The social, demographic, and clinical predictors of COVID-19 severity: A national study of United States Veterans Open Access

Abstract

Introduction: Understanding the risk factors for COVID-19 disease and severity remains a public

health priority. Demographic and clinical factors put individuals at higher risk. These

characteristics do not operate in a vacuum but coexist with social determinants of health (SDOH)

to influence health outcomes. This study aims to identify how individual and community level

SDOH characteristics along with demographic and clinical factors are associated with COVID-

19 disease severity.

Methods: This national cross-sectional study investigated 220,848 active Veterans tested for

COVID-19 between February 20, 2020 and October 20, 2021. Variables of interest included

individual demographic, clinical, and SDOH characteristics. Census variables were incorporated

for community SDOH factors. Multiple logistic regression models were constructed using a

backwards elimination approach to examine factors associated with COVID-19 hospitalization

and intensive care unit (ICU) admission.

Results: Participants were predominately male, 60 years or older, non-Hispanic white, had

completed high-school or vocational/technical school, and lived in an urban residence.

Compared to those not hospitalized, those who were hospitalized were older, more likely to be

male, of Black/African American or Asian race, have an income less than $39,999, live in an urban

residence, and have a higher Elixhauser comorbidity index. The strongest predictors for COVID-

19 hospitalization included Gini inequality index (OR=2.88), race (non-Hispanic black or

African American OR=1.48, Asian OR=1.48, and Native Hawaiian/other pacific or American

Indian/Alaska native OR=1.25 compared to white), and income less than $39,999 (OR=1.22).

Comorbid conditions with increased odds of hospitalization included heart failure (OR=1.93),

chronic kidney disease (CKD) (OR=1.86) and chronic obstructive pulmonary disease (COPD)

(OR=1.77). For COVID-19 ICU admission, Asian vs. White (OR=1.46), rural vs. urban

(OR=1.22), COPD (OR=1.34), and CKD (OR=1.24) were the strongest demographic and

comorbid predictors.

Discussion: A combination of clinical, demographic, individual SDOH, and community level

SDOH factors predict COVID-19 hospitalization and can inform patient risk stratification and

discharge planning. These factors can be incorporated into a comprehensive risk assessment tool

for COVID-19 hospitalization while ICU admission may be better explained by laboratory

values or hospital characteristics. Public health interventions should target communities of color

with higher inequality indices and SDOH risk factors.

Table of Contents

Introduction ....................................................................................................................................2

Methods ..........................................................................................................................................7

Study Design and Population ............................................................................................................7

Data Sources ....................................................................................................................................7

Data Measures ................................................................................................................................. 7

Statistical Analysis ......................................................................................................................... 10

Results ...........................................................................................................................................11

Discussion & Conclusion .................................................................................................................14

References ......................................................................................................................................19

Tables and Figures ...........................................................................................................................24

Figure 1 .......................................................................................................................................... 24

Figure 2 .......................................................................................................................................... 25

Table 1 ........................................................................................................................................... 26

Table 2 ............................................................................................................................................ 29

Table 3 ............................................................................................................................................ 31

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	Health disparities Social determinants of health COVID-19 Racial/ethnic disparities
Committee Chair / Thesis Advisor	Julie Gazmararian, Emory University

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