By Claudia Castillo Zambrano, MD, and Alexander S. Niven, MD
Dr. Castillo Zambrano is Research Trainee, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. Dr. Niven is Consultant, Division of Pulmonary/Critical Care Medicine, Mayo Clinic, Rochester, MN.
SYNOPSIS: Patients who identify with racial or ethnic minority groups who present with sepsis or acute respiratory failure are more likely to be admitted to the intensive care unit (ICU) when compared to white patients. Capacity strain reduced the frequency of ICU admission but did not modify the differences seen between these groups.
SOURCE: Chesley CF, Anesi GL, Chowdhury M, et al. Characterizing equity of intensive care unit admissions for sepsis and acute respiratory failure. Ann Am Thorac Soc 2022;19:2044-2052.
Prior work has demonstrated that patients who identify as racial and ethnic minorities with sepsis or acute respiratory failure have worse outcomes than the general population. There are many complex contributing factors to this problem. Minority groups have less access to preventive care services, more frequent comorbidities, and often seek care in hospitals with higher complication, readmission, and mortality rates. Minority patients also tend to receive more intensive therapy and testing toward the end of life, and the impact of patient preference and resource utilization choices on this observation are unclear. Differences in care processes have been identified as a major and the most readily modifiable area to improve outcomes in minority patient populations, and capacity strain (approaching or exceeding the limit of a healthcare unit’s ability to provide high-quality care for patients due to resource limitations) may exacerbate unconscious or explicit biases and further increase disparities in clinical decision-making.1
In this retrospective cohort study, Chesley et al examined differences in intensive care unit (ICU) or ward admission decisions in patients presenting to the emergency department with sepsis or acute respiratory failure (ARF). They used a large database that included detailed clinical information on a diverse patient population who received care in the city and greater metropolitan area of Philadelphia and in northern California between 2013 and 2018. To focus on patients in whom the decision for admission location may be discretionary, they excluded individuals who required mechanical ventilation or vasopressor support and those who had a level of acuity that made ICU admission unlikely (Laboratory Based Acute Physiology [LAPS2] Score < 100). Patient race and ethnicity were self-identified and stratified into non-Hispanic white, non-Hispanic Black, non-Hispanic Asian and Pacific Islander (AAPI), non-Hispanic multiracial, and Hispanic categories. In circumstances where self-identification was not possible, hospital staff made the determination.
The authors also analyzed the impact of capacity strain using a previously developed index, which consisted of a multivariable composite measure of 22 metrics in three domains (occupancy, census disease acuity, and census turnover). This model was modified to exclude race or ethnicity as variables and used a logistic regression model to focus on the emergency department disposition decision within a variety of patient and system covariates with stratification by admitting hospital and presenting diagnosis.
Of the 102,362 eligible patients identified, 82.7% and 41.0% met criteria for sepsis and ARF, respectively (23.8% met criteria for both). There were significant differences in baseline characteristics, and patients who identified as Black were the youngest, least likely to use private insurance, and most likely to be full code. Patients with ARF were more likely to be admitted to the ICU (P < 0.001), and capacity strain was inversely related with ICU admission across all patient groups. Interestingly, in the fully adjusted models, AAPI (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.16-1.37; P < 0.001) followed by Hispanic patients (OR, 1.11; 95% CI, 1.02-1.21; P = 0.02) had the highest independent odds of ICU admission, with no significant differences observed among patients in other racial and ethnic categories compared to admission rates in white patients. The level of capacity strain did not further influence the probability of ICU admission between racial and ethnic patient categories.
COMMENTARY
Health disparities have been well documented in the United States, and the solutions to ensure healthcare equity remain daunting and elusive. A recent systematic review confirmed that these disparities extend across a variety of important ICU outcomes, although the observed differences in crude mortality rates often disappear when data are controlled for the most common confounders, including age, socioeconomic status, severity of illness at admission, and hospital type.2 Equity is one of the six aims that defines “high-quality care,” which also should be safe, effective, patient-centered, and timely.3
The impact and importance of processes of care on patient outcomes in times of capacity strain both prior to and during the COVID-19 pandemic are well-documented.4,5 Given the constant increasing demands for critical care, ranging from routine fluctuations to mass casualties and epidemics, understanding the factors that may influence the equity of medical decision-making and changes in processes of care under different practice conditions becomes critically important.2 ICU triage guidelines base the decision for ICU admission primarily on the potential for the patient to benefit from intensive care services. Without strong evidence of such in many clinical situations, this decision becomes increasingly discretionary.6
Chesley et al’s findings that patients from minority groups with sepsis and ARF are equally or more likely than white patients to receive ICU admission regardless of the level of capacity strain are in some ways reassuring, despite the authors’ extensive attempts in their discussion to refute this conclusion. However, one of the major limitations of this large, retrospective cohort study is its inability to further discern the major patient and clinician factors that drove these decisions.
Palliative care and end-of-life planning are generally underused in the United States, for example, but this especially is the case among underrepresented groups as this cohort again demonstrates.7 The impact of cultural differences on goals of care conversations in the setting of critical illness also is poorly understood.8 The authors also reasonably proposed that language barriers may drive clinical uncertainty, prompting a bias toward ICU admission as a “safety net” for clinical deterioration. We agree with their call for further work using causal effect techniques to better determine if preferential ICU admission favorably influences patient outcomes, along with careful consideration of the value proposition that it may or may not offer.
A widely accepted conceptual model groups health equity research into three phases: detecting disparities, understanding disparity determinants, and identifying interventions to reduce disparities.9 Although this article by Chesley et al provides an incremental advance in our understanding within the first domain, there clearly is much more that must be done in this and other areas of critical care. As medical providers, we must act as a catalyst for change, acknowledging and addressing explicit and implicit bias in our everyday practice while this important work is being done.10 We also must reverse recent downward trends in underrepresented minorities across pulmonary and critical care medicine training programs to ensure that our subspecialty better reflects the diversity of the patient population that we serve.11
REFERENCES
- Anesi GL, Chowdhury M, Small DS, et al. Association of a novel index of hospital capacity strain with admission to intensive care units. Ann Am Thorac Soc 2020;17:1440-1447.
- McGowan SK, Sarigiannis KA, Fox SC, et al. Racial disparities in ICU outcomes: A systematic review. Crit Care Med 2022;50:1-20.
- Halpern SD. ICU capacity strain and the quality and allocation of critical care. Curr Opin Crit Care 2011;17:648-657.
- Gabler NB, Ratcliffe SJ, Wagner J, et al. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med 2013;188:800-806.
- Domencq JP, Lal A, Sheldrick CP, et al. Outcomes of patients with coronavirus disease 2019 receiving organ support therapies: The International Viral Infection and Respiratory Illness Universal Study Registry. Crit Care Med 2021;49:437-448.
- Jain S, Valley TS. Who receives ICU care during times of strain? Triage and the potential for racial disparities. Ann Am Thorac Soc 2022;19:1973-1974.
- Jones T, Luth EA, Lin SY, Brody AA. Advance care planning, palliative care, and end-of-life care interventions for racial and ethnic underrepresented groups: A systematic review. J Pain Symptom Manage 2021;62:e248-e260.
- Muni S, Engelberg RA, Treece PD, et al. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest 2011;139:1025-1033.
- Kilbourne AM, Switzer G, Hyman K, et al. Advancing health disparities research within the health care system: A conceptual framework. Am J Public Health 2006;96:2113-2121.
- Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: Addressing racial and gender disparities in critical care. Anesthesiol Clin 2020;38:357-368.
- Santhosh L, Babik JM. Diversity in the pulmonary and critical care medicine pipeline. Trends in gender, race, and ethnicity among applicants and fellows. ATS Sch 2020;1:152-160.
