New Findings Illustrate How Standardized Care Reduces Disparities in the ICU

Racial and ethnic minorities in the U.S. have traditionally experienced higher rates of comorbidities, which are often compounded as a result of healthcare access inequality. The COVID-19 pandemic further illustrated this trend. In urban centers, minority groups and individuals are more likely to have decreased access to timely intervention, an inability to undergo social distancing due to work-related demands, language barriers and larger household sizes. To better understand the implications of these effects, Cleveland Clinic researchers examined whether race and/or ethnicity is associated with inequalities in critical care management of COVID-19 within the Northeastern Ohio community. These findings recently appeared in the Journal of Racial and Ethnic Health Disparities.

The retrospective cohort study focused on 2064 patients who tested positive for COVID-19 between March and December 2020 and required ICU admission at Cleveland Clinic. The primary outcomes of the study was mortality, and the secondary outcome was length of hospital stay. The study’s authors hypothesized that patients who identify as Black or Hispanic in Cleveland, OH, may be more susceptible to poor COVID-19 outcomes following ICU admission, including increased length of stay and increased mortality rates, as compared to non-Hispanic white patients.

Higher comorbidities among racial and ethnic minorities

Of the study’s participants, 41.8% were female, 33% identified as Black, and 6.7% identified as being of non-white or non-Black race. The Black cohort was slightly younger than the white cohort (66 vs. 77 years old). Black patients had significantly higher prevalence of asthma (26.3% vs. 20.4%, p = 0.003), CKD (48.6% vs. 36.7%, p < 0.001) and diabetes (68.1% vs. 56.0%, p < 0.001) as compared to white patients. Black patients had a lower prevalence of malignant neoplasms (37.3 vs 45.0%, p = 0.0001). Hispanic patients had a significantly higher prevalence of liver disease (32.6% vs. 22.2%, p = 0.022). There were no significant differences between Black and white patients for chronic cardiac disease, COPD, CAD, dementia, HTN, hematological malignancies, solid organ and bone marrow transplants, malnutrition, liver disease and immunodeficiencies. Median APACHE scores, a predictor of ICU mortality, were fairly similar for Black and white patients [54 and 55, respectively (p = 0.40)].

“In our study, Black patients had a higher prevalence of asthma, diabetes, chronic kidney disease and hypertension, while Hispanic patients had a greater incidence of liver disease,” explains Abhijit Duggal, MD, a critical care physician in Cleveland Clinic’s Respiratory Institute and principal author of the study. “Nationally, Black and Hispanic patients are at a higher risk of COVID-19 infection and death from the virus because of inequalities in chronic disease prevention and management. These conditions are risk factors for more severe cases of COVID-19.”

Differences in care

During their ICU stays, a similar percentage of Black and white patients required intubation (41.9% vs. 42.7%, respectively, p > 0.05). The mean intubation times for both groups were also comparable (7.0 vs. 8.2 days). Although the median length of time in the hospital was similar for Black patients and white patients (10.6 vs. 11.5 days, respectively, p = 0.056), the median length of ICU stay was statistically different between the two groups (3.4 vs. 4.4 days, respectively, p = 0.003). The authors found that certain factors were statistically significant in regard to mortality. These include: APACHE score at ICU admission (OR = 1.02; 95% CI = 1.01 to 1.02), CKD (OR = 1.34; 95% CI = 1.05 to 1.71), malignant neoplasms (OR = 1.28, 95% CI = 1.03 to 1.59), antibiotic use (OR = 1.69, 95% CI = 1.04 to 2.73), vasopressor requirement (OR = 3.97; 95% CI = 3.12 to 5.05) and age (OR = 1.06, 95% CI = 1.04 to 1.07). After adjustment for underlying disease conditions, and severity of disease there was no difference in mortality based on race or ethnicity.

Outcomes

Based on their findings, the authors believe that in a health care system which is not stressed, race and ethnicity were not associated with COVID-19 associated mortality. This study also highlights the significant disparity pre-ICU pathophysiologic and underlying comorbidities among the populations based on race and ethnicity. It is these underlying conditions along with the severity of disease as measured by the APACHE score, were independently associated with mortality.

Early in the pandemic, Cleveland Clinic implemented several strategies to care for patients with COVID-19. These included ensuring available care at its main campus and several regional hospitals, using an ICU operations team to improve care and standardize best practices, offering training modules to all ICU providers and multidisciplinary care.

“At the end of the day, expanding healthcare access should be a major goal for providers,” says Dr. Duggal. “The effects of access inequality are two-fold — not only does access affect how patients are cared for when they are sick, but it also affects their future health. These effects are also compounded by situations that increase demand and deplete resources, such as a pandemic. We believe this this work demonstrates that equitable healthcare not only is possible, but with a standardized approach, it can be achieved. This is especially important for patients of traditionally disadvantaged racial and ethnic minorities.”