RR:C19 Evidence Scale rating by reviewer:
Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.
The authors state that they wanted to look at age as a variable in the changing patient demographic of the coronavirus disease (COVID) pandemic. The authors have investigated the role of chronic disease comorbidity and race stratified by various age groups in the evolution of the COVID pandemic.
This large data set reconfirms previously reported disparities in race and comorbidity but takes a step further by looking at these in different age groups. The authors have noted a racial disparity for hospitalization, intensive care unit admission, and mortality in the overall population. It would have been interesting to look at mortality in the hospitalized population in addition to mortality in the community population since multiple publications have reported that a racial disparity in mortality is not observed in hospitalized patients (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698674/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7718605/).
The impact of having comorbidity is well presented in the figures. When comorbidity is present, there is a higher adjusted risk of suffering as a worse outcome (hospitalization, intensive care requirement, or death) in the younger population than in the older population. The authors have demonstrated that racial disparities are amplified in the younger population compared to the older population, similar to what we reported in a non-COVID population. (https://www.jacc.org/doi/full/10.1016/S0735-1097%2821%2901578-3)
The authors’ conclusion is justified by the results they have presented. The burden of disparities is higher in the younger population than in the older population. Their hypothesis that this may be due to economic inequity and riskier behavior is also well reasoned. Most studies focus on elderly adults and the Medicare population due to specific grants for these populations. The authors make a good argument that studies need to always include the younger population as the burden of disease and the long-term consequences of the same may be far more significant.
The United States lacks a robust national database which significantly hampers population health research. This study demonstrates the merits of establishing a national medical database. Individual patient-level data would be required to tease out the effects of socioeconomic disparities and systemic racism. The lack of any such database hampers health equity research.
The authors have acknowledged their limitations. It would be interesting to follow up their work with a more updated dataset. If it were possible to look at geographic (rural/urban, state by state, etc.) disparities and adjust for the same, the work would be even more impactful.