| Summary: | <h4>Background</h4> Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood. <h4>Objective</h4> To characterize socioeconomic and chronic disease-related mechanisms underlying these differences. <h4>Design</h4> Observational cohort study. <h4>Setting</h4> Outpatient and emergency care. <h4>Patients</h4> 12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020. <h4>Interventions</h4> Nasopharyngeal PCR test for SARS-CoV-2 infection. <h4>Measurements</h4> Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases. <h4>Results</h4> We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91–3.59] times (at age 20) to 2.37 [1.54–3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive. <h4>Limitations</h4> Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2. <h4>Conclusion</h4> Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates.
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