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Racial/Ethnic Disparities in Severity of COVID-19 Lung Disease on Admission X-Ray

Key findings

  • This retrospective study compared initial lung disease severity of COVID-19 on admission chest x-rays of 116 white/non-Hispanic patients and 210 non-white patients
  • Non-white patients were more likely than white patients to present with increased COVID-19 disease severity, measured by modified Radiographic Assessment of Lung Edema (mRALE) score
  • For both groups of patients, increasing mRALE severity scores were associated with a higher likelihood of experiencing adverse clinical outcomes
  • Radiologists should also seek opportunities to collaborate with other medical specialists and community stakeholders to increase access to care for vulnerable individuals

Chest X-ray (CXR) plays a key role in assessing disease severity during initial evaluation of patients with symptoms of COVID-19. There is some evidence that greater lung disease severity at COVID-19 presentation predicts adverse outcomes such as intubation or death.

Efren J. Flores, MD, an officer of Radiology Community Health Improvement and Equity in the Department of Radiology at Massachusetts General Hospital, and colleagues have determined that non-white patients with COVID-19 are more likely than white/non-Hispanic patients to present with increased disease severity on admission CXR, which increases their risk of experiencing adverse outcomes. Their report appears in Radiology.

Study Details

The retrospective study involved 326 adults, ages 23 to 98, who were hospitalized at Mass General with confirmed COVID-19 between March 14 and April 10, 2020. There were 210 patients of color (Hispanic, 68%; Black, 13%; Asian, 5%; other/unavailable, 15%) and 116 white/non-Hispanic patients. The median time to presentation was seven days (range, 5–10) and six days (range, 3–10), respectively (P = .01).

Most patients presented from neighborhoods with relatively higher proportions of Hispanic individuals, lower median household income and higher population density as measured by the number of people per room. Patients with limited English proficiency comprised 43% of the cohort.

Primary Analysis

The severity of lung disease was graded on a simplified version of the modified Radiographic Assessment of Lung Edema (mRALE) scale. Each lung was scored based on the percentage involvement of opacified lung. For lungs with any opacity, the overall density of the opacity was scored.

Admission CXRs revealed at least one lung abnormality in 98% of patients. On multivariable regression analysis, non-white patients had higher mRALE scores than white/non-Hispanic patients (adjusted average difference, 1.6; 95% CI, 0.5–2.7; P = .005).

Clinical Outcomes

All patients were followed until April 24, 2020. In adjusted analyses, increasing mRALE scores were associated with a higher likelihood of experiencing a composite outcome of intubation, ICU admission or death:

  1. White/non-Hispanic patients—HR, 1.3; P < .001
  2. Non-white patients—HR, 1.2; P < .001


Increased lung disease severity scores were independently associated with:

  • Limited English proficiency
  • Delayed presentation
  • Obesity

Implications for Practice

The results of this study might guide radiologists to develop algorithms for early detection of populations that are particularly at risk of developing COVID-19 disease and having a more severe clinical course. Radiologists should also seek opportunities to collaborate with other medical specialists and community stakeholders to increase access to care for vulnerable individuals, including making imaging available at infectious disease clinics, assisting patients to connect with community resources and public health initiatives and providing information about COVID-19 in languages other than English.

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