Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19

Abstract

Background: Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care use SOFA score to allocate medical resources during the COVID-19 pandemic. Research Question: Are SOFA scores disproportionately elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients? Study Design and Methods: Retrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged ≥18 admitted with COVID-19 from March 29th to August 1st, 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcomes was SOFA score, with peak score within 24 hours of admission dichotomized as <6 or ≥6. Results: Of 2982 patients admitted with COVID-19, 2320 met inclusion criteria and were analyzed, of whom 1058 (45.6%) were Non-Hispanic White, 645 (27.8%) were Hispanic, and 617 (26.6%) were Non-Hispanic Black. Median age was 65.0 and 1226 (52.8%) were female. In univariate logistic screen and in full multivariate model, Non-Hispanic Black patients but not Hispanic patients had greater odds of an elevated SOFA score ≥6 when compared to Non-Hispanic White patients (OR 1.49, 95%CI 1.11-1.99). Interpretation: Crisis standards of care utilizing the SOFA score to allocate medical resources would be more likely to deny these resources to Non-Hispanic Black patients.

SOFA score performs worse than age for predicting mortality in patients with COVID-19

“…Additionally, there was no significant difference in mortality rate between White and Black COVID-19 patients at SOFA scores greater than 2. Notably, a prior study of patients from the same COVID-19 cohort, Black patients had 1.5 times the odds of a SOFA score ≥ 6 than white patients, even when adjusting for age, sex, insurance status, BMI, liver and renal diseases (23). This suggests that Black patients with COVID-19 may be more likely than White patients to be assigned higher SOFA scores but will have similar mortality rates at those higher SOFA scores.…”

“…This study was exempted by the Yale University Institutional Review Board (2000027747). The patient cohort is described extensively in a prior, publicly available manuscript (23).…”

POINT: Is Considering Social Determinants of Health Ethically Permissible for Fair Allocation of Critical Care Resources During the COVID-19 Pandemic? Yes

“…Two recent studies from large, diverse cohorts in Chicago, Illinois, and New Haven, Connecticut, found that Black patients have a worse survival prognosis at the time of triage compared with White patients and would therefore be more frequently disadvantaged by a triage strategy focused narrowly on prognosis of survival to hospital discharge. 7 , 8 …”

On race, human variation, and who gets and dies of sepsis

“…For reasons that cannot be ruled out as environmental or a product of care, Black patients are noted to often have higher creatinine levels than White patients with the same level of kidney function (Diao et al, 2021). High creatinine levels when incorporated into SOFA scores, however, often result in US Black patients having a higher SOFA score than White patients, but not higher in‐hospital mortality, suggesting that in Black sepsis patients are more likely to be assessed as being more pathologically advanced than they are (Miller et al, 2021; Roy et al, 2021; Tolchin et al, 2021). The systemic error generated by SOFA scoring can alter the end of care treatment based on a score‐based assessment of likelihood of intervention benefit, or prioritization for care at all when hospitals are overwhelmed and must implement Crisis of Care Standards that prioritize patients with the highest likelihood of survival (Tolchin et al, 2021).…”

“…In the United States, numerous providers continue to apply a “race coefficient” when estimating kidney function using creatinine (via estimated glomerular filtration rate), which tends to under‐diagnose Black patients for kidney dysfunction leading to life endangering care disparities (reviewed in Ahmed et al, 2021). Via different mechanisms, Like eGFR, SOFA scores can act as quantifiable justification for denial of care, because the score is not reflexive – it is not sensitive to variation between biomarkers and organ function known to occur across the human population, and most importantly, is does not account for the multitude of problems known to delay treatment and lower the standard of care that BIPOC patients experience and that increase indicators of organ dysfunction (Tolchin et al, 2021).…”