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1Title:DisaggregatingAsianRaceRevealsCOVID-19DisparitiesamongAsianAmericansatNewYorkCity'sPublicHospitalSystemAuthorsRoopaKalyanaramanMarcello,MPH1JohannaDolle,MPA1AreebaTariq,MS1SharanjitKaur,MPH,MBA1LindaWong,MD,MPH2JoanCurcio,MD2RosyThachil,MD3StellaS.
Yi,PhD,MPH4NadiaIslam,PhD4Affiliations1.
NYCHealth+Hospitals,OfficeofPopulationHealth2.
NYCHealth+Hospitals/Elmhurst3.
NYCHealth+Hospitals/Jacobi4.
NYUGrossmanSchoolofMedicine,DepartmentofPopulationHealth.
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;https://doi.
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20233155doi:medRxivpreprintNOTE:Thispreprintreportsnewresearchthathasnotbeencertifiedbypeerreviewandshouldnotbeusedtoguideclinicalpractice.
2AbstractThereisgrowingrecognitionoftheburdenofCOVID-19amongAsianAmericans,butdataonoutcomesamongAsianethnicsubgroupsremainextremelylimited.
Weconductedaretrospectiveanalysisof85,328patientstestedforCOVID-19atNewYorkCity'spublichospitalsystembetweenMarch1andMay31,2020,todescribecharacteristicsandCOVID-19outcomesofAsianethnicsubgroupscomparedtoAsiansoverallandotherracial/ethnicgroups.
SouthAsianshadthehighestratesofpositivityandhospitalizationamongAsians,secondonlytoHispanicsforpositivityandBlacksforhospitalization.
Chinesepatientshadthehighestmortalityrateofallgroupsandwerenearly1.
5timesmorelikelytodiethanWhites.
ThehighburdenofCOVID-19amongSouthAsianandChineseAmericansunderscorestheurgentneedsforimproveddatacollectionandreportingaswellaspublichealthprogramandpolicyeffortstomitigatethedisparateimpactofCOVID-19amongthesecommunities.
Keywords:COVID-19,Coronavirus,Pandemics,AsianAmericans,HealthDisparities,EthnicDisparities,PublicHealth,PopulationHealth,Immigrants.
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20233155doi:medRxivpreprint3NewYorkCity(NYC)wasthefirstregionintheUnitedStates(U.
S.
)toexperienceasignificantburdenofCOVID-19,withmorethan200,000cases,50,000hospitalizations,and17,000deathsbetweenMarch1andMay31,2020.
1NYCHealth+Hospitals(NYCH+H),thecity'spublichospitalsystemandthelargestinthenation,washithardestinthecityandthenationduringthistime,withmanyofits11hospitalshavingnearedcapacityandadditionaltemporaryfacilitieshavingopenedtoaccommodatethethousandsofpatientswithsevereillness.
EvidencefromNYCandthenationsincethattime,includingfromtheCentersforDiseaseControlandPrevention(CDC),hasshownthatBlacksandHispanicsbearasubstantiallyhigherburdenofCOVID-19thanWhites,withAsianAmericansreportedasexperiencingonlyaslightlyhigherburdenthanWhites.
2,3,4,5,6However,communityleadersandexpertsinAsianAmericanhealthinNYC–whichishometothelargestoverallAsianandSouthAsianpopulationsinthenation–andacrossthecountryhavevoicedconcernsaboutthelackofattentiontothesubstantialburdenofCOVID-19amongAsianAmericans,manyofwhomhavesimilarclinical,social,andeconomiccharacteristicsasotherAmericansofcolor.
7,8,9,10Thisisdueinlargeparttotwokeyfactors:1)anundercountofAsianAmericansinhealthsystemrecordsbecauseofinadequateorinaccuratedatacollectionandreportingofAsianAmericans'raceand/orethnicity(i.
e.
,as"other,""unknown,"oranincorrectrace,e.
g.
,AmericanIndian/NativeAmericanraceinsteadofAsianraceandIndianethnicity),and2)aggregatingallAsianethnicgroupsintoasingleracecategory,therebyobscuringdifferencesincharacteristicsandoutcomesbetweenthesediversegroups.
Arecentsystematicreviewandmeta-analysisof50studiesfromtheU.
S.
andtheUnitedKingdom(U.
K.
)foundahigherriskofCOVID-19infectionamongAsiansandBlacksarecomparedtoWhitesandalikelyhigherriskofintensivecareunitadmissionanddeathonly.
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20233155doi:medRxivpreprint4amongAsiansascomparedtoWhites.
11SeveralstudiesfromtheU.
K.
,wherethereisalargeAsianandespeciallySouthAsianpopulation,haveshownanincreasedburdenofCOVID-19amongcertainAsianethnicsubgroups,mostlySouthAsianandIndo-Caribbeancommunities.
12RecentmediareportsintheU.
S.
havebeguntoilluminatetheheretoforelargelyinvisibleburdenofCOVID-19amongAsianAmericans,butdatatothisendarestilllackingfromhealthsystemsandhealthdepartments.
13,14,15ArecentCDCanalysisofexcessdeathsduetoCOVID-19foundasubstantialburdenamongAsianAmericans,witha36.
6%increaseindeathsin2020ascomparedtotheaveragefrom2015-2019,farhigherthanthe11.
9%increaseamongWhitesandsecondonlytothe53.
6%increaseamongHispanics.
16Still,theimpactofCOVID-19amongAsianAmericansanddistinctAsianethnicsubgroupshasnotyetbeenfullyelucidated.
Assuch,thisstudyhastwokeyobjectives.
First,wesoughttocharacterizeCOVID-19clinicalanddemographicriskfactorsandoutcomesamongAsianAmericanstestedforCOVID-19atNYC'spublichospitalsystem,whichservesthousandsofAsianAmericanseachyear.
Second,wesoughttoidentifyifdifferencesexistincharacteristicsandoutcomesbetweenAsianethnicsubgroupsandotherracialgroups.
StudyDataandMethodsDataSourcesNYCH+H'selectronichealthrecord(EHR)databasewasusedtoidentifyallpatientswhoreceivedaSARS-CoV-2testatNYCH+HbetweenMarch1andMay31,withfollowupthroughAugust15,2020.
Demographicdataandselectcomorbiditieswereextractedforallpatients,whereavailable,aswereCOVID-19-relatedoutcomes(testdates,testresults,datesofhospitalizationanddischarge,anddateofin-hospitaldeath,whereapplicable).
Theprimaryvariablesofinterestwererace,ethnicity,age,andCOVID-19-relatedoutcomes(positivetest,.
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20233155doi:medRxivpreprint5hospitalization,in-hospitalmortality).
NYCH+HclassifiesHispanicethnicityasauniqueracecategoryratherthananadditionalethnicity.
OwingtoknowndeficienciesincompletenessofrecordedraceandethnicitywithintheNYCH+HEHR,race,ethnicity,andlanguagedataintheEHRandvalidatedAsiansurnamelists(SupplementTable1)wereusedtoclassifyindividualsintooneofthreeAsianethnicgroups(SouthAsian[Afghani,Bangladeshi,Indian,Nepalese,Pakistani,SriLankan],Chinese,andallotherAsian).
17,18,19BecauseofthelargeoverlapbetweenFilipinoandHispanicsurnames,wedidnotcategorizeanysurnamesasFilipino;however,Filipinopatientswhoseraceand/orethnicitywererecordedasAsianand/orFilipinointheEHRwerecategorizedintothe"otherAsian"group.
TheprimaryoutcomeswereapositiveSARS-CoV-2test,hospitalizationfor,anddeathfromCOVID-19.
Secondaryoutcomeswerepatientdemographicsandcomorbidities.
StatisticalAnalysisPatientdemographicsandcomorbiditiesweresummarizedasdescriptivestatistics,withcategoricaldatapresentedasfrequency(percentage)andnumericdataasmean(SD)ormedian(interquartilerange[IQR]),asappropriate.
Pearsonchi-squaretestswereusedtoexaminedifferencesbetweendemographicandclinicalcharacteristicsbyraceandethnicity.
Multivariablelogisticregressionanalyseswereperformedtoassesswhetherracial/ethnicdisparitiesinmortalitypersistaftercontrollingforotherdemographics(i.
e.
,sex,age)andcomorbidities(e.
g.
,diabetes,obesity)knowntobeassociatedwithadverseoutcomesfromCOVID-19basedonpublishedliterature.
Werantwomodels:oneaggregatedallAsianethnicsubgroupsintoasingleAsianracecategoryandtheotherdisaggregatedAsianraceintothethreespecifiedethnicsubgroups.
Wepresentedthe.
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20233155doi:medRxivpreprint6associationbetweenriskfactorsandoutcomeofdeathasoddsratiosand95%confidenceintervals.
Forallanalyses,ap-valueof<0.
05wasconsideredstatisticallysignificant.
AllanalyseswereperformedusingRversion3.
6andSASEnterpriseGuideversion7.
15.
ThisstudywasapprovedbytheBiomedicalResearchAllianceofNewYorkInstitutionalReviewBoard.
Informedconsentwasnotrequiredbecauseoftheretrospectivenatureofthisstudy.
LimitationsThisstudyhadseverallimitations.
First,itincludedonlypatientsfromasinglehealthsystem;however,NYCH+Histhelargestpublichospitalsysteminthenation,servingmorethan1millionpatientseachyearatmorethan70sites,including11hospitals,acrossthecity'sfiveboroughs.
NYCH+Hservesahighlydiversepatientpopulation,includingthousandsoflowerincomeAsianAmericans,whoaretypicallyunderrepresentedinnationaldatasets,soourfindingscanbegeneralizedtootherareaswithsimilarAsianAmericanpopulationsthatmaybesmallerorunderstudied.
20Second,weutilizedonlyclinicalanddemographicdataavailablefromtheEHR;socialneedsscreeningwasrolledoutacrossthesystemlastyearbutcollectionandreportingremainslimited,soweexcludedthesedata.
Third,nearlyhalfofpatientstestedwerenewtoNYCH+H,soaclinicalhistorywasnotavailableforthem.
However,mostnewpatientswhowerehospitalizedhadBMIanddiagnosesenteredintheirEHRfollowingtheiradmission,sokeyclinicalpredictorsofmortalitywereavailablefornearlyallhospitalizedpatients.
Fourth,wedidnotanalyzeoutcomesforthegroupofpatientscategorizedasAsiansolelybasedonraceenteredintheEHR,asthisgroupwasnearlyhalfthesizeofthegroupidentifiedthroughsurname-basedethnicityidentification.
Fifth,wedidnotclassifyasFilipinothroughsurnamematchinganyindividualswhowerenotalreadyidentifiedasFilipinointheEHR;assuch,this.
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20233155doi:medRxivpreprint7groupislikelyunderrepresentedinouranalysisrelativetootherAsianethnicsubgroups,but,becauseFilipinoscompriseasmallproportionofallAsiansinNYC,thislikelydoesnotbearanysubstantialimpactuponourfindings.
Sixth,ourreportingoftestresultsandhospitalizationbyrace/ethnicitywasnotadjustedforage.
Seventh,weincludedonlyin-hospitalmortalityanddidnotincludemortalityforpatientswhodiedafterdischargefromthehospital.
Finally,wedidnotadjustBMIcategoriesforAsianethnicgroupstoalignwithWHOrecommendations,whichcategorizeindividualsofAsianraceasoverweightandobeseatlowerBMIvaluesthantheoverallpopulation.
Assuch,theprevalenceofoverweightandobesityamongindividualsofAsianraceislikelyunderestimatedinourstudy.
10StudyResultsCharacteristicsofAsianAmericanPatientsOfthe85,328adultstestedforSARS-CoV-2,9,971(11.
7%)wereidentifiedasAsianthroughacombinationofEHRraceandethnicitydataandsurnamematching.
Ofthese,4,804(48.
2%)wereSouthAsian,2,214(22.
2%)wereChinese,and2,953(29.
6%)wereofotherAsianethnicgroups(Table1).
ChinesepatientsweretheoldestamongAsians,withamedianageof53years(IQR38-64),andtheywereamongtheoldestofallracialandethnicgroups.
ChinesepatientswerealsomostfrequentlynewpatientstoNYCH+H(50.
6%)amongallAsianethnicsubgroupsaswellasallracialgroups.
SouthAsiansweremostlikelyamongAsianstoutilizeEmergencyMedicaid(2.
2%)andMedicaid(23.
6%),secondoverallonlytoHispanics(6.
2%and24.
7%,respectively).
Amongallracialgroups,commercialinsurancewasutilizedmostfrequentlybyWhiteandAsianpatients(38.
4%and37.
0%,respectively),butthishighrateamongAsianswasdrivenbyindividualsnotofSouthAsianorChinesedescent(45.
4%).
ChronicdiseaseswereprevalentamongSouthAsians,whohadasubstantiallyhigherrateof.
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20233155doi:medRxivpreprint8obesity(14.
1%withBMI≥30and<40and1.
7%withBMI≥40),diabetes(23.
1%),hypertension(26.
0%),andheartdisease(22.
0%)thanotherAsianethnicsubgroups;theserateswerecomparabletoandinsomecaseshigherthanthoseobservedamongBlackandHispanicpatients.
COVID-19OutcomesofAsianAmericanPatientsAmongallracialgroups,Asianshadthesecondhighestrateoftestingpositive(27.
9%);SouthAsianshadthehighestrateamongAsianethnicgroups(30.
8%),secondonlytoHispanics(32.
1%)overall(Figure1).
51.
6%ofAsianswhotestedpositivewerehospitalized,alowerproportionthanthatofBlacksandWhites;however,rateswerehigheramongChinese(52.
6%)andSouthAsianpatients(54.
7%),thelatterofwhomhadthesecondhighestrateamongallgroups.
The25.
5%mortalityrateamongAsianswassecondonlytoWhites(33.
6%).
DisaggregationintoethnicsubgroupsrevealedthatChinesepatientshadasubstantiallyhighermortalityrate(35.
7%)thanSouthAsians(23.
7%)andotherAsians(21.
0%),andthisratewasthehighestamongallracialgroups.
ThisdisparityinmortalityamongChinesepatientspersistedevenafteradjustingforage,otherdemographics,andcomorbidities(OR1.
44,95%CI[1.
035,2.
011],p=0.
03)(Table2).
However,nodisparitywasobservedbetweentheaggregateAsianracegroupascomparedtoWhites(OR1.
15,95%CI[0.
93,1.
43],p=0.
21).
UseofEmergencyMedicaidandbeinganewpatientatNYCH+Hwerealsoassociatedwithincreasedoddsofdeath(OR2.
86,95%CI[2.
30,3.
54],p<0.
001andOR2.
03,95%CI[1.
79,2.
30],p<0.
001,respectively).
DiscussionThisstudyisthefirsttohighlightdisparitiesinCOVID-19outcomesamongAsianAmericanethnicsubgroupsintheUnitedStates.
WefoundasubstantialburdenofCOVID-19.
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20233155doi:medRxivpreprint9amongSouthAsianandChinesepatientsinNYC'spublichospitalsystem,withratessimilartothoseobservedamongBlacksandHispanics.
DisaggregatingAsianraceintoethnicsubgroupsrevealedadisproportionateburdenofCOVID-19infectionandhospitalizationamongSouthAsiansandmortalityamongChinesepatients,withthelatterhavingthehighestlikelihoodofdeathamongallracial/ethnicgroups.
Ratesofpositivity,hospitalization,andmortalityweresubstantiallyloweramongtheoverallAsianracegroupthanamongindividualethnicsubgroups.
Todate,thedisproportionateburdenofCOVID-19amongAsianethnicsubgroupshasbeenmaskedinU.
S.
-basedstudiesexaminingdisparitiesbyrace/ethnicitybyaggregatingallAsianethnicgroupsintoasingleAsianracecategory,whichhassubsequentlyhinderedanappropriatepublichealthresponse.
AsianAmericans,especiallythoseofSouthAsianandChinesedescent,haveseveralkeyclinicalriskfactorsincommonwithBlacksandHispanics.
AsiansexperienceoverweightandobesityatlowerBMIvaluesthanindividualsofotherracialgroups,resultinginahigherprevalenceoftheseconditionsthanexpected.
21Additionally,SouthAsianshavehighratesofdiabetesandhypertensionthatarecomparabletothoseobservedamongBlackandHispanicindividuals,andtheyhaveadisproportionateburdenofmorbidityandmortalityfromcardiovasculardisease.
ThesefactorsareknowntoputindividualsatelevatedriskofCOVID-19infection,hospitalization,anddeath,andtheyarehighlyprevalentamongmanyAsianAmericans.
22,23ManyAsianAmericansexperiencesocialfactorsthatareknowntoincreasetheriskofexposureforCOVID-19,includinglivinginmulti-generationalhousing,jobsasfrontlineoressentialworkers,lackofpaidsickleave,andlimitedaccesstolinguisticallyandculturallyappropriatehealthcare.
24,25Furthermore,thesocialconditionsthatdriveracialandethnic.
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20233155doi:medRxivpreprint10disparitiesindiabetesandhypertensionamongBlackandHispanicAmericans,includingpoverty,limitedaccesstohealthcare,limitedEnglishlanguageproficiency,andotherupstreamdeterminantsofhealth,aresimilarinthelargelyimmigrantAsianpatientpopulationatNYCH+H.
ThehighrateofinfectionobservedamongSouthAsiansmaybeduetofactorsthatincreasethelikelihoodofexposure(e.
g.
,jobsinessentialservices)orimpedetheabilitytoisolateifinfected(e.
g.
,crowdedhousing,lackofpaidsickleave)thatarewell-establishedasriskfactorsamongothergroupsofcolorintheU.
S.
Arecentanalysisofcommunity-levelfactorsassociatedwithracialandethnicCOVID-19disparitiesfoundthat"householdsizeandfoodserviceoccupationarestronglyassociatedwiththeriskofCOVID-19infection"andthatthesefactors"maybecontributingtothehighernumberofCOVID-19casesinBlackandLatinocommunities.
"26ThesefactorsarealsocommonamongNewYorkersofAsiandescent,particularlyamongthosewhoarerecentimmigrants,whichmaypartiallyexplainthehighrateofinfectionweobservedamongSouthAsians.
Thissameanalysisalsofoundthattheproportionofforeign-bornnon-citizenswaspositivelyassociatedwiththenumberofCOVID-19casesinacommunity,whichmayalsoexplainhigherratesofCOVID-19amongAsianNewYorkersaswellasamongHispanicNewYorkers,manyofwhomarealsorecentimmigrants.
Furthermore,AsianAmericansaremostlikelyofallracialgroupstoliveinlarger,multi-generationalhouseholds,furtherdrivingtheirriskofCOVID-19exposureandinfection.
27DatafromtheU.
S.
BureauofLaborStatistics(BLS)indicatingthatBlacksandHispanicsarelessabletoworkfromhomeascomparedtoWhitesandAsianshavebeencitedtoexplainthesocialfactorsdrivingCOVID-19,butthesedatadonottakeintoaccountthesocioeconomicvariationwithinracialgroupsandfurtherservetomaskthehighburdenofCOVID-19among.
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20233155doi:medRxivpreprint11Asianethnicsubgroups.
28NYC'sAsiandiasporaisdiversebothethnicallyandsocioeconomically,withmanyNewYorkersofSouthAsiandescentworkinginlowwagejobsforwhichworkingfromhomeisnotpossible.
U.
S.
BLSdatashowthatonly9%oflow-wage(<25thpercentile)workersareabletoworkathomeascomparedto62%ofworkersinthehighestincomequartile,whichbetterexplainshigherinfectionratesamongSouthAsiansinNYC.
Thesesocialfactorsareevenmorecommonamongrecentimmigrants,whomaydelayseekingcareduetotheirimmigrationstatus.
Thisisthoughttohavebeenexacerbatedbytherecentpublicchargerule,whichputslegallypresentimmigrantsatriskofbeingdeniedpermanentresidentstatusiftheyutilizelocal,state,orfederalgovernmentpublicbenefits.
29AninjunctionwasissuedinJuly2020thatpreventedtheU.
S.
DepartmentofHomelandSecurityfromenforcingtheruleduringtheCOVID-19publichealthemergency,andtheU.
S.
CustomsandImmigrationServicesencouragedimmigrantstoseekcareforCOVID-19symptoms,statingthattheywill"neitherconsidertesting,treatment,norpreventativecare(includingvaccines,ifavaccinebecomesavailable)relatedtoCOVID-19aspartofapublicchargeinadmissibilitydetermination,norasrelatedtothepublicbenefitconditionapplicabletocertainnonimmigrantsseekinganextensionofstayorchangeofstatus,evenifsuchtreatmentisprovidedorpaidforbyoneormorepublicbenefits,asdefinedintherule(e.
g.
federallyfundedMedicaid).
"30However,anecdotesfromcommunityorganizationsinNYCthatserveimmigrants,especiallythoseofAsiandescent,andarecentstudyofimmigrantsinTexasfoundthatimmigrantsavoidedseekingmedicalcareorenrollinginpublicbenefitsduetoconcernsaboutthepublicchargeruleandtheimpactontheirimmigrationstatus.
31,32,33Thisdelayinoravoidanceofseekingcaremay.
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20233155doi:medRxivpreprint12partiallyexplainthehighratesofhospitalizationandmortalityobservedamongSouthAsianandChinesepatients,respectively.
OurfindingthatChineseAmericanshadthehighestmortalityrateofallracial/ethnicgroupsandwerenearly1.
5moretimeslikelytodiethanWhites(OR1.
44,95%CI[1.
04,2.
01])isconcerning.
ThiselevatedburdenwasrevealedonlywhentheoverallAsianracecategorywasdisaggregatedintoethnicsubgroups,astheoverallAsianracegroupdidnothaveasignificantlyhigherlikelihoodofdeaththanWhites(OR1.
15,95%CI[0.
93,1.
43],p=0.
21).
SincetheemergenceofCOVID-19inearly2020,ChineseandotherAsianAmericanshaveexperiencedincreasedxenophobia,discrimination,andharassment:onequarterofAsianNewYorkerssurveyedreportedwitnessingorexperiencingharassment,violence,orracismrelatedtoCOVID-19,andmorethanhalfofChineseAmericanadultsandtheirchildrenacrosstheU.
S.
reportedbeingtargetedbyCOVID-19relatedracialdiscriminationeitherinpersonoronline,whichwasassociatedwithpoorermentalhealth.
34,35,36Furthermore,thisincreaseinharassmentandracismmaybeleadingtoreluctancetoand/orfearofleavingone'shomeforcareortesting,whichmaybeexacerbatingChinesepatients'knownreluctancetoseektimelycare,therebyleadingtomoresevereillnessthatmaybemoredifficulttotreatsuccessfully.
36,37Additionally,treatmentpatternsmayhavebeeninfluencedbyearlydataonworseoutcomesamongBlacksandHispanicsandthe"modelminority"myththatAsiansaretypicallyhealthierthanotherracialgroups.
38OurfindingsunderscoretheurgencyofadditionalresearchintothefactorsleadingtohighermortalityamongChineseAmericans.
WefoundthatpatientsutilizingEmergencyMedicaidwerenearlythreetimesaslikelytodieaspatientsutilizingcommercialinsurance(OR2.
86,95%CI[2.
30,3.
54]).
Inourstudy,EmergencyMedicaidusewasmostfrequentamongHispanics(6.
2%),followedbySouthAsians.
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20233155doi:medRxivpreprint13(2.
2%)andbothAsiansoverallandChinesepatients(2.
0%forboth),groupswhichcontainlargenumbersofundocumentedimmigrants.
ThemarkedlyhigherlikelihoodofdeathobservedamongpatientsutilizingEmergencyMedicaidlikelyreflectsdelayedcareseekingamongundocumentedimmigrants.
InNewYorkState,EmergencyMedicaidforundocumentedimmigrantswasexpandedearlyinthepandemictocoverCOVID-19testingandtreatment.
39However,itislikelythatmanyundocumentedimmigrantsdelayedorevenavoidedcareduetoconcernsoverreportingoftheirimmigrationstatus.
40Similarly,wefoundthat,ascomparedtopatientswithahistoryofoutpatientprimaryorspecialtycarevisitsatNYCH+H,patientswhowerenewtotheNYCH+Hsystemweretwiceaslikelytodie(OR2.
03,95%CI[1.
79,2.
30])andpatientswhohadonlyaninpatientoremergencydepartmentvisitwere1.
4timesmorelikelytodie(OR1.
36,95%CI[1.
16,1.
60]).
ObservationsfromcliniciansacrosstheNYCH+Hsystemindicatethatthismaybedueinparttopoorerhealthstatusamongnewpatientsandthosewhohadpreviouslyonlyhadanacutecarevisit,astheymaynothavebeenreceivingregularcareforchronicconditionsormayhavehadpoorlycontrolledand/orundiagnosedchronicconditionsknowntobeariskfactorforCOVID-19.
Theseobservationsarealignedwithresearchshowingpoorerhealthoutcomesamongpatientswhodelayreceivingcare,particularlyimmigrants.
41,42,43ThesepatientsalsomayhavepresentedwithmoresevereCOVID-19illnessowingtoalackofengagementwithhealthcareandconcernsoverpresentingforcareinlightoffederalrulingsonpublicchargeandimmigrationenforcement.
WefoundthatChinesepatientsweremostfrequentlynewtoNYCH+H(50.
6%),whichmayreflecttheirknownreluctancetoanddelayinseekingcare,asdescribedabove.
36AsianAmericansarefacinguniquechallengesspecifictoCOVID-19,butthesehavebeenlargelyoverlookedtodatebyhealthcareandpublichealthagencies.
Asmentioned.
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20233155doi:medRxivpreprint14previously,AsianAmericans,especiallythoseofChineseheritage,haveexperiencedasignificantincreaseinxenophobiaandharassment,whichaffectsnotonlytheirCOVID-19careseekingbutalsoworsensmentalhealth.
Additionally,althoughourdatadonotreportspecificallyonFilipinoAmericans,recentdatashowthatFilipinonursesaredyingatadisproportionatelyhigherratethanothernurses:theycomprisejust4%ofthenursingworkforceintheU.
S.
butnearlyonethirdofCOVID-19deathsamongthisgroup.
44Thisisdueinparttotheiroverrepresentationinhigher-riskrolesinhospitals,includingintensivecareunits,aswellastotheirfrequentroleasfamilycaregivers.
45Finally,theCOVID-19pandemichashadanunprecedentedeconomicimpactonAsianAmericans,manyofwhomareemployeesorownersofsmallbusinesses,withunemploymentratessoaringduetobusinessclosures:morethanonein10AsianAmericansintheU.
S.
arecurrentlyunemployed.
46InNewYorkCity,theunemploymentrateamongAsianssoaredfrom3.
4%inFebruarytoastaggering25.
6%inMay;althoughthishasbeenslowlydeclininginrecentmonths,thisdramaticriseinunemploymentisthelargestamonganyracial/ethnicgroup.
47,48,49,50OurfindingsshedimportantlightonthehiddenburdenofCOVID-19amongAsianAmericans.
CommunityleadersandexpertsinAsianAmericanhealthinNYCandacrossthecountryhavevoicedconcernsaboutthesubstantialburdenofCOVID-19amongAsianAmericans,particularlyamongspecificethnicsubgroups,sincethestartofthepandemicinNYC,yetdatatothisendhavebeenlacking.
7,8,15ThelackofdataontheburdenofCOVID-19amongAsianethnicsubgroupsintheU.
S.
hasimpededanappropriatepublichealthresponse,includingtargetedcommunicationcampaignsonpreventionandenhancedtestingandtracingamongthehardesthitcommunities.
.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint15ThesefindingsalsoprovidecriticalinsightsthatcanhelpinformpublichealthinitiativesandpoliciestoaddressthedisproportionateburdenofCOVID-19amongcommunitiesofcolor,includingAsianAmericans.
Specifically,policiesandstrategiesthatimproveaccesstotesting,isolation,andearlycaremayhelpreducedisparitiesandmitigatethespreadofCOVID-19amongcommunitiesthathavebeenhardesthitandwilllikelycontinuetobeathighriskofexposureasaresultoftheiremploymentandhousingaswellasatincreasedriskofhospitalizationanddeathduetotheirimmigrationstatus.
ConclusionInNewYorkCity,substantialdifferencesexistinCOVID-19outcomesbetweenAsianethnicsubgroups,butthesehavebeenmaskedbyreportingallAsianethnicsubgroupsasasingleAsianracialgroup.
Specifically,SouthAsianandChineseAmericansexperienceadverseCOVID-19outcomesathighratesthatarecomparabletothoseobserved–andknownforseveralmonths–amongBlacksandHispanics.
OurfindingsconfirmandvalidatecommunityobservationsandconcernsofadisproportionateburdenofCOVID-19amongSouthAsianandChineseAmericans.
Furthermore,ourfindingsunderscorethecriticalneedfordisaggregatingAsianethnicgroupsindatacollectionandreportinginordertoappropriatelyallocateresourcestothehardesthitcommunities,includingtestingandcommunicationregardingseekingcareaswellaspublichealthpoliciestomitigateriskfactorsandimprovehealthequity.
.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint16Table1.
CharacteristicsandComorbiditiesofPatientsTestedforSARS-CoV-2byRaceandEthnicitydTotalWhiteBlackHispanicAsianSouthAsiand%ofAsianChinese%ofAsianOtherAsian%ofAsianOtherUnknownPvalueNo.
(%)85328(100.
0)8037(9.
4)20827(24.
4)25119(29.
4)9971(11.
7)4804(5.
6)48.
2%2214(2.
6)22.
2%2953(3.
5)29.
6%13505(15.
8)7869(9.
2)SexMale40306(47.
2)4025(50.
1)8822(42.
4)12550(50.
0)4469(44.
8)2350(48.
9)1026(46.
3)1093(37.
0)6523(48.
3)3917(49.
8)<0.
01AgeMedian[IQR]51[38,62]53[37,64]54[40,64]51[40,62]49[35,61]49[35,60]53[38,64]47[35,59]48[34,60]49[35,61]18-4431381(36.
8)2903(36.
1)6510(31.
3)8662(34.
5)4124(41.
4)2054(42.
8)762(34.
4)1308(44.
3)5904(43.
7)3278(41.
7)<0.
0145-6436927(43.
3)3126(38.
9)9564(45.
9)11428(45.
5)4163(41.
8)1939(40.
4)936(42.
3)1288(43.
6)5462(40.
4)3184(40.
5)65-7410647(12.
5)1067(13.
3)2964(14.
2)3188(12.
7)1079(10.
8)542(11.
3)293(13.
2)244(8.
3)1403(10.
4)946(12.
0)75+6373(7.
5)941(11.
7)1789(8.
6)1841(7.
3)605(6.
1)269(5.
6)223(10.
1)113(3.
8)736(5.
4)461(5.
9)PayerCommercial22464(26.
3)3083(38.
4)6342(30.
5)3471(13.
8)3687(37.
0)1580(32.
9)766(34.
6)1341(45.
4)3965(29.
4)1916(24.
3)<0.
01EmergencyMedicaid2409(2.
8)91(1.
1)254(1.
2)1559(6.
2)195(2.
0)104(2.
2)44(2.
0)47(1.
6)234(1.
7)76(1.
0)Medicaid17809(20.
9)1200(14.
9)5154(24.
7)5180(20.
6)1801(18.
1)1128(23.
5)290(13.
1)38313.
0)3379(25.
0)1095(13.
9)Medicare12602(14.
8)1646(20.
5)3812(18.
3)3600(14.
3)1050(10.
5)500(10.
4)371(16.
8)179(6.
1)1733(12.
8)761(9.
7)Self-Pay27393(32.
1)1790(22.
3)4659(22.
4)10449(41.
6)2986(29.
9)1363(28.
4)697(31.
5)926(31.
4)3684(27.
3)3825(48.
6)Other2651(3.
1)227(2.
8)606(2.
9)860(3.
4)252(2.
5)129(2.
7)46(2.
1)77(2.
6)510(3.
8)196(2.
5)HistorywithH+H2214AcuteOnly8426(9.
9)849(10.
6)2801(13.
4)2336(9.
3)779(7.
8)468(9.
7)146(6.
6)165(5.
6)1418(10.
5)243(3.
1)<0.
01Outpatient36257(42.
5)3287(40.
9)10150(48.
7)11158(44.
4)5218(52.
3)2384(49.
6)948(42.
8)1886(63.
9)5382(39.
9)1062(13.
5)<0.
01New40645390178761162539741952112090267056564.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint17(47.
6)(48.
5)(37.
8)(46.
3)(39.
9)(40.
6)(50.
6)(30.
5)(49.
6)(83.
4)ChronicconditionsaObesitybBMI≥30and<4012636(14.
8)967(12.
0)3898(18.
7)4545(18.
1)1085(10.
9)679(14.
1)126(5.
7)280(9.
5)1735(12.
8)406(5.
2)<0.
01BMI≥402391(2.
8)202(2.
5)1020(4.
9)558(2.
2)127(1.
3)82(1.
7)17(0.
8)28(0.
9)387(2.
9)97(1.
2)ChronicdiseasescDiabetes16499(19.
3)1138(14.
2)5058(24.
3)5657(22.
5)1900(19.
1)1108(23.
1)318(14.
4)474(16.
1)2238(16.
6)508(6.
5)<0.
01Hypertension21184(24.
8)1952(24.
3)7458(35.
8)5987(23.
8)2265(22.
7)1250(26.
0)452(20.
4)563(19.
1)2778(20.
6)744(9.
5)Heartdisease16535(19.
4)1786(22.
2)5407(26.
0)4600(18.
3)1862(18.
7)1055(22.
0)391(17.
7)416(14.
1)2316(17.
1)564(7.
2)Cancer7082(8.
3)657(8.
2)2240(10.
8)2488(9.
9)706(7.
1)365(7.
6)167(7.
5)174(5.
9)822(6.
1)169(2.
1)Liverdisease2622(3.
1)277(3.
4)671(3.
2)923(3.
7)276(2.
8)150(3.
1)66(3.
0)60(2.
0)404(3.
0)71(0.
9)CKD4591(5.
4)413(5.
1)1952(9.
4)1101(4.
4)445(4.
5)255(5.
3)92(4.
2)98(3.
3)525(3.
9)155(2.
0)Abbreviations:IQR,interquartilerange;H+H,NYCHealth+Hospitals;BMI,bodymassindex;CKD,chronickidneydisease.
aAllpercentagesarebasedonthefullpopulationtested,notjustindividualswithavailablevalues.
b50.
8%ofpatientstesteddidnothaveaBMIvalueavailable.
cChronicdiseasestatusisbasedonthepresenceofadiagnosisinthepatient'srecord.
dOverallpercentageofAsianethnicsubgroupsisamongallAsians,notthefullpopulationtested.
.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprintFigure1.
COVID-19OutcomesbyRace/Ethnicity*Ratesareunadjusted18.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint19Table2.
OddsofDeathamongPatientsHospitalizedwithCOVID-19bySelectCharacteristicsAdjustedOR(95%CI)(n=9836)aP-valueRace/EthnicitybWhiteReference---Black0.
77(0.
64,0.
93)0.
006Hispanic1.
1(0.
91,1.
33)0.
34Other0.
99(0.
80,1.
23)0.
95Unknown/Declined/Missing0.
94(0.
69,1.
28)0.
69Asianc1.
15(0.
93,1.
43)0.
21SouthAsian1.
06(0.
82,1.
37)0.
68Chinese1.
44(1.
04,2.
01)0.
03OtherAsian1.
08(0.
76,1.
54)0.
66PayerdCommercialReference---EmergencyMedicaid2.
86(2.
30,3.
54)<0.
001Medicaid1.
03(0.
86,1.
24)0.
76Medicare1.
16(0.
97,1.
38)0.
11Self-pay0.
34(0.
26,0.
45)<0.
001Other0.
86(0.
47,1.
58)0.
62HistorywithH+HeOutpatientReference---New2.
03(1.
79,2.
30)<0.
001AcuteOnly1.
36(1.
16,1.
60)<0.
001Abbreviations:OR,oddsratio;CI,confidenceinterval;H+H,NYCHealth+Hospitals.
aOnlypatientswitharecordedBMIvaluewereincluded.
bReferencegroupisWhiterace.
cResultsfromModel1runwithaggregatedAsianracegroup;allotherresultsarefromModel2runwithAsianracedisaggregatedintothreeethnicgroups.
dReferencegroupiscommercialinsurance.
eReferencegroupispatientswithpreviousoutpatientvisits.
.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
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0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint
Yi,PhD,MPH4NadiaIslam,PhD4Affiliations1.
NYCHealth+Hospitals,OfficeofPopulationHealth2.
NYCHealth+Hospitals/Elmhurst3.
NYCHealth+Hospitals/Jacobi4.
NYUGrossmanSchoolofMedicine,DepartmentofPopulationHealth.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprintNOTE:Thispreprintreportsnewresearchthathasnotbeencertifiedbypeerreviewandshouldnotbeusedtoguideclinicalpractice.
2AbstractThereisgrowingrecognitionoftheburdenofCOVID-19amongAsianAmericans,butdataonoutcomesamongAsianethnicsubgroupsremainextremelylimited.
Weconductedaretrospectiveanalysisof85,328patientstestedforCOVID-19atNewYorkCity'spublichospitalsystembetweenMarch1andMay31,2020,todescribecharacteristicsandCOVID-19outcomesofAsianethnicsubgroupscomparedtoAsiansoverallandotherracial/ethnicgroups.
SouthAsianshadthehighestratesofpositivityandhospitalizationamongAsians,secondonlytoHispanicsforpositivityandBlacksforhospitalization.
Chinesepatientshadthehighestmortalityrateofallgroupsandwerenearly1.
5timesmorelikelytodiethanWhites.
ThehighburdenofCOVID-19amongSouthAsianandChineseAmericansunderscorestheurgentneedsforimproveddatacollectionandreportingaswellaspublichealthprogramandpolicyeffortstomitigatethedisparateimpactofCOVID-19amongthesecommunities.
Keywords:COVID-19,Coronavirus,Pandemics,AsianAmericans,HealthDisparities,EthnicDisparities,PublicHealth,PopulationHealth,Immigrants.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint3NewYorkCity(NYC)wasthefirstregionintheUnitedStates(U.
S.
)toexperienceasignificantburdenofCOVID-19,withmorethan200,000cases,50,000hospitalizations,and17,000deathsbetweenMarch1andMay31,2020.
1NYCHealth+Hospitals(NYCH+H),thecity'spublichospitalsystemandthelargestinthenation,washithardestinthecityandthenationduringthistime,withmanyofits11hospitalshavingnearedcapacityandadditionaltemporaryfacilitieshavingopenedtoaccommodatethethousandsofpatientswithsevereillness.
EvidencefromNYCandthenationsincethattime,includingfromtheCentersforDiseaseControlandPrevention(CDC),hasshownthatBlacksandHispanicsbearasubstantiallyhigherburdenofCOVID-19thanWhites,withAsianAmericansreportedasexperiencingonlyaslightlyhigherburdenthanWhites.
2,3,4,5,6However,communityleadersandexpertsinAsianAmericanhealthinNYC–whichishometothelargestoverallAsianandSouthAsianpopulationsinthenation–andacrossthecountryhavevoicedconcernsaboutthelackofattentiontothesubstantialburdenofCOVID-19amongAsianAmericans,manyofwhomhavesimilarclinical,social,andeconomiccharacteristicsasotherAmericansofcolor.
7,8,9,10Thisisdueinlargeparttotwokeyfactors:1)anundercountofAsianAmericansinhealthsystemrecordsbecauseofinadequateorinaccuratedatacollectionandreportingofAsianAmericans'raceand/orethnicity(i.
e.
,as"other,""unknown,"oranincorrectrace,e.
g.
,AmericanIndian/NativeAmericanraceinsteadofAsianraceandIndianethnicity),and2)aggregatingallAsianethnicgroupsintoasingleracecategory,therebyobscuringdifferencesincharacteristicsandoutcomesbetweenthesediversegroups.
Arecentsystematicreviewandmeta-analysisof50studiesfromtheU.
S.
andtheUnitedKingdom(U.
K.
)foundahigherriskofCOVID-19infectionamongAsiansandBlacksarecomparedtoWhitesandalikelyhigherriskofintensivecareunitadmissionanddeathonly.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint4amongAsiansascomparedtoWhites.
11SeveralstudiesfromtheU.
K.
,wherethereisalargeAsianandespeciallySouthAsianpopulation,haveshownanincreasedburdenofCOVID-19amongcertainAsianethnicsubgroups,mostlySouthAsianandIndo-Caribbeancommunities.
12RecentmediareportsintheU.
S.
havebeguntoilluminatetheheretoforelargelyinvisibleburdenofCOVID-19amongAsianAmericans,butdatatothisendarestilllackingfromhealthsystemsandhealthdepartments.
13,14,15ArecentCDCanalysisofexcessdeathsduetoCOVID-19foundasubstantialburdenamongAsianAmericans,witha36.
6%increaseindeathsin2020ascomparedtotheaveragefrom2015-2019,farhigherthanthe11.
9%increaseamongWhitesandsecondonlytothe53.
6%increaseamongHispanics.
16Still,theimpactofCOVID-19amongAsianAmericansanddistinctAsianethnicsubgroupshasnotyetbeenfullyelucidated.
Assuch,thisstudyhastwokeyobjectives.
First,wesoughttocharacterizeCOVID-19clinicalanddemographicriskfactorsandoutcomesamongAsianAmericanstestedforCOVID-19atNYC'spublichospitalsystem,whichservesthousandsofAsianAmericanseachyear.
Second,wesoughttoidentifyifdifferencesexistincharacteristicsandoutcomesbetweenAsianethnicsubgroupsandotherracialgroups.
StudyDataandMethodsDataSourcesNYCH+H'selectronichealthrecord(EHR)databasewasusedtoidentifyallpatientswhoreceivedaSARS-CoV-2testatNYCH+HbetweenMarch1andMay31,withfollowupthroughAugust15,2020.
Demographicdataandselectcomorbiditieswereextractedforallpatients,whereavailable,aswereCOVID-19-relatedoutcomes(testdates,testresults,datesofhospitalizationanddischarge,anddateofin-hospitaldeath,whereapplicable).
Theprimaryvariablesofinterestwererace,ethnicity,age,andCOVID-19-relatedoutcomes(positivetest,.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint5hospitalization,in-hospitalmortality).
NYCH+HclassifiesHispanicethnicityasauniqueracecategoryratherthananadditionalethnicity.
OwingtoknowndeficienciesincompletenessofrecordedraceandethnicitywithintheNYCH+HEHR,race,ethnicity,andlanguagedataintheEHRandvalidatedAsiansurnamelists(SupplementTable1)wereusedtoclassifyindividualsintooneofthreeAsianethnicgroups(SouthAsian[Afghani,Bangladeshi,Indian,Nepalese,Pakistani,SriLankan],Chinese,andallotherAsian).
17,18,19BecauseofthelargeoverlapbetweenFilipinoandHispanicsurnames,wedidnotcategorizeanysurnamesasFilipino;however,Filipinopatientswhoseraceand/orethnicitywererecordedasAsianand/orFilipinointheEHRwerecategorizedintothe"otherAsian"group.
TheprimaryoutcomeswereapositiveSARS-CoV-2test,hospitalizationfor,anddeathfromCOVID-19.
Secondaryoutcomeswerepatientdemographicsandcomorbidities.
StatisticalAnalysisPatientdemographicsandcomorbiditiesweresummarizedasdescriptivestatistics,withcategoricaldatapresentedasfrequency(percentage)andnumericdataasmean(SD)ormedian(interquartilerange[IQR]),asappropriate.
Pearsonchi-squaretestswereusedtoexaminedifferencesbetweendemographicandclinicalcharacteristicsbyraceandethnicity.
Multivariablelogisticregressionanalyseswereperformedtoassesswhetherracial/ethnicdisparitiesinmortalitypersistaftercontrollingforotherdemographics(i.
e.
,sex,age)andcomorbidities(e.
g.
,diabetes,obesity)knowntobeassociatedwithadverseoutcomesfromCOVID-19basedonpublishedliterature.
Werantwomodels:oneaggregatedallAsianethnicsubgroupsintoasingleAsianracecategoryandtheotherdisaggregatedAsianraceintothethreespecifiedethnicsubgroups.
Wepresentedthe.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint6associationbetweenriskfactorsandoutcomeofdeathasoddsratiosand95%confidenceintervals.
Forallanalyses,ap-valueof<0.
05wasconsideredstatisticallysignificant.
AllanalyseswereperformedusingRversion3.
6andSASEnterpriseGuideversion7.
15.
ThisstudywasapprovedbytheBiomedicalResearchAllianceofNewYorkInstitutionalReviewBoard.
Informedconsentwasnotrequiredbecauseoftheretrospectivenatureofthisstudy.
LimitationsThisstudyhadseverallimitations.
First,itincludedonlypatientsfromasinglehealthsystem;however,NYCH+Histhelargestpublichospitalsysteminthenation,servingmorethan1millionpatientseachyearatmorethan70sites,including11hospitals,acrossthecity'sfiveboroughs.
NYCH+Hservesahighlydiversepatientpopulation,includingthousandsoflowerincomeAsianAmericans,whoaretypicallyunderrepresentedinnationaldatasets,soourfindingscanbegeneralizedtootherareaswithsimilarAsianAmericanpopulationsthatmaybesmallerorunderstudied.
20Second,weutilizedonlyclinicalanddemographicdataavailablefromtheEHR;socialneedsscreeningwasrolledoutacrossthesystemlastyearbutcollectionandreportingremainslimited,soweexcludedthesedata.
Third,nearlyhalfofpatientstestedwerenewtoNYCH+H,soaclinicalhistorywasnotavailableforthem.
However,mostnewpatientswhowerehospitalizedhadBMIanddiagnosesenteredintheirEHRfollowingtheiradmission,sokeyclinicalpredictorsofmortalitywereavailablefornearlyallhospitalizedpatients.
Fourth,wedidnotanalyzeoutcomesforthegroupofpatientscategorizedasAsiansolelybasedonraceenteredintheEHR,asthisgroupwasnearlyhalfthesizeofthegroupidentifiedthroughsurname-basedethnicityidentification.
Fifth,wedidnotclassifyasFilipinothroughsurnamematchinganyindividualswhowerenotalreadyidentifiedasFilipinointheEHR;assuch,this.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint7groupislikelyunderrepresentedinouranalysisrelativetootherAsianethnicsubgroups,but,becauseFilipinoscompriseasmallproportionofallAsiansinNYC,thislikelydoesnotbearanysubstantialimpactuponourfindings.
Sixth,ourreportingoftestresultsandhospitalizationbyrace/ethnicitywasnotadjustedforage.
Seventh,weincludedonlyin-hospitalmortalityanddidnotincludemortalityforpatientswhodiedafterdischargefromthehospital.
Finally,wedidnotadjustBMIcategoriesforAsianethnicgroupstoalignwithWHOrecommendations,whichcategorizeindividualsofAsianraceasoverweightandobeseatlowerBMIvaluesthantheoverallpopulation.
Assuch,theprevalenceofoverweightandobesityamongindividualsofAsianraceislikelyunderestimatedinourstudy.
10StudyResultsCharacteristicsofAsianAmericanPatientsOfthe85,328adultstestedforSARS-CoV-2,9,971(11.
7%)wereidentifiedasAsianthroughacombinationofEHRraceandethnicitydataandsurnamematching.
Ofthese,4,804(48.
2%)wereSouthAsian,2,214(22.
2%)wereChinese,and2,953(29.
6%)wereofotherAsianethnicgroups(Table1).
ChinesepatientsweretheoldestamongAsians,withamedianageof53years(IQR38-64),andtheywereamongtheoldestofallracialandethnicgroups.
ChinesepatientswerealsomostfrequentlynewpatientstoNYCH+H(50.
6%)amongallAsianethnicsubgroupsaswellasallracialgroups.
SouthAsiansweremostlikelyamongAsianstoutilizeEmergencyMedicaid(2.
2%)andMedicaid(23.
6%),secondoverallonlytoHispanics(6.
2%and24.
7%,respectively).
Amongallracialgroups,commercialinsurancewasutilizedmostfrequentlybyWhiteandAsianpatients(38.
4%and37.
0%,respectively),butthishighrateamongAsianswasdrivenbyindividualsnotofSouthAsianorChinesedescent(45.
4%).
ChronicdiseaseswereprevalentamongSouthAsians,whohadasubstantiallyhigherrateof.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint8obesity(14.
1%withBMI≥30and<40and1.
7%withBMI≥40),diabetes(23.
1%),hypertension(26.
0%),andheartdisease(22.
0%)thanotherAsianethnicsubgroups;theserateswerecomparabletoandinsomecaseshigherthanthoseobservedamongBlackandHispanicpatients.
COVID-19OutcomesofAsianAmericanPatientsAmongallracialgroups,Asianshadthesecondhighestrateoftestingpositive(27.
9%);SouthAsianshadthehighestrateamongAsianethnicgroups(30.
8%),secondonlytoHispanics(32.
1%)overall(Figure1).
51.
6%ofAsianswhotestedpositivewerehospitalized,alowerproportionthanthatofBlacksandWhites;however,rateswerehigheramongChinese(52.
6%)andSouthAsianpatients(54.
7%),thelatterofwhomhadthesecondhighestrateamongallgroups.
The25.
5%mortalityrateamongAsianswassecondonlytoWhites(33.
6%).
DisaggregationintoethnicsubgroupsrevealedthatChinesepatientshadasubstantiallyhighermortalityrate(35.
7%)thanSouthAsians(23.
7%)andotherAsians(21.
0%),andthisratewasthehighestamongallracialgroups.
ThisdisparityinmortalityamongChinesepatientspersistedevenafteradjustingforage,otherdemographics,andcomorbidities(OR1.
44,95%CI[1.
035,2.
011],p=0.
03)(Table2).
However,nodisparitywasobservedbetweentheaggregateAsianracegroupascomparedtoWhites(OR1.
15,95%CI[0.
93,1.
43],p=0.
21).
UseofEmergencyMedicaidandbeinganewpatientatNYCH+Hwerealsoassociatedwithincreasedoddsofdeath(OR2.
86,95%CI[2.
30,3.
54],p<0.
001andOR2.
03,95%CI[1.
79,2.
30],p<0.
001,respectively).
DiscussionThisstudyisthefirsttohighlightdisparitiesinCOVID-19outcomesamongAsianAmericanethnicsubgroupsintheUnitedStates.
WefoundasubstantialburdenofCOVID-19.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint9amongSouthAsianandChinesepatientsinNYC'spublichospitalsystem,withratessimilartothoseobservedamongBlacksandHispanics.
DisaggregatingAsianraceintoethnicsubgroupsrevealedadisproportionateburdenofCOVID-19infectionandhospitalizationamongSouthAsiansandmortalityamongChinesepatients,withthelatterhavingthehighestlikelihoodofdeathamongallracial/ethnicgroups.
Ratesofpositivity,hospitalization,andmortalityweresubstantiallyloweramongtheoverallAsianracegroupthanamongindividualethnicsubgroups.
Todate,thedisproportionateburdenofCOVID-19amongAsianethnicsubgroupshasbeenmaskedinU.
S.
-basedstudiesexaminingdisparitiesbyrace/ethnicitybyaggregatingallAsianethnicgroupsintoasingleAsianracecategory,whichhassubsequentlyhinderedanappropriatepublichealthresponse.
AsianAmericans,especiallythoseofSouthAsianandChinesedescent,haveseveralkeyclinicalriskfactorsincommonwithBlacksandHispanics.
AsiansexperienceoverweightandobesityatlowerBMIvaluesthanindividualsofotherracialgroups,resultinginahigherprevalenceoftheseconditionsthanexpected.
21Additionally,SouthAsianshavehighratesofdiabetesandhypertensionthatarecomparabletothoseobservedamongBlackandHispanicindividuals,andtheyhaveadisproportionateburdenofmorbidityandmortalityfromcardiovasculardisease.
ThesefactorsareknowntoputindividualsatelevatedriskofCOVID-19infection,hospitalization,anddeath,andtheyarehighlyprevalentamongmanyAsianAmericans.
22,23ManyAsianAmericansexperiencesocialfactorsthatareknowntoincreasetheriskofexposureforCOVID-19,includinglivinginmulti-generationalhousing,jobsasfrontlineoressentialworkers,lackofpaidsickleave,andlimitedaccesstolinguisticallyandculturallyappropriatehealthcare.
24,25Furthermore,thesocialconditionsthatdriveracialandethnic.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint10disparitiesindiabetesandhypertensionamongBlackandHispanicAmericans,includingpoverty,limitedaccesstohealthcare,limitedEnglishlanguageproficiency,andotherupstreamdeterminantsofhealth,aresimilarinthelargelyimmigrantAsianpatientpopulationatNYCH+H.
ThehighrateofinfectionobservedamongSouthAsiansmaybeduetofactorsthatincreasethelikelihoodofexposure(e.
g.
,jobsinessentialservices)orimpedetheabilitytoisolateifinfected(e.
g.
,crowdedhousing,lackofpaidsickleave)thatarewell-establishedasriskfactorsamongothergroupsofcolorintheU.
S.
Arecentanalysisofcommunity-levelfactorsassociatedwithracialandethnicCOVID-19disparitiesfoundthat"householdsizeandfoodserviceoccupationarestronglyassociatedwiththeriskofCOVID-19infection"andthatthesefactors"maybecontributingtothehighernumberofCOVID-19casesinBlackandLatinocommunities.
"26ThesefactorsarealsocommonamongNewYorkersofAsiandescent,particularlyamongthosewhoarerecentimmigrants,whichmaypartiallyexplainthehighrateofinfectionweobservedamongSouthAsians.
Thissameanalysisalsofoundthattheproportionofforeign-bornnon-citizenswaspositivelyassociatedwiththenumberofCOVID-19casesinacommunity,whichmayalsoexplainhigherratesofCOVID-19amongAsianNewYorkersaswellasamongHispanicNewYorkers,manyofwhomarealsorecentimmigrants.
Furthermore,AsianAmericansaremostlikelyofallracialgroupstoliveinlarger,multi-generationalhouseholds,furtherdrivingtheirriskofCOVID-19exposureandinfection.
27DatafromtheU.
S.
BureauofLaborStatistics(BLS)indicatingthatBlacksandHispanicsarelessabletoworkfromhomeascomparedtoWhitesandAsianshavebeencitedtoexplainthesocialfactorsdrivingCOVID-19,butthesedatadonottakeintoaccountthesocioeconomicvariationwithinracialgroupsandfurtherservetomaskthehighburdenofCOVID-19among.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint11Asianethnicsubgroups.
28NYC'sAsiandiasporaisdiversebothethnicallyandsocioeconomically,withmanyNewYorkersofSouthAsiandescentworkinginlowwagejobsforwhichworkingfromhomeisnotpossible.
U.
S.
BLSdatashowthatonly9%oflow-wage(<25thpercentile)workersareabletoworkathomeascomparedto62%ofworkersinthehighestincomequartile,whichbetterexplainshigherinfectionratesamongSouthAsiansinNYC.
Thesesocialfactorsareevenmorecommonamongrecentimmigrants,whomaydelayseekingcareduetotheirimmigrationstatus.
Thisisthoughttohavebeenexacerbatedbytherecentpublicchargerule,whichputslegallypresentimmigrantsatriskofbeingdeniedpermanentresidentstatusiftheyutilizelocal,state,orfederalgovernmentpublicbenefits.
29AninjunctionwasissuedinJuly2020thatpreventedtheU.
S.
DepartmentofHomelandSecurityfromenforcingtheruleduringtheCOVID-19publichealthemergency,andtheU.
S.
CustomsandImmigrationServicesencouragedimmigrantstoseekcareforCOVID-19symptoms,statingthattheywill"neitherconsidertesting,treatment,norpreventativecare(includingvaccines,ifavaccinebecomesavailable)relatedtoCOVID-19aspartofapublicchargeinadmissibilitydetermination,norasrelatedtothepublicbenefitconditionapplicabletocertainnonimmigrantsseekinganextensionofstayorchangeofstatus,evenifsuchtreatmentisprovidedorpaidforbyoneormorepublicbenefits,asdefinedintherule(e.
g.
federallyfundedMedicaid).
"30However,anecdotesfromcommunityorganizationsinNYCthatserveimmigrants,especiallythoseofAsiandescent,andarecentstudyofimmigrantsinTexasfoundthatimmigrantsavoidedseekingmedicalcareorenrollinginpublicbenefitsduetoconcernsaboutthepublicchargeruleandtheimpactontheirimmigrationstatus.
31,32,33Thisdelayinoravoidanceofseekingcaremay.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint12partiallyexplainthehighratesofhospitalizationandmortalityobservedamongSouthAsianandChinesepatients,respectively.
OurfindingthatChineseAmericanshadthehighestmortalityrateofallracial/ethnicgroupsandwerenearly1.
5moretimeslikelytodiethanWhites(OR1.
44,95%CI[1.
04,2.
01])isconcerning.
ThiselevatedburdenwasrevealedonlywhentheoverallAsianracecategorywasdisaggregatedintoethnicsubgroups,astheoverallAsianracegroupdidnothaveasignificantlyhigherlikelihoodofdeaththanWhites(OR1.
15,95%CI[0.
93,1.
43],p=0.
21).
SincetheemergenceofCOVID-19inearly2020,ChineseandotherAsianAmericanshaveexperiencedincreasedxenophobia,discrimination,andharassment:onequarterofAsianNewYorkerssurveyedreportedwitnessingorexperiencingharassment,violence,orracismrelatedtoCOVID-19,andmorethanhalfofChineseAmericanadultsandtheirchildrenacrosstheU.
S.
reportedbeingtargetedbyCOVID-19relatedracialdiscriminationeitherinpersonoronline,whichwasassociatedwithpoorermentalhealth.
34,35,36Furthermore,thisincreaseinharassmentandracismmaybeleadingtoreluctancetoand/orfearofleavingone'shomeforcareortesting,whichmaybeexacerbatingChinesepatients'knownreluctancetoseektimelycare,therebyleadingtomoresevereillnessthatmaybemoredifficulttotreatsuccessfully.
36,37Additionally,treatmentpatternsmayhavebeeninfluencedbyearlydataonworseoutcomesamongBlacksandHispanicsandthe"modelminority"myththatAsiansaretypicallyhealthierthanotherracialgroups.
38OurfindingsunderscoretheurgencyofadditionalresearchintothefactorsleadingtohighermortalityamongChineseAmericans.
WefoundthatpatientsutilizingEmergencyMedicaidwerenearlythreetimesaslikelytodieaspatientsutilizingcommercialinsurance(OR2.
86,95%CI[2.
30,3.
54]).
Inourstudy,EmergencyMedicaidusewasmostfrequentamongHispanics(6.
2%),followedbySouthAsians.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint13(2.
2%)andbothAsiansoverallandChinesepatients(2.
0%forboth),groupswhichcontainlargenumbersofundocumentedimmigrants.
ThemarkedlyhigherlikelihoodofdeathobservedamongpatientsutilizingEmergencyMedicaidlikelyreflectsdelayedcareseekingamongundocumentedimmigrants.
InNewYorkState,EmergencyMedicaidforundocumentedimmigrantswasexpandedearlyinthepandemictocoverCOVID-19testingandtreatment.
39However,itislikelythatmanyundocumentedimmigrantsdelayedorevenavoidedcareduetoconcernsoverreportingoftheirimmigrationstatus.
40Similarly,wefoundthat,ascomparedtopatientswithahistoryofoutpatientprimaryorspecialtycarevisitsatNYCH+H,patientswhowerenewtotheNYCH+Hsystemweretwiceaslikelytodie(OR2.
03,95%CI[1.
79,2.
30])andpatientswhohadonlyaninpatientoremergencydepartmentvisitwere1.
4timesmorelikelytodie(OR1.
36,95%CI[1.
16,1.
60]).
ObservationsfromcliniciansacrosstheNYCH+Hsystemindicatethatthismaybedueinparttopoorerhealthstatusamongnewpatientsandthosewhohadpreviouslyonlyhadanacutecarevisit,astheymaynothavebeenreceivingregularcareforchronicconditionsormayhavehadpoorlycontrolledand/orundiagnosedchronicconditionsknowntobeariskfactorforCOVID-19.
Theseobservationsarealignedwithresearchshowingpoorerhealthoutcomesamongpatientswhodelayreceivingcare,particularlyimmigrants.
41,42,43ThesepatientsalsomayhavepresentedwithmoresevereCOVID-19illnessowingtoalackofengagementwithhealthcareandconcernsoverpresentingforcareinlightoffederalrulingsonpublicchargeandimmigrationenforcement.
WefoundthatChinesepatientsweremostfrequentlynewtoNYCH+H(50.
6%),whichmayreflecttheirknownreluctancetoanddelayinseekingcare,asdescribedabove.
36AsianAmericansarefacinguniquechallengesspecifictoCOVID-19,butthesehavebeenlargelyoverlookedtodatebyhealthcareandpublichealthagencies.
Asmentioned.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint14previously,AsianAmericans,especiallythoseofChineseheritage,haveexperiencedasignificantincreaseinxenophobiaandharassment,whichaffectsnotonlytheirCOVID-19careseekingbutalsoworsensmentalhealth.
Additionally,althoughourdatadonotreportspecificallyonFilipinoAmericans,recentdatashowthatFilipinonursesaredyingatadisproportionatelyhigherratethanothernurses:theycomprisejust4%ofthenursingworkforceintheU.
S.
butnearlyonethirdofCOVID-19deathsamongthisgroup.
44Thisisdueinparttotheiroverrepresentationinhigher-riskrolesinhospitals,includingintensivecareunits,aswellastotheirfrequentroleasfamilycaregivers.
45Finally,theCOVID-19pandemichashadanunprecedentedeconomicimpactonAsianAmericans,manyofwhomareemployeesorownersofsmallbusinesses,withunemploymentratessoaringduetobusinessclosures:morethanonein10AsianAmericansintheU.
S.
arecurrentlyunemployed.
46InNewYorkCity,theunemploymentrateamongAsianssoaredfrom3.
4%inFebruarytoastaggering25.
6%inMay;althoughthishasbeenslowlydeclininginrecentmonths,thisdramaticriseinunemploymentisthelargestamonganyracial/ethnicgroup.
47,48,49,50OurfindingsshedimportantlightonthehiddenburdenofCOVID-19amongAsianAmericans.
CommunityleadersandexpertsinAsianAmericanhealthinNYCandacrossthecountryhavevoicedconcernsaboutthesubstantialburdenofCOVID-19amongAsianAmericans,particularlyamongspecificethnicsubgroups,sincethestartofthepandemicinNYC,yetdatatothisendhavebeenlacking.
7,8,15ThelackofdataontheburdenofCOVID-19amongAsianethnicsubgroupsintheU.
S.
hasimpededanappropriatepublichealthresponse,includingtargetedcommunicationcampaignsonpreventionandenhancedtestingandtracingamongthehardesthitcommunities.
.
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0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint15ThesefindingsalsoprovidecriticalinsightsthatcanhelpinformpublichealthinitiativesandpoliciestoaddressthedisproportionateburdenofCOVID-19amongcommunitiesofcolor,includingAsianAmericans.
Specifically,policiesandstrategiesthatimproveaccesstotesting,isolation,andearlycaremayhelpreducedisparitiesandmitigatethespreadofCOVID-19amongcommunitiesthathavebeenhardesthitandwilllikelycontinuetobeathighriskofexposureasaresultoftheiremploymentandhousingaswellasatincreasedriskofhospitalizationanddeathduetotheirimmigrationstatus.
ConclusionInNewYorkCity,substantialdifferencesexistinCOVID-19outcomesbetweenAsianethnicsubgroups,butthesehavebeenmaskedbyreportingallAsianethnicsubgroupsasasingleAsianracialgroup.
Specifically,SouthAsianandChineseAmericansexperienceadverseCOVID-19outcomesathighratesthatarecomparabletothoseobserved–andknownforseveralmonths–amongBlacksandHispanics.
OurfindingsconfirmandvalidatecommunityobservationsandconcernsofadisproportionateburdenofCOVID-19amongSouthAsianandChineseAmericans.
Furthermore,ourfindingsunderscorethecriticalneedfordisaggregatingAsianethnicgroupsindatacollectionandreportinginordertoappropriatelyallocateresourcestothehardesthitcommunities,includingtestingandcommunicationregardingseekingcareaswellaspublichealthpoliciestomitigateriskfactorsandimprovehealthequity.
.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint16Table1.
CharacteristicsandComorbiditiesofPatientsTestedforSARS-CoV-2byRaceandEthnicitydTotalWhiteBlackHispanicAsianSouthAsiand%ofAsianChinese%ofAsianOtherAsian%ofAsianOtherUnknownPvalueNo.
(%)85328(100.
0)8037(9.
4)20827(24.
4)25119(29.
4)9971(11.
7)4804(5.
6)48.
2%2214(2.
6)22.
2%2953(3.
5)29.
6%13505(15.
8)7869(9.
2)SexMale40306(47.
2)4025(50.
1)8822(42.
4)12550(50.
0)4469(44.
8)2350(48.
9)1026(46.
3)1093(37.
0)6523(48.
3)3917(49.
8)<0.
01AgeMedian[IQR]51[38,62]53[37,64]54[40,64]51[40,62]49[35,61]49[35,60]53[38,64]47[35,59]48[34,60]49[35,61]18-4431381(36.
8)2903(36.
1)6510(31.
3)8662(34.
5)4124(41.
4)2054(42.
8)762(34.
4)1308(44.
3)5904(43.
7)3278(41.
7)<0.
0145-6436927(43.
3)3126(38.
9)9564(45.
9)11428(45.
5)4163(41.
8)1939(40.
4)936(42.
3)1288(43.
6)5462(40.
4)3184(40.
5)65-7410647(12.
5)1067(13.
3)2964(14.
2)3188(12.
7)1079(10.
8)542(11.
3)293(13.
2)244(8.
3)1403(10.
4)946(12.
0)75+6373(7.
5)941(11.
7)1789(8.
6)1841(7.
3)605(6.
1)269(5.
6)223(10.
1)113(3.
8)736(5.
4)461(5.
9)PayerCommercial22464(26.
3)3083(38.
4)6342(30.
5)3471(13.
8)3687(37.
0)1580(32.
9)766(34.
6)1341(45.
4)3965(29.
4)1916(24.
3)<0.
01EmergencyMedicaid2409(2.
8)91(1.
1)254(1.
2)1559(6.
2)195(2.
0)104(2.
2)44(2.
0)47(1.
6)234(1.
7)76(1.
0)Medicaid17809(20.
9)1200(14.
9)5154(24.
7)5180(20.
6)1801(18.
1)1128(23.
5)290(13.
1)38313.
0)3379(25.
0)1095(13.
9)Medicare12602(14.
8)1646(20.
5)3812(18.
3)3600(14.
3)1050(10.
5)500(10.
4)371(16.
8)179(6.
1)1733(12.
8)761(9.
7)Self-Pay27393(32.
1)1790(22.
3)4659(22.
4)10449(41.
6)2986(29.
9)1363(28.
4)697(31.
5)926(31.
4)3684(27.
3)3825(48.
6)Other2651(3.
1)227(2.
8)606(2.
9)860(3.
4)252(2.
5)129(2.
7)46(2.
1)77(2.
6)510(3.
8)196(2.
5)HistorywithH+H2214AcuteOnly8426(9.
9)849(10.
6)2801(13.
4)2336(9.
3)779(7.
8)468(9.
7)146(6.
6)165(5.
6)1418(10.
5)243(3.
1)<0.
01Outpatient36257(42.
5)3287(40.
9)10150(48.
7)11158(44.
4)5218(52.
3)2384(49.
6)948(42.
8)1886(63.
9)5382(39.
9)1062(13.
5)<0.
01New40645390178761162539741952112090267056564.
CC-BY-NC-ND4.
0InternationallicenseItismadeavailableunderaistheauthor/funder,whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint17(47.
6)(48.
5)(37.
8)(46.
3)(39.
9)(40.
6)(50.
6)(30.
5)(49.
6)(83.
4)ChronicconditionsaObesitybBMI≥30and<4012636(14.
8)967(12.
0)3898(18.
7)4545(18.
1)1085(10.
9)679(14.
1)126(5.
7)280(9.
5)1735(12.
8)406(5.
2)<0.
01BMI≥402391(2.
8)202(2.
5)1020(4.
9)558(2.
2)127(1.
3)82(1.
7)17(0.
8)28(0.
9)387(2.
9)97(1.
2)ChronicdiseasescDiabetes16499(19.
3)1138(14.
2)5058(24.
3)5657(22.
5)1900(19.
1)1108(23.
1)318(14.
4)474(16.
1)2238(16.
6)508(6.
5)<0.
01Hypertension21184(24.
8)1952(24.
3)7458(35.
8)5987(23.
8)2265(22.
7)1250(26.
0)452(20.
4)563(19.
1)2778(20.
6)744(9.
5)Heartdisease16535(19.
4)1786(22.
2)5407(26.
0)4600(18.
3)1862(18.
7)1055(22.
0)391(17.
7)416(14.
1)2316(17.
1)564(7.
2)Cancer7082(8.
3)657(8.
2)2240(10.
8)2488(9.
9)706(7.
1)365(7.
6)167(7.
5)174(5.
9)822(6.
1)169(2.
1)Liverdisease2622(3.
1)277(3.
4)671(3.
2)923(3.
7)276(2.
8)150(3.
1)66(3.
0)60(2.
0)404(3.
0)71(0.
9)CKD4591(5.
4)413(5.
1)1952(9.
4)1101(4.
4)445(4.
5)255(5.
3)92(4.
2)98(3.
3)525(3.
9)155(2.
0)Abbreviations:IQR,interquartilerange;H+H,NYCHealth+Hospitals;BMI,bodymassindex;CKD,chronickidneydisease.
aAllpercentagesarebasedonthefullpopulationtested,notjustindividualswithavailablevalues.
b50.
8%ofpatientstesteddidnothaveaBMIvalueavailable.
cChronicdiseasestatusisbasedonthepresenceofadiagnosisinthepatient'srecord.
dOverallpercentageofAsianethnicsubgroupsisamongallAsians,notthefullpopulationtested.
.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprintFigure1.
COVID-19OutcomesbyRace/Ethnicity*Ratesareunadjusted18.
CC-BY-NC-ND4.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
;https://doi.
org/10.
1101/2020.
11.
23.
20233155doi:medRxivpreprint19Table2.
OddsofDeathamongPatientsHospitalizedwithCOVID-19bySelectCharacteristicsAdjustedOR(95%CI)(n=9836)aP-valueRace/EthnicitybWhiteReference---Black0.
77(0.
64,0.
93)0.
006Hispanic1.
1(0.
91,1.
33)0.
34Other0.
99(0.
80,1.
23)0.
95Unknown/Declined/Missing0.
94(0.
69,1.
28)0.
69Asianc1.
15(0.
93,1.
43)0.
21SouthAsian1.
06(0.
82,1.
37)0.
68Chinese1.
44(1.
04,2.
01)0.
03OtherAsian1.
08(0.
76,1.
54)0.
66PayerdCommercialReference---EmergencyMedicaid2.
86(2.
30,3.
54)<0.
001Medicaid1.
03(0.
86,1.
24)0.
76Medicare1.
16(0.
97,1.
38)0.
11Self-pay0.
34(0.
26,0.
45)<0.
001Other0.
86(0.
47,1.
58)0.
62HistorywithH+HeOutpatientReference---New2.
03(1.
79,2.
30)<0.
001AcuteOnly1.
36(1.
16,1.
60)<0.
001Abbreviations:OR,oddsratio;CI,confidenceinterval;H+H,NYCHealth+Hospitals.
aOnlypatientswitharecordedBMIvaluewereincluded.
bReferencegroupisWhiterace.
cResultsfromModel1runwithaggregatedAsianracegroup;allotherresultsarefromModel2runwithAsianracedisaggregatedintothreeethnicgroups.
dReferencegroupiscommercialinsurance.
eReferencegroupispatientswithpreviousoutpatientvisits.
.
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(whichwasnotcertifiedbypeerreview)preprintThecopyrightholderforthisthisversionpostedNovember24,2020.
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org/10.
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11.
23.
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