Abstract
IMPORTANCE: Timely outpatient treatment for COVID-19 reduces the risk of hospitalization and death in high-risk patients. However, large racial and ethnic inequities in treatment have been observed across the US. The relative contributions of care mechanisms that create barriers (eg, access to home tests or telemedicine) are unknown. OBJECTIVE: To examine the relative contribution of structural and encounter-level factors associated with racial and ethnic disparities in oral antiviral prescribing for COVID-19. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study using electronic health record data from a large northeastern health care system, medication order receipt was estimated across racial and ethnic minority groups. The sample comprised patients aged 18 years or older with documented positive COVID-19 test results from January 1, 2022, through January 31, 2024. EXPOSURES: Race and ethnicity as recorded in patient electronic health records. MAIN OUTCOMES AND MEASURES: The primary outcome was prescription orders of nirmatrelvir/ritonavir or molnupiravir within 7 days of a positive COVID-19 test result. Nested linear probability models were used, adjusting for clinical characteristics (age, sex, comorbidities, and contraindications), public health determinants (vaccination, insurance, and language), time fixed effects, and encounter-level characteristics (virtual care, diagnostic test type, and clinic site). The relative contribution of these factors to racial and ethnic prescription disparity was then partitioned. RESULTS: The sample consisted of 201 964 patients with positive COVID-19 test results (mean [SD] age, 54.0 [18.2] years; 64.6% female; 0.1% identified as American Indian or Alaska Native, 3.7% as Black, 6.5% as Hispanic or Latino, 79.0% as White, 1.1% as other, and 4.7% as unknown race and ethnicity). Most were commercially insured (66.4%). Unadjusted prescription rates were 10.8 percentage points (95% CI, 9.7-11.8 percentage points) lower for Black compared with White patients and 9.8 percentage points (95% CI, 9.0-10.6 percentage points) lower for Latino patients. Black and Latino patients were less likely than White patients to be diagnosed with in-clinic antigen tests (-8.4 percentage points [95% CI, -9.2 to -7.5 percentage points] and -7.7 percentage points [95% CI, -8.3 to -7.0 percentage points], respectively), by home antigen tests (-10.3 percentage points [95% CI, -11.5 to -9.2 percentage points] and -14.1 percentage points [95% CI, -14.9 to -13.2 percentage points], respectively), or to have received care virtually (-16.2 percentage points [95% CI, -17.3 to -15.0 percentage points] and -18.4 percentage points [95% CI, -19.3 to -17.5 percentage points], respectively). Observable covariates fully accounted for the unadjusted prescription differences, with 53% of the racial and ethnic prescription gap for Black patients and 39% for Latino patients explained by encounter-level factors. CONCLUSIONS AND RELEVANCE: This cross-sectional study found that racial and ethnic disparities in COVID-19 treatment are substantial and partially explainable by encounter-level factors, particularly differences in diagnostic test type, virtual care access, and site of care. These findings suggest that targeted interventions, including expanding rapid test access and virtual care, may improve equity in outpatient COVID-19 treatment.