea, a predominantly Spanish-speaking Hispanic community, that the hospital was seeing in Boston, Flores and his team set out to determine whether socioeconomic factors and social determinants were to blame.
“It got to the point where half of our patient population admitted with COVID-19 were underrepresented minorities,” he explained.
To see whether health disparities were at play, Flores’ team examined data from 326 patients who were hospitalized with confirmed COVID-19 infection between March 27, 2020, and April 10, 2020. They analyzed chest X-rays and found non-white patients did, in fact, have much worse lung disease upon admission to the hospital than white or non-Hispanic patients. And, with that increased severity came a higher likelihood of intensive care unit admission, intubation, and death, Flores said.
According to the results, 318 patients – 98 percent – had at least one abnormality on chest X-ray. In addition, non-white patients had significantly higher modified Radiographic Assessment of Lung Edema (mRALE) scores than white patients. Higher scores are associated with higher likelihood of experiencing composite adverse outcome with no evidence of interaction.
When the team examined additional data, they found several factors contributed to the greater severity upon a patient’s presentation at the hospital. Not only did this group have a higher prevalence of pre-existing co-morbidities, such as high blood pressure, but they also tended to delay treatment. In many cases, Flores explained, these patients, who are frequently low-income, faced the difficult choice of taking off work to seek care or continuing to work despite their deteriorating symptoms. Many also had limited English proficiency.
“Limited English proficiency is an additional socio-economic factor that really influences many aspects of access to care,” he said. “When we were first learning how the disease spread, there was all this rapidly evolving information coming out that was not available in languages other than English, and that lag in availability of actional health information for non-English speaking individuals was really critical for many patients trying to navigate a complex medical system with a disease from a virus that is so aggressive.”
These languages barriers, he said, point to the need not only for more written, culturally-tailored health information multiple languages, but also for providers and other health professionals who can speak with patients in their first language.
It is also highly likely that additional factors are contributing to the higher rate of significant disease in these groups. Frequently, racial and ethnic minorities live in multi-generational households in areas with higher population density, making it easier to spread the virus. And, many working-age patients have jobs that do not translate easily to working remotely, and they have limited-to-no paid time off, ensuring that taking time to go to the doctor or hospital could be a financial hardship.
“Many of these patients delay their care because they’re considered essential workers and they don’t have a lot of sick leave, but also it’s difficult for them to leave because they are living on a weekly paycheck and have other dependents,” Flores explained. “It wasn’t uncommon for us to go into the medical record when we were interpreting their exams and see that many of them worked at grocery stores or warehouses.”
The Radiologist’s Role
So, what can a radiologist do? Quite a lot, in fact, Flores said.
First, radiologists play a vital role in identifying the patients who are at higher risk earlier.
“Health equity is every medical specialty’s responsibility, but I believe radiology is uniquely positioned to take a bigger role not only in population health, but in public health efforts,” he said. “The findings of this study could assist radiologists in the development of algorithms to identify vulnerable and at-risk populations.”
But, it is also imperative for radiologists to participate in the creation of multi-disciplinary collaborations with other specialists, community stakeholders, and public health initiatives that can directly address disparities. For example, they could help launch infectious disease clinics that include imaging and COVID-19 testing or develop actionable health information for communities with limited English proficiency. The goal, he said, is to improve the efficacy of public health interventions to augment care access.
“We did this study not only to gain a better understanding of these emerging disparities, but also to discover how we can use this information to craft a better path toward equity together,” Flores said.