Encounter-Level Factors Drive Racial Disparities in COVID-19 Treatment Access

About half of the disparities in outpatient COVID-19 treatment among Black and Latino patients were attributable to encounter-level factors, such as the type of diagnostic test used and the site of care, when compared with their White counterparts, according to a study published in JAMA Network Open.1

The researchers noted that timely outpatient treatment significantly reduces the risk of severe disease and hospitalization, particularly for high-risk individuals. To help expand access, the FDA issued emergency use authorizations in December 2021 for oral antiviral therapies nirmatrelvir/ritonavir (Paxlovid; Pfizer) and molnupiravir (Lagevrio; Merck and Ridgeback Biotherapeutics), both of which were subsidized by the federal government.2

Despite these efforts, disparities in treatment access quickly emerged. Patients most at risk for severe disease, particularly those from low-income backgrounds and racial and ethnic minority groups, were among the least likely to receive outpatient treatment.3 The researchers described this gap as a major public health challenge, both for the ongoing COVID-19 response and for the equitable distribution of treatments during future public health emergencies.1

Encounter-level factors played a key role in limiting outpatient COVID-19 treatment for Black and Latino patients. | Image Credit: Mike Mareen - stock.adobe.com

To better understand the drivers of these disparities, they conducted a cross-sectional study assessing the contributions of structural and encounter-level barriers to prescribing oral antiviral therapies for COVID-19. They used electronic health record data from Mass General Brigham, a large academic health system in New England, to analyze treatment patterns across racial and ethnic groups. The study cohort included adult patients with positive COVID-19 test results between January 1, 2022, and January 31, 2024.

The primary outcome was whether patients received a prescription for nirmatrelvir/ritonavir or molnupiravir within 7 days of a positive COVID-19 test result. The researchers applied nested probability models, adjusting for time-fixed effects, clinical characteristics, public health determinants (language, vaccination, and insurance), and encounter-level variables (virtual care, diagnostic test type, and clinic site). They then estimated the contribution of each factor to racial and ethnic disparities in COVID-19 treatment prescription.

The study included 201,964 patients with positive COVID-19 test results and a mean (SD) age of 54.0 (18.2) years. In terms of race and ethnicity, 79.0% identified as White, 6.5% as Hispanic or Latino, 3.7% as Black, 4.7% as unknown, 1.1% as other, and 0.1% as American Indian or Alaska Native.

Compared with White patients, unadjusted prescription rates were 10.8 percentage points (95% CI, 9.7-11.8) lower for Black patients and 9.8 percentage points (95% CI, 9.0-10.6) lower for Latino patients. Black and Latino patients were also less likely to be diagnosed using in-clinic antigen tests (–8.4 [95% CI, –9.2 to –7.5] and –7.7 [95% CI, –8.3 to –7.0] percentage points, respectively) or home antigen tests (–10.3 [95% CI, –11.5 to –9.2] and –14.1 [95% CI, –14.9 to –13.2] percentage points, repectively).

Additionally, Black (–16.2 percentage points; 95% CI, –17.3 to –15.0) and Latino (–18.4 percentage points; 95% CI, –19.3 to –17.5) patients were less likely than White patients to have received care virtually.

Among Black patients, 53% of the variation in prescription rates was explained by encounter-level characteristics, with 27% by differences in the site of care, 21% by the COVID-19 test type used, and 5% by virtual care use or the lack thereof. For Latino patients, 39% of the disparity in prescription rates was attributable to encounter-level characteristics, with 23% explained by test type, 8% by virtual care use, and 8% by site of care.

Lastly, the researchers acknowledged their study’s limitations, including the exclusion of symptomatic patients who did not undergo testing or lacked access to care. Nonetheless, they expressed confidence in their findings and offered actionable opportunities for addressing these disparities.

“These findings suggest that targeted interventions, including expanding rapid test access and virtual care, may improve equity in outpatient COVID-19 treatment,” the authors wrote.

References

1. Bromley-Dulfano R, Barnett ML. Racial inequities and access to COVID-19 treatment. JAMA Netw Open. 2025;8(7):e2518459. doi:10.1001/jamanetworkopen.2025.18459
2. AJMC Staff. What we're reading: US authorizes Pfizer oral COVID-19 drug; omicron may be milder; more cities require vaccinations. AJMC®. December 23, 2021. Accessed July 7, 2025. https://www.ajmc.com/view/what-we-re-reading-us-authorizes-pfizer-oral-covid-19-drug-omicron-may-be-milder-more-cities-require-vaccinations
3. AJMC Staff. What we're reading: tuberculosis cases rise; racial disparities in Paxlovid treatment; cancer death rates decline. AJMC. October 28, 2022. Accessed July 7, 2025. https://www.ajmc.com/view/what-we-re-reading-tuberculosis-cases-rise-racial-disparities-in-paxlovid-treatment-cancer-death-rates-decline