Response by Eberly et al to Letter Regarding Article, “Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center”

Eberly, Lauren A.; Wispelwey, Bram; Richterman, Aaron; Beckett, Anne G.; Manchanda, Emily C. Cleveland; Marsh, Regan H.; Chang, Cindy Y.; Glynn, Robert J.; Brooks, Katherine C.; Boxer, Robert; Kakoza, Rose M.; Goldsmith, Jennifer; Loscalzo, Joseph; Lewis, Eldrin F.; Morse, Michelle

doi:10.1161/circheartfailure.120.007193

Cited by 29 publications

(37 citation statements)

References 4 publications

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“…in-hospital implementation may also help to address inequities or biases in care. 19 The GDMT intervention utilized an entirely virtual platform with no direct communication with patients. Therefore, such efforts could be efficiently scaled across other chronic cardio-renal-metabolic conditions (e.g.…”

Section: Discussionmentioning

confidence: 99%

Virtual optimization of guideline‐directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT‐HF pilot study

Bhatt

Varshney

Nekoui

et al. 2021

European J of Heart Fail

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Section: Discussionmentioning

confidence: 99%

Virtual optimization of guideline‐directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT‐HF pilot study

Bhatt

Varshney

Nekoui

et al. 2021

European J of Heart Fail

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“…16 Artificially high SpO 2 readings in the emergency department could affect the perceived need for cardiology service admission for heart failure management, possibly explaining the finding that Black and Hispanic patients were less likely than White patients to be admitted to a cardiology service. 17 The objective of this study was to assess if there are disparities in supplemental oxygen administration between Asian, Black, and Hispanic patients and White patients in the ICU and whether they are associated with discrepancies in pulse oximeter performance.…”

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confidence: 99%

Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit

et al. 2022

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IMPORTANCE Pulse oximetry (SpO 2 ) is routinely used for transcutaneous monitoring of blood oxygenation, but it can overestimate actual oxygenation. This is more common in patients of racial and ethnic minority groups. The extent to which these discrepancies are associated with variations in treatment is not known. OBJECTIVE To determine if there are racial and ethnic disparities in supplemental oxygen administration associated with inconsistent pulse oximeter performance. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study was based on the Medical Information Mart for Intensive Care (MIMIC)-IV critical care data set. Included patients were documented with a race and ethnicity as Asian, Black, Hispanic, or White and were admitted to the intensive care unit (ICU) for at least 12 hours before needing advanced respiratory support, if any. Oxygenation levels and nasal cannula flow rates for up to 5 days from ICU admission or until the time of intubation, noninvasive positive pressure ventilation, high-flow nasal cannula, or tracheostomy were analyzed. MAIN OUTCOMES AND MEASURESThe primary outcome was time-weighted average supplemental oxygen rate. Covariates included race and ethnicity, sex, SpO 2 -hemoglobin oxygen saturation discrepancy, data duration, number and timing of blood gas tests on ICU days 1 to 3, partial pressure of carbon dioxide, hemoglobin level, average respiratory rate, Elixhauser comorbidity scores, and need for vasopressors or inotropes. RESULTSThis cohort included 3069 patients (mean [SD] age, 66.9 [13.5] years; 83 were Asian, 207 were Black, 112 were Hispanic, 2667 were White). In a multivariable linear regression, Asian (coefficient, 0.602; 95% CI, 0.263 to 0.941; P = .001), Black (coefficient, 0.919; 95% CI, 0.698 to 1.140; P < .001), and Hispanic (coefficient, 0.622; 95% CI, 0.329 to 0.915; P < .001) race and ethnicity were all associated with a higher SpO 2 for a given hemoglobin oxygen saturation. Asian (coefficient, −0.291; 95% CI, −0.546 to −0.035; P = .03), Black (coefficient, −0.294; 95% CI, −0.460 to −0.128; P = .001), and Hispanic (coefficient, −0.242; 95% CI, −0.463 to −0.020; P = .03) race and ethnicity were associated with lower average oxygen delivery rates. When controlling for the discrepancy between average SpO 2 and average hemoglobin oxygen saturation, race and ethnicity were not associated with oxygen delivery rate. This discrepancy mediated the effect of race and ethnicity (−0.157; 95% CI, −0.250 to −0.057; P = .002). CONCLUSIONS AND RELEVANCEIn this cohort study, Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, and this was associated with differences in pulse oximeter performance, which may contribute to known race and ethnicity-based disparities in care.

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“…[16][17][18][19][20] It has been earlier acknowledged that such standardized score methods could actually introduce potential biases on the final results of study groups. 21,22 It will also remain quite difficult for researchers to precisely tease out what chest pain management patterns may be primarily attributable to variations in provider ordering, patient preferences, or other unmeasured factors. 3,9,23 Readers should still consider that such standardized chest pain protocols have been shown to decrease racial treatment variations, reduce long term healthcare costs and improve care access.…”

Section: Discussionmentioning

confidence: 99%

Racial Variations in Emergency Department Management of Chest Pain in a Community-based Setting

Greenberg

Schultz

Cobb

et al. 2022

Spartan Medical Research Journal

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INTRODUCTION Chest pain is one of the most common chief presenting complaints occurring in most Emergency Departments. The HEART score is a validated risk stratification tool commonly used to evaluate chest pain. Prior research has demonstrated the existence of complex racial variations in health care, specifically in what tests are ordered (or accepted by patients) during evaluation and treatment of cardiac disease. The authors hypothesized that chest pain management (i.e., disposition to hospital/observation unit and rates of stress testing) patterns and longitudinal outcomes (i.e., death and 30-day readmission) would occur differently in African Americans despite systematic use of the HEART score. METHODS Funded by the Statewide Campus System, this study was comprised of a retrospective chart review of a sample of eligible patients presenting with chest pain to the authors’ 345-bed community-based Michigan hospital. RESULTS Of the 1,412 eligible sample patients, 886 (63%) reported their racial affiliation as White, 473 (33%) African-American, and 53 (4%) “Other”. The average HEART score in Whites was 3.92 (SD = 1.89) compared to 3.31 (SD = 1.79) in African-Americans, (p < 0.01, 95% CI: 0.40-0.82). However, White patients’ odds of admission to observation or inpatient was 1.49 times higher (95% CI: 1.04 - 2.15), with every unit increase in HEART score increasing the odds ratio of admission by 3.24 times (95% CI: 2.79 - 3.76). White patients were also 2.37 times more likely to receive (or accept) stress tests than African American patients (95% CI: 1.41 - 3.88). Only five (0.01%) of 458 White patients with HEART score between 4 and 6 experienced 30-day readmission or death whereas seven (0.04%) of 193 African-American patients experienced these outcomes (p = 0.04 with OR 3.40, 95% CI: 1.07 - 10.9). CONCLUSIONS Although the authors were unable to precisely distinguish the provider (e.g., desire to order testing) and patient-driven (e.g., desire to accept testing) factors likely to contribute to measured differences, these results suggest continued complex racial variations concerning hospital admission and stress testing in chest pain patients. Further studies are needed to analyze potential systems or subject-level factors influencing the multi-dimensional phenomenon of chest pain management across racial affiliation.

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Response by Eberly et al to Letter Regarding Article, “Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center”

Cited by 29 publications

References 4 publications

Virtual optimization of guideline‐directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT‐HF pilot study

Virtual optimization of guideline‐directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT‐HF pilot study

Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit

Racial Variations in Emergency Department Management of Chest Pain in a Community-based Setting

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