Racial, Ethnic, and Rural Disparities in U.S. Veteran COVID-19 Vaccine Rates

• Published in: AJPM Focus
• Main Authors: Ethan L. Bernstein, MD, Eric C. DeRycke, MPH, Ling Han, MD, PhD, Melissa M. Farmer, PhD, Lori A. Bastian, MD, Bevanne Bean-Mayberry, MD, Brett Bade, MD, Cynthia Brandt, MD, MPH, Kristina Crothers, MD, Melissa Skanderson, MSW, Christopher Ruser, MD, Juliette Spelman, MD, Isabel S. Bazan, MD, Amy C. Justice, MD, PhD, Christopher T. Rentsch, PhD, Kathleen M. Akgün, MD, MS
• Format: Article in Journal/Newspaper
• Language: English
• Published: Elsevier 2023
• Subjects: COVID-19; vaccine; health disparities; veterans; rurality; Public aspects of medicine; RA1-1270; Indian; Pacific; North Atlantic
• Online Access: https://doi.org/10.1016/j.focus.2023.100094; https://doaj.org/article/8103ca5e23d049cdaa75b19cf6edc966

Introduction: Race-, ethnicity-, and rurality-related disparities in COVID-19 vaccine uptake have been documented in the U.S. We determined whether these disparities existed among patients at the Department of Veterans Affairs, the largest healthcare system in the U.S. Methods: Using Department of Veterans Affairs Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least 1 primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race and ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on the 2019 home address at the ZIP code level. Our primary outcome was time to first COVID-19 vaccination between December 15, 2020 and June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or 1 outpatient International Classification of Diseases codes), service connection (any/none, using standardized Department of Veterans Affairs cut offs for disability compensation), and influenza vaccination in 2019–2020 (yes/no). Results: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3 [SD=14.4] vs unvaccinated=57.7 [18.0], p<0.0001). They were more likely to identify as Black (18.2% vs 16.1%, p<0.0001), Hispanic (7.0% vs 6.6%, p<0.0001), or Asian American Pacific Islander (2.0% vs 1.7%, p<0.0001). In addition, they were more likely to reside in urban settings (68.0% vs 62.8, p<0.0001). Relative to non-Hispanic White urban veterans, the reference group for whom race/ethnicity–urban/rural hazard ratios were reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native groups. Urban Black groups and rural Black groups were 12% (hazard ratio=1.12; 95% CI=1.12, 1.13) and 6% (hazard ratio=1.06; 95% ...