Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure
Authors: Abdelmalek Fred M. , Angriman Federico , Moore Julie , Liu Kuan , Burry Lisa , Seyyed-Kalantari Laleh , Mehta Sangeeta , Gichoya Judy , Celi Leo Anthony , Tomlinson George , Fralick Michael , Yarnell Christopher J. 
Published: November 2022

Importance

Differential use of therapies for respiratory failure according to patient race/ethnicity may represent health inequity and could impact patient survival.

Objective

Measure the association between patient race/ethnicity and the use of invasive ventilation, and the impact of any association on survival.

Design

Retrospective cohort analysis using a Bayesian multistate model that adjusted for baseline covariates and time-varying severity.

Setting

Multicenter study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) and Phillips eICU (eICU) databases from the USA.

Participants

Non-intubated adults receiving oxygen within the first 24 hours of ICU admission.

Exposure

Patient race/ethnicity (Asian, Black, Hispanic, white).

Main outcomes and measures

Primary output was the cause-specific hazard ratio (HR) of invasive ventilation for patient race/ethnicity. Secondary output was change in 28-day survival mediated by differences in invasive ventilation rate. We reported posterior means and 95% credible intervals (CrI).

Results

We studied 38,263 patients, 52% (20,033) from MIMIC-IV and 48% (18,230) from eICU, 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,923). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The rate of invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, lower rates of invasive ventilation did not mediate differences in survival. For a reference patient with inspired oxygen (FiO2) varied from 0.5 to 1.0, the change in survival mediated by lower rates of invasive ventilation ranged from probable benefit (probability 0.82 for Asian patients, 0.91 for Black patients, and 0.93 for Hispanic patients) at FiO2 0.5 to probable harm (probability 0.87 for Asian patients, 0.92 for Black patients, and 0.97 for Hispanic patients) at FiO2 1.0, although the mean absolute changes in mortality were all less than 1.5%.

Conclusions

Asian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. The changes in 28-day survival mediated by this difference ranged from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0, and there was no difference in survival for the average patient.

Key Points

Question

What is the association between patient race/ethnicity and the use of invasive ventilation in hypoxemic respiratory failure, and what is the impact of any differences on survival?

Findings

We studied 38,263 patients from two US databases, who were 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,118). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The hazard ratio (HR) for invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, race/ethnicity differences in invasive ventilation rates did not mediate differences in 28-day survival. For the reference patient, at inspired oxygen fractions up to 0.9, lower invasive ventilation rates mediated a modest survival benefit, whereas at inspired oxygen fraction of 1.0, the lower invasive ventilation rates mediated a modest survival decrease, although the absolute changes were all less than 1.5%.

Meaning

Asian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. Although this difference had no impact on 28-day survival for the average patient, the change in survival mediated by lower rates of invasive ventilation could range from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0.