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The association of race and ethnicity with COVID-19 outcomes in patients with SLE

Nov 22, 2022
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Learning objective: After reading this article, learners will be able to describe how race/ethnicity may impact COVID-19 outcomes in systemic lupus erythematosus.

Differing rates of morbidity and mortality have been reported following infection with SARS-CoV-2 in people from different races and ethnicities, with Black and Hispanic patients often experiencing worse outcomes compared with White patients.1 Patients with systemic lupus erythematosus (SLE) who are non-White also show more severe SLE symptoms and have a higher mortality rate.1

The impact of the COVID-19 pandemic on patients with SLE of different race and ethnicity has not been previously assessed in the US.1 In this article we summarize a paper by Manuel Ugarte-Gil, et al.1, published in Arthritis Care Research, on the association between race and ethnicity and COVID‑19 outcomes in patients with SLE.

Study design

Patients with SLE and COVID-19 who were added to the COVID-19 Global Rheumatology Alliance (C19-GRA) registry between March 24, 2020, and August 27, 2021, were included in the study. Data on the race and ethnicity of the patient was entered by the physician treating each case.

COVID-19 outcomes were split into the following four categories:

  1. Not hospitalized
  2. Hospitalized with no oxygenation
  3. Hospitalized with any ventilation or oxygenation
  4. Death

Results

Results from 469 patients with SLE were included in this study and the baseline characteristics are shown in Table 1. Of the patients included on this study, 90.6% were female, the mean age was 46.4 years, 34.3% were White, 26.9% were Black, 32.8% were Hispanic, and 6% were other/mixed. White patients had a higher mean age of 50.4 years, but a lower number of comorbidities (50.3% had 0) compared with the other groups.

The majority of patients were classed as having disease activity that was minimal or low (58.4%) and 55.7% had ≥1 comorbidity.

Table 1. Baseline patient characteristics*

Characteristic, % (unless otherwise stated)

Total
(N = 469)

White
(n = 161)

Black
(n = 126)

Hispanic
(n = 154)

Other/ mixed
(n = 28)

Mean age, years (SD)

46.4 (13.7)

50.4 (14.5)

45.8 (13.1)

43.2

(12.0)

42.9 (15.2)

Female

90.6

91.3

92.1

89.6

85.7

Date of COVID-19 diagnosis

 

 

 

 

 

              Prior to Jun 15, 2020

39.2

32.3

57.9

32.5

32.1

              Jun 16, 2020, to Sep 30, 2020

14.7

11.8

16.7

17.5

7.1

              Oct 1, 2020, to Aug 27, 2021

46.1

55.9

25.4

50.0

60.7

Comorbidities

 

 

 

 

 

              0

44.4

50.3

38.1

43.5

42.9

              1

33.9

34.2

34.1

33.1

35.7

              ≥2

21.8

15.5

27.8

23.4

21.4

Specific comorbidities

 

 

 

 

 

              Chronic renal insufficiency or
              ESRD

13.7

6.2

15.9

16.2

32.1

              Hypertension or CVD

36.7

31.7

46.0

35.1

32.1

Disease activity

 

 

 

 

 

              Remission

20.7

23.6

17.5

20.1

21.4

              Minimal or low

58.4

57.8

63.5

55.8

53.6

              Moderate

15.1

11.8

12.7

19.5

21.4

              Severe or high

2.1

1.9

4.0

1.3

0.0

              Missing

3.6

5.0

2.4

3.3

3.6

CVD, cardiovascular disease; ESRD, end-stage renal disease; SD, standard deviation; SLE, Systemic lupus erythematosus.
*Adapted from Ugarte-Gil, et al.1
Data on outcome available.

The COVID-19 outcomes, split between the different racial and ethnic groups, are shown in Figure 1. White patients with SLE and COVID-19 were not hospitalized in 86.3% of cases, whereas only 63.5% of Black patients were not admitted. Black patients showed the highest percentage of patients hospitalized without requiring ventilation, at 14.3%.

Black and Hispanic patients were the most likely to require ventilation or oxygenation in hospital (both 17.5%) compared with White or other/mixed patients. In addition, 4.8% of Black patients died, compared with 3.9% of Hispanic patients, 3.6% of other/mixed patients, and 3.1% of White patients, who had the lowest fatality rate.

Figure 1. COVID-19 outcomes*

*Adapted from Ugarte-Gil, et al.1

Multivariate analysis carried out on the COVID-19 outcome data showed that Black and Hispanic patients had significantly increased odds ratios for severe outcomes compared with White patients (Table 3). Patients who were Black also showed a significantly increased odds ratio for being hospitalized compared with White patients.  

Table 3. Multivariate analysis of the association between race/ethnicity and COVID-19 outcomes in patients with SLE in the US*

Race/ethnicity

Ordinal outcome
(N = 469)

Hospitalization
(n = 497)

OR (95% CI)

p value

OR (95% CI)

p-value

White

Ref

 

Ref

 

Black

2.73 (1.365.53)

<0.01

2.15 (1.163.99)

0.02

Hispanic

2.76 (1.345.69)

<0.01

1.73 (0.943.16)

0.08

Other

1.13 (0.343.77)

0.85

1.22 (0.423.49)

0.71

CI, cumulative incidence; OR, odds ratio.
*Adapted from Ugarte-Gil, et al.1
This model included four mutually independent outcomes: (1) not hospitalized, (2) hospitalized with no oxygenation, (3) hospitalized with any ventilation or oxygenation, or (4) death. Both models were adjusted by sex, age, region, time period, comorbidities (including specific comorbidities [renal disease and hypertension/cardiovascular disease] and number of other comorbidities), disease activity (remission, low, moderate, or high), glucocorticoids as a categorical variable (0, 15, ≥6 mg/day), and immunosuppressive medication category.

Limitations

As the C19-GRA registry used was one that collected data reported by physicians, the results may have been biased to include more severe cases, as these were more likely to seek medical help. Other selection biases may also exist, such as differences in access to healthcare. This study did not take into account confounding variables, such as poverty, and other issues that may underlie the disparities in health outcomes in the US. These data are from the US and may not be generalizable to other countries. Race and ethnicity were entered by the attending physician and may not have been entered in accordance with the ethnicity the patient self-identified as. In addition, some variables assessed had small patient numbers, so the outcomes assessed should be treated with caution.

The impact of vaccination on outcome was not analyzed in this study, as the majority of cases were recorded prior to the availability of any of the COVID-19 vaccines.

Conclusion

Black and Hispanic patients with SLE have been reported to have more severe SLE symptoms and a higher mortality rate in the US. In addition, Black or Hispanic individuals without SLE also demonstrate poorer outcomes following cases of COVID-19 in the US. This trend continues when examining the association between race and ethnicity and COVID-19 outcome, with Black and Hispanic patients with SLE faring worse compared with White patients. The authors of this study attributed this association to socioeconomic factors and inequality when accessing healthcare.

Black and Hispanic patients with SLE showed worse post-COVID-19 outcomes than white patients in the US. This result may reflect the inequality in access to healthcare for Black and Hispanic patients, who are more likely to be from a poorer socioeconomic background and have fewer healthcare services locally available to them.

  1. Ugarte-Gil MF, Alarcón GS, Seet AM, et al. Association between race/ethnicity and COVID-19 outcomes in systemic lupus erythematosus (SLE) patients from the United States: Data from the COVID-19 Global Rheumatology Alliance. Arthritis Care Res. Online ahead of print. DOI: 10.1002/acr.25039

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