key: cord-0285222-03jw6xdw authors: Abdel Magid, H. S.; Ferguson, J. M.; Cleve, R. V.; Purnell, A.; Osborne, T. F. title: Differences in COVID-19 Risk by Race and County-Level Social Determinants of Health Among Veterans date: 2021-10-22 journal: nan DOI: 10.1101/2021.10.20.21265149 sha: a9b292f579ffde985ce73fe799960029be29fc18 doc_id: 285222 cord_uid: 03jw6xdw COVID-19 disparities by area-level social determinants of health (SDH) may be impacting U.S. Veterans. This retrospective analysis utilized COVID-19 data from the U.S. Department of Veterans Affairs (VA)s EHR and geographically linked county-level data from 18 area-based socioeconomic measures. The risk of testing positive with Veterans county-level SDHs adjusting for demographics, comorbidities, and facility characteristics was calculated using generalized linear models. We found an exposure-response relationship whereby individual COVID-19 infection risk increased with each increasing quartile of adverse county-level SDH such as the percentage of residents in a county without a college degree, eligible for Medicaid, and living in crowded housing. Disparities in COVID-19 infection and mortality vary across the US. 1-3 These disparities, particularly among racial and ethnic minorities, may be driven by area-level social determinants of health (SDH) and structural resources. [4] [5] [6] In this report, we combine electronic health record (EHR) data from the U.S. Department of Veterans Affairs (VA) with county-level characteristics to assess associations between area-level SDH and COVID-19 infection risk among Veterans with the goal of optimizing care and prevention strategies for our patients. We retrospectively examined records from Veterans actively enrolled in VA healthcare and who were tested for SARS-CoV-2 at VA between February 8, 2020 and December 28, 2020. Methods have been previously described in detail. 7 In brief, we included demographic characteristics from the VA's EHR database and used the Veteran's home zip code to geographically link publicly available area-based SDH as it has been previously identified being critical for COVID-19 health equity in previous literature. 1, [8] [9] [10] [11] [12] A detailed table describing each county-level SDH, source, and original variable name from the source are provided in Supplementary Table 1 . We categorized each area-based SDH into quartiles according to the positive case distribution in our analytic sample. We excluded Veterans missing county-level SDH and one VHA facility with fewer than 5 COVID-19 positive cases. The final analytic sample comprised 778,599 Veterans. We used generalized linear models to report risk ratios and 95% confidence intervals for the risk of testing COVID-19 positive for key SDH. To examine effect modification by race between SDH and COVID-19 positivity risk, we stratified our analysis by race including White, Black, and Other Veterans (includes Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander). All models were adjusted for individual demographics, facility All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 22, 2021. ; characteristics, state, and other SDH characteristics that are important for health equity but not identified a-priori as primary SDH characteristics of interest. 1, [8] [9] [10] [11] [12] Model standard errors are clustered by VA facility. We conducted all statistical analyses using Stata Version 15 (StataCorp LLC). This quality assessment project received a Determination of Non-Research from Stanford Institutional Review Board as well as by VA determination. As of December 28, 2020, among the 779,599 Veterans tested at VA, 77,692 (10%) The relative risk for testing positive for COVID-19 among Black Veterans living in counties in the All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 22, 2021. ; top versus bottom quartile of percentage of persons who are non-White was 1.16 (95% CI: 1.01, 1.33), however, among White Veterans the RR was attenuated (1.08 (95% CI: 0.95, 1.10)). Among Black Veterans living in counties in the top versus bottom quartile of percentage of households with multigenerational housing, the risk of testing positive for COVID-19 was 1.14 (95% CI: 1.04, 1.25), yet among White Veterans the RR was 1.01 (95% CI: 0.93, 1.10). Among Other Veterans, living in a county in the top versus bottom quartile of percentage of residents 25 years or older without 4+ years of college education was associated with a 31% (95% CI: 1.09-1.59) higher risk of testing positive for COVID-19 versus the lowest quartile. Comparing the top versus the bottom quartile, little to no differences were seen among the percentage of persons in deep poverty, percentage without a computer or broadband, and percentage non-US-born residents. Our results show that Veterans living in areas with lower education levels, higher Medicaid eligibility, crowded housing, non-White residents, and multigenerational housing are experiencing higher risks of COVID-19 infection, a trend which has been noted in other evaluations. 1,3,10,13 Notably our assessment revealed important associations for our Veterans, such as percentage of residents who are non-White, multigenerational housing, and percentage of residents without a college degree varied in race-stratified models, strengthening for Black and Other Veterans, compared to White Veterans which provides important insights for our targeted interventions. A strength of our work is that our findings also demonstrate the association between distinct county-level SDH and COVID-19 cases which was possible due to the large cohort size from a nationwide database from the largest integrated healthcare system in the United States. Moreover, our assessment was designed to provide a more precise evaluation to direct targeted enhancement for of our patients which was also achieved by reducing confounding factors from All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 22, 2021. ; chronic health conditions which are more common in our population and attenuate the effects of individual-level socioeconomic and VA facility-level characteristics. Our evaluation is focused on evaluating the association of area-level county-level SDH and COVID-19 test and test positivity of our unique Veteran population, who are on average are male, older, and have more comorbidities than the general US population, which limits generalizability. 13 Furthermore, our evaluation does not assign weights to the county-level SDH relative to each other since there is no strong evidence to rigorously assign importance across categories. 1 The association between COVID-19 infection risk and Veterans' county-level SDH may be stronger than the estimated results presented here owing to the fact that some of the covariates adjusted for in this analysis may likely be mediators in the pathway, which would attenuate risk. Lastly, Veterans' home address may not fully capture where Veterans spend most of their time which may result in exposure misclassification, however, we anticipate misclassification would be attenuated by county-level aggregation. In this evaluation of Veterans, we identified that county-level SDH factors influence COVID-19 infection risk, informing our understanding of how to improve care strategies, targeted interventions, policy, and resource allocation for Veterans. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 22, 2021. ; US-county level variation in intersecting individual, household and community characteristics relevant to COVID-19 and planning an equitable response: a cross-sectional analysis Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study Revealing the Unequal Burden of COVID-19 by Income, Race/Ethnicity, and Household Crowding: US County Versus Zip Code Analyses COVID-19 and Racial/Ethnic Disparities COVID-19 and african americans Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study Differences in COVID-19 Testing and Test Positivity Among Veterans, United States Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income. American journal of preventive medicine Disease and healthcare burden of COVID-19 in the United States US racial inequality may be as deadly as COVID-19 Association Between Income Inequality and County-Level COVID-19 Cases and Deaths in the US Food Insufficiency and Mental Health in the U.S. During the COVID-19 Pandemic 2018 survey of veteran enrollees' health and use of health care