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Publication Briefs

Study Shows Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans

Sociodemographic factors and comorbidity burden have emerged as major risk factors for COVID-19 infection and mortality. Black, American Indian/Alaska Native (AI/AN), and Hispanic persons have been reported to have higher risk of COVID-19 infection and mortality than White and non-Hispanic persons, but other sociodemographic and clinical risk factors may be changing over time due to marked changes in the use of prophylactic measures and access to care, as well as viral characteristics (i.e., emergence of new variants) and availability of treatments (i.e., different pharmacotherapies). This population-based cohort study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare, including 216,046 who tested positive and 10,230 who died of COVID-19 during the study period. Using VA data, investigators also assessed Veterans' sociodemographic factors and comorbidity burden.


  • Strongly positive associations of Black race, AI/AN race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time.
  • The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021.
  • Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality.


  • Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.


  • This study included only cases of COVID-19 identified within the VA healthcare system.

Drs. Ioannou and O’Hare are part of HSR&D’s Denver/Seattle Center of Innovation for Veteran-Centered & Value-Driven Care. Dr. Ferguson is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Ioannou G, Ferguson J, O’Hare A, et al. Changes in the Associations of Race and Rurality with SARS-CoV-2 Infection, Mortality and Case Fatality in the United States from February 2020 to March 2021: A Population-based Cohort Study. PLoS Medicine. October 21, 2021;18(10): e1003807.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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