Chest x-rays show more severe COVID-19 in non-white patients

July 16, 2020

OAK BROOK, Ill. (July 16, 2020) - Racial/ethnic minority patients admitted to the hospital with COVID-19 infection are more likely to have more severe disease on chest X-rays than white/non-Hispanic patients, increasing the likelihood of adverse outcomes, such as intubation or death, according to a study published in the journal Radiology.

Emerging data show that racial/ethnic minorities have been disproportionately affected by COVID-19. Socioeconomic factors and pre-existing medical conditions like hypertension are likely contributing factors to this disparity. Furthermore, limited English proficiency may introduce additional linguistic and health literacy barriers to care, potentially resulting in delays seeking medical attention and greater severity of disease at the time of admission to the hospital with COVID-19 infection.

Radiologists from Massachusetts General Hospital (MGH) saw these disparities firsthand in April among patients admitted to the hospital with confirmed COVID-19 infection, and at one of the hospital's respiratory infection clinics in Chelsea, a city just north of Boston that is home to a predominantly Spanish-speaking Hispanic community. A significant proportion of the patients who visited the Chelsea clinic had COVID-19, and the level of disease the radiologists observed on chest imaging was markedly more severe than that seen at other respiratory infection clinics in Boston. These disparities were more evident among patients admitted to the hospital with confirmed COVID-19 infection.

"It got to the point where half of our patient population admitted with COVID-19 were underrepresented minorities," said study coauthor Efren J. Flores, M.D., a radiologist at MGH.

Dr. Flores and colleagues set out to study these observed disparities in greater detail with an eye toward developing a better understanding of some of the factors involved. They hope to use this information to guide risk mitigation strategies and improve outcomes among racial/ethnic minority groups. They looked at data from 326 patients hospitalized with confirmed COVID-19 infection between March 27 and April 10, 2020. Analysis of chest X-ray results revealed that non-white patients had significantly more severe lung disease on admission than white/non-Hispanic patients. Increased disease severity on chest X-rays increased the likelihood of adverse clinical outcomes, including admission to the intensive care unit, intubation and death.

As expected, the increased severity of lung disease on chest X-rays among non-white patients correlated with a combination of factors, including delay in seeking care at the hospital, higher prevalence of pre-existing comorbidities and limited English proficiency.

"Limited English proficiency is an additional socioeconomic factor that really influences many aspects of access to care," Dr. Flores said. "When we were first learning how the disease spreads, there was all this rapidly evolving information coming out that was not available in languages other than English, and that lag in availability of actionable health information for non-English speaking individuals was really critical for many patients trying to navigate a complex medical system with a disease from a virus that is so aggressive."

The connection between limited English proficiency and disease severity underscores the importance of having multilingual, culturally tailored health information available, Dr. Flores said, especially as the number of infections climbs in different parts of the country.

Disparities in access to care and disease severity are not limited to linguistic barriers. Racial/ethnic non-white communities disproportionately experience lower socioeconomic status, adding another layer of complexity when accessing care. Living and working arrangements also likely played a role in the severity of COVID-19 among these patients, the study authors said. Racial and ethnic minority populations tend to live in multigenerational households and communities of higher population density, making social distancing difficult. In addition, they are more often employed in jobs not conducive to remote work with limited paid time off, thus increasing their exposure to COVID-19.

"Many of these patients delay their care because they're considered essential workers and they don't have a lot of sick leave, but also it's difficult for them to leave because they are living on a weekly paycheck and have other dependents," Dr. Flores said. "It wasn't uncommon for us to go into the medical record when we were interpreting their exams and see that many of them worked at grocery stores or warehouses."

The study findings highlight the important role radiologists play in providing earlier identification of higher-risk patients and developing multidisciplinary collaborations to help address these disparities, according to Dr. Flores.

"Health equity is every medical specialty's responsibility, but I believe radiology is uniquely positioned to take a bigger role not only in population health but in public health efforts," he said. "Our ability to provide care in different settings is what allowed us to make the clinical observation that patients coming to this one particular clinic and those being admitted to the hospital were presenting with a higher rate of positive findings that were also more severe. That really offered a window into the disparities that were translating into greater disease severity and worse outcomes."

Moving forward, the findings of this study could assist radiologists in the development of algorithms to identify vulnerable and at-risk populations. This could spur collaborations with other medical specialties, community stakeholders, and public health initiatives to enhance the effectiveness of public health interventions that increase access to care.

"We did this study not only to gain a better understanding of these emerging disparities, but also to discover how we can use this information to craft a better path towards equity together," Dr. Flores said.
"Racial/Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed COVID-19: A Retrospective Cohort Study." Collaborating with Dr. Flores were Nicholos P. Joseph, B.A., Nicholas J. Reid, B.Sc., Avik Som, M.D., Ph.D., Matthew D. Li, M.D., Emily P. Hyle, M.D., Caitlin M. Dugdale, M.D., Min Lang, M.D., Joseph R. Betancourt, M.D., M.P.H., Francis Deng, M.D., Dexter P. Mendoza, M.D., Brent P. Little, M.D., and Anand K. Narayan, M.D., Ph.D.

Radiology is edited by David A. Bluemke, M.D., Ph.D., University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, and owned and published by the Radiological Society of North America, Inc. (

RSNA is an association of radiologists, radiation oncologists, medical physicists and related scientists promoting excellence in patient care and health care delivery through education, research and technologic innovation. The Society is based in Oak Brook, Illinois. (
For patient-friendly information on chest X-ray, visit

Radiological Society of North America

Related Lung Disease Articles from Brightsurf:

Gut microbiome link to deadly lung disease
Research led by the Centenary Institute, the University of Technology Sydney and the University of Queensland has shown for the first time a link between chronic obstructive pulmonary disease (COPD), an often fatal lung condition, and the gut microbiome.

Safe pregnancy is possible for women with interstitial lung disease
A new study shows that women with interstitial lung disease (ILD) related to autoimmune disease may not need to terminate their pregnancies--despite the increased risk of adverse outcomes--provided they have close monitoring from their team of multidisciplinary physicians before, during and after pregnancy.

New treatments for deadly lung disease could be revealed by 3D modeling
A 3D bioengineered model of lung tissue built by University of Michigan researchers is poking holes in decades worth of flat, Petri dish observations into how the deadly disease pulmonary fibrosis progresses.

'Social smokers' face disproportionate risk of death from lung disease and lung cancer
'Social smokers' are more than twice as likely to die of lung disease and more than eight times as likely to die of lung cancer than non-smokers, according to research presented at the European Respiratory Society International Congress.

New insights into lung tissue in COVID-19 disease
Physicists at the University of Göttingen, together with pathologists and lung specialists at the Medical University of Hannover, have developed a three-dimensional imaging technique that enables high resolution and three-dimensional representation of damaged lung tissue following severe Covid-19.

Exhaled biomarkers can reveal lung disease
Using specialized nanoparticles, MIT engineers have developed a way to diagnose pneumonia or other lung diseases by analyzing the breath exhaled by the patient.

New clues to lung-scarring disease may aid treatment
Scientists at Vanderbilt University Medical Center (VUMC) and the Translational Genomics Research Institute (TGen) in Phoenix, Arizona, have discovered previously unreported genetic and cellular changes that occur in the lungs of people with pulmonary fibrosis (PF).

COPD as a lung stem cell disease
Two internationally renowned stem cell researchers at the University of Houston have found an abundance of abnormal stem cells in the lungs of patients who suffer from Chronic Obstructive Pulmonary Disease (COPD), a leading cause of death worldwide.

Scientists discover three genes associated with fatal lung disease
Researchers at the Universities of Leicester and Nottingham have discovered parts of the DNA that put some people at higher risk of an incurable lung disease called idiopathic pulmonary fibrosis (IPF).

Tumor secreted ANGPTL2 facilitates recruitment of neutrophils to the lung to promote lung pre-metastatic niche formation and targeting ANGPTL2 signaling affects metastatic disease
The authors determined that tumor-derived ANGPTL2 stimulates lung epithelial cells, which is essential for primary tumor-induced neutrophil recruitment in lung and subsequent pre-metastatic niche formation.

Read More: Lung Disease News and Lung Disease Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to