Pharma Focus Asia

Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans

Christopher T. Rentsch , Farah Kidwai-Khan , Janet P. Tate , Lesley S. Park , Joseph T. King Jr ,
Melissa Skanderson , Ronald G. Hauser, Anna Schultze, Christopher I. Jarvis, Mark Holodniy, Vincent Lo Re III, Kathleen M. Akgün, Kristina Crothers, Amy C. Justice



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.


The United States has the highest number of reported symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and related deaths in the world, accounting for one-fourth of global totals as of July 22, 2020 [1]. There is growing concern that racial and ethnic minority communities are experiencing a disproportionate burden of morbidity and mortality from symptomatic SARS-CoV-2 infection or coronavirus disease 2019 (COVID-19) [2–8]. One statewide study investigating racial disparities followed 3,481 COVID-19 cases in Louisiana and found that non-Hispanic Black individuals represented 77% of hospitalizations and 71% of deaths despite only making up 31% of the total source population [9]. Thus, the potential for racial and ethnic disparities in COVID-19 have been deemed an urgent public health research priority [10]. However, most studies investigating racial and ethnic disparities have focused on hospitalized patients or have not characterized who received testing or tested positive for COVID-19 [9,11–15]. Given that COVID-19 testing was not performed at random, particularly in the early phases of the pandemic, evaluating underlying testing patterns and changes over time may provide important context for interpreting findings from models of COVID-19 outcomes. In addition, it is not yet known whether disparities in COVID-19 infection or severe outcomes are explained, at least in part, by differences in underlying health conditions, smoking and alcohol use, geographic location, or urban versus rural residence—essential information if we are to design effective interventions.


Data source

The VA is the largest integrated healthcare system in the US and comprises over 1,200 points of care (i.e., sites) nationwide including hospitals, medical centers, and community outpatient clinics. All care is recorded in an electronic health record with daily uploads into the VA Corporate Data Warehouse. Available data include demographics, outpatient and inpatient encounters, diagnoses, smoking and alcohol health behaviors, and pharmacy dispensing records.

This study was approved by the institutional review boards of VA Connecticut Healthcare System and Yale University. It has been granted a waiver of informed consent and is Health Insurance Portability and Accountability Act compliant. The analyses herein were not pre-specified in a formal protocol, rather were informed by hypotheses drawn from prior work [16]. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (S1 STROBE Checklist).


This study examined racial and ethnic disparities in testing and subsequent COVID-19 mortality among approximately 6 million individuals receiving care in the US. We found that Black and Hispanic individuals were more likely to be tested and to test positive for COVID-19 than White individuals, even after comprehensive adjustment for underlying health conditions, other demographics, and geographic location. Among the variables assessed in this study, age, rural/urban residence, and site of care explained more of the racial/ethnic disparity in testing positive for COVID-19 than comorbidities, substance use, or medication history. While the disparity between Black and White individuals decreased over time, the disparity was strongest in the Midwest and at VA sites that experienced an early or resurgent outbreak. There was no variation observed in the disparity between Hispanic and White individuals by calendar time, region, or outbreak pattern. While individuals from minority backgrounds appeared to experience excess burden of COVID-19, among those infected, there was no observed difference in 30-day mortality by race/ethnicity group. The apparent racial/ethnic disparity in mortality in unadjusted data was principally explained by differing age structures between the populations.


The authors wish to recognize Dr. Kendall Bryant as the NIAAA Scientific Collaborator for this study.

The views and opinions expressed in this paper are those of the authors and do not necessarily represent those of the Department of Veterans Affairs or the United States Government.

Citation: Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, et al. (2020) Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 17(9): e1003379.

Academic Editor: Jonathan Zelner, University of Michigan School of Public Health, UNITED STATES

Received: June 11, 2020; Accepted: August 31, 2020; Published: September 22, 2020

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: Due to US Department of Veterans Affairs (VA) regulations and our ethics agreements, the analytic data sets used for this study are not permitted to leave the VA firewall without a Data Use Agreement. This limitation is consistent with other studies based on VA data. However, VA data are made freely available to researchers with an approved VA study protocol. For more information, please visit or contact the VA Information Resource Center at

Funding: This work was supported by the National Institute on Alcohol Abuse and Alcoholism [ACJ: U01-AA026224, U24-AA020794, U01-AA020790, U10-AA013566]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: COVID-19, coronavirus disease 2019; OR, odds ratio; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; VA, Department of Veterans Affairs.

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