Pulse Oximeter Bias and Inequities in Retrospective Studies––Now What?

Moore, Kelvin; Gudelunas, Koa; Lipnick, Michael S; Bickler, Philip E.; Hendrickson, Carolyn M.

doi:10.4187/respcare.10654

Cited by 6 publications

(5 citation statements)

References 12 publications

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“…Improved accuracy of pulse oximeters, which play an important role in triage and treatment decisions, is critical to delivery of timely and equitable care to patients with COVID-19. The implications of pulse oximeter errors likely extend to other acute respiratory illnesses and oxygen supplementation in chronic respiratory disease, which necessitate ongoing investigation …”

Section: Discussionmentioning

confidence: 99%

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Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Fawzy,

Wu,

Wang

et al. 2023

JAMA Netw Open

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ImportanceMany pulse oximeters have been shown to overestimate oxygen saturation in persons of color, and this phenomenon has potential clinical implications. The relationship between overestimation of oxygen saturation with timing of COVID-19 medication delivery and clinical outcomes remains unknown.ObjectiveTo investigate the association between overestimation of oxygen saturation by pulse oximetry and delay in administration of COVID-19 therapy, hospital length of stay, risk of hospital readmission, and in-hospital mortality.Design, Setting, and ParticipantsThis cohort study included patients hospitalized for COVID-19 at 186 acute care facilities in the US with at least 1 functional arterial oxygen saturation (SaO2) measurement between March 2020 and October 2021. A subset of patients were admitted after July 1, 2020, without immediate need for COVID-19 therapy based on pulse oximeter saturation (SpO2 levels of 94% or higher without supplemental oxygen).ExposuresSelf-reported race and ethnicity, difference between concurrent SaO2 and pulse oximeter saturation (SpO2) within 10 minutes, and initially unrecognized need for COVID-19 therapy (first SaO2 reading below 94% despite SpO2 levels of 94% or above).Main Outcome and MeasuresThe association of race and ethnicity with degree of pulse oximeter measurement error (SpO2 − SaO2) and odds of unrecognized need for COVID-19 therapy were determined using linear mixed-effects models. Associations of initially unrecognized need for treatment with time to receipt of therapy (remdesivir or dexamethasone), in-hospital mortality, 30-day hospital readmission, and length of stay were evaluated using mixed-effects models. All models accounted for demographics, clinical characteristics, and hospital site. Effect modification by race and ethnicity was evaluated using interaction terms.ResultsAmong 24 504 patients with concurrent SpO2 and SaO2 measurements (mean [SD] age, 63.9 [15.8] years; 10 263 female [41.9%]; 3922 Black [16.0%], 7895 Hispanic [32.2%], 2554 Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, or another race or ethnicity [10.4%], and 10 133 White [41.4%]), pulse oximetry overestimated SaO2 for Black (adjusted mean difference, 0.93 [95% CI, 0.74-1.12] percentage points), Hispanic (0.49 [95% CI, 0.34-0.63] percentage points), and other (0.53 [95% CI, 0.35-0.72] percentage points) patients compared with White patients. In a subset of 8635 patients with a concurrent SpO2 − SaO2 pair without immediate need for COVID-19 therapy, Black patients were significantly more likely to have pulse oximetry values that masked an indication for COVID-19 therapy compared with White patients (adjusted odds ratio [aOR], 1.65; 95% CI, 1.33-2.03). Patients with an unrecognized need for COVID-19 therapy were 10% less likely to receive COVID-19 therapy (adjusted hazard ratio, 0.90; 95% CI, 0.83-0.97) and higher odds of readmission (aOR, 2.41; 95% CI, 1.39-4.18) regardless of race (P for interaction = .45 and P = .14, respectively). There was no association of unrecognized need for COVID-19 therapy with in-hospital mortality (aOR, 0.84; 95% CI, 0.71-1.01) or length of stay (mean difference, −1.4 days; 95% CI, −3.1 to 0.2 days).Conclusions and RelevanceIn this cohort study, overestimation of oxygen saturation by pulse oximetry led to delayed delivery of COVID-19 therapy and higher probability of readmission regardless of race. Black patients were more likely to have unrecognized need for therapy with potential implications for population-level health disparities.

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Section: Discussionmentioning

confidence: 99%

“…The implications of pulse oximeter errors likely extend to other acute respiratory illnesses and oxygen supplementation in chronic respiratory disease, which necessitate ongoing investigation. 31 …”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Fawzy,

Wu,

Wang

et al. 2023

JAMA Netw Open

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“…The studies above demonstrate that not only is there significant bias in measurement of oxygen saturation in individuals with darker skin tones, it also translates into poorer healthcare delivery and clinical outcomes for these patients, which further perpetuates health inequities. The literature also highlights that the magnitude of inaccuracy with different skin tones is variable and not well-quantified, differing by device and other patient factors, including low perfusion ( 49 , 58 ). These studies were all performed in HICs, and there is a critical paucity of such data in LMICs.…”

Section: Methodsmentioning

confidence: 99%

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors

et al. 2023

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Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO2 targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO2 ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO2 values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO2 range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO2 target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

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“…To the Editor A ddressing and understanding skin colorassociated bias in pulse oximetry is a patient safety and health equity priority. 1 Updated regulatory requirements and standards are needed to improve population diversity in device validation studies and provide greater assurance concerning performance. Skin pigmentation measurement methods (PMMs) are either subjective or objective, typically using colormatching scales and light-based measurement devices, respectively.…”

Section: Challenges Of Subjective Skin Color Scales: the Case For The...mentioning

confidence: 99%

“…To the Editor G uidelines recommend maintaining endotracheal cuff pressure within 20 to 30 cm H 2 O to reduce the incidence of ventilator-associated pneumonia (VAP) and airway damage. 1 Cuff pressure changes due to various factors and should be adjusted promptly. Auto-inflators have been shown to be highly effective in maintaining safe pressure levels and reducing the risk of underinflation or overinflation of the cuff.…”

Section: A Hydraulic Auto-inflator For Endotracheal Tube Cuff Pressur...mentioning

confidence: 99%

Challenges of Subjective Skin Color Scales: The Case for the Use of Objective Pigmentation Measurement Methods in Regulatory Pulse Oximetry Studies

Verkruysse,

Jaffe,

Lipnick

et al. 2024

Anesthesia &Amp; Analgesia

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Decreased maximum clot firmness in rotational thromboelastometry (ROTEM®) is associated with bleeding during extracorporeal mechanical circulatory support. Perfusion. 2016;31:625-633. 4. Crochemore T, Görlinger K, Lance MD. Early goal-directed hemostatic therapy for severe acute bleeding management in the intensive care unit: a narrative review. Anesth Analg. 2023;138:499-513. 5. Buscher H, Zhang D, Nair P. A pilot, randomised controlled trial of a rotational thromboelastometry-based algorithm to treat bleeding episodes in extracorporeal life support: the TEM protocol in ECLS study (TEMPEST).

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Pulse Oximeter Bias and Inequities in Retrospective Studies––Now What?

Cited by 6 publications

References 12 publications

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors

Challenges of Subjective Skin Color Scales: The Case for the Use of Objective Pigmentation Measurement Methods in Regulatory Pulse Oximetry Studies

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