Could routine race-adjustment of spirometers exacerbate racial disparities in COVID-19 recovery?

Anderson, Meredith A; Malhotra, Atul; Non, Amy L.

doi:10.1016/s2213-2600(20)30571-3

Cited by 27 publications

(20 citation statements)

References 8 publications

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“…Unlike the use of race and ethnicity in the calculation of glomerular filtration rate 37 or interpretation of pulmonary function testing, 38 which have come under recent scrutiny, the race and ethnicity-based discrepancy of pulse oximetry exposes a fundamental flaw in the acquisition rather than interpretation of data, although all the aforementioned biases are associated with systematic underdiagnosis of disease or withholding of therapies for racial and ethnic minority groups. [39][40][41][42][43] Although the principal objective of the study was to characterize relative biases in pulse oximetry, the absolute biases identified among all racial and ethnic minority groups are notable. While some variability may be explained by the allowance of 10 minutes between paired SpO 2 and SaO 2 measurements, such variability would not explain the systematic error among White patients that is separate from the pulse oximeter's imprecision.…”

Section: Discussionmentioning

confidence: 99%

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

et al. 2022

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guides triage and therapy decisions for COVID-19. Whether reported racial inaccuracies in oxygen saturation measured by pulse oximetry are present in patients with COVID-19 and associated with treatment decisions is unknown. OBJECTIVE To determine whether there is differential inaccuracy of pulse oximetry by race or ethnicity among patients with COVID-19 and estimate the association of such inaccuracies with time to recognition of eligibility for oxygen threshold-specific COVID-19 therapies. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of clinical data from 5 referral centers and community hospitals in the Johns Hopkins Health System included patients with COVID-19 who self-identified as Asian, Black, Hispanic, or White.EXPOSURES Concurrent measurements (within 10 minutes) of oxygen saturation levels in arterial blood (SaO 2 ) and by pulse oximetry (SpO 2 ). MAIN OUTCOMES AND MEASURESFor patients with concurrent SpO 2 and SaO 2 measurements, the proportion with occult hypoxemia (SaO 2 <88% with concurrent SpO 2 of 92%-96%) was compared by race and ethnicity, and a covariate-adjusted linear mixed-effects model was produced to estimate the association of race and ethnicity with SpO 2 and SaO 2 difference. This model was applied to identify a separate sample of patients with predicted SaO 2 levels of 94% or less before an SpO 2 level of 94% or less or oxygen treatment initiation. Cox proportional hazards models were used to estimate differences by race and ethnicity in time to recognition of eligibility for guideline-recommended COVID-19 therapies, defined as an SpO 2 level of 94% or less or oxygen treatment initiation. The median delay among individuals who ultimately had recognition of eligibility was then compared. RESULTS Of 7126 patients with COVID-19, 1216 patients (63 Asian [5.2%], 478 Black [39.3%], 215 Hispanic [17.7%], and 460 White [37.8%] individuals; 507 women [41.7%]) had 32 282 concurrently measured SpO 2 and SaO 2 . Occult hypoxemia occurred in 19 Asian (30.2%), 136 Black (28.5%), and 64 non-Black Hispanic (29.8%) patients compared with 79 White patients (17.2%). Compared with White patients, SpO 2 overestimated SaO 2 by an average of 1.7% among Asian (95% CI, 0.5%-3.0%), 1.2% among Black (95% CI, 0.6%-1.9%), and 1.1% among non-Black Hispanic patients (95% CI, 0.3%-1.9%). Separately, among 1903 patients with predicted SaO 2 levels of 94% or less before an SpO 2 level of 94% or less or oxygen treatment initiation, compared with White patients, Black patients had a 29% lower hazard (hazard ratio, 0.71; 95% CI, 0.63-0.80), and non-Black Hispanic patients had a 23% lower hazard (hazard ratio, 0.77; 95% CI, 0.66-0.89) of treatment eligibility recognition. A total of 451 patients (23.7%) never had their treatment eligibility recognized, most of whom (247 [54.8%]) were Black. Among the remaining 1452 (76.3%) who had eventual recognition of treatment eligibility, Black patients had a median delay of 1.0 hour (95% CI, 0.23-1.9 hours; P = .01) longer than White patients. There was no signif...

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Section: Discussionmentioning

confidence: 99%

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

et al. 2022

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“…In this, Jefferson wrote extensively of the “difference of structure in the pulmonary apparatus” with reference to a deficiency in the respiratory cycle between Black enslaved people compared to White people 4 . Although Jefferson's writings lacked empiric investigation, racial differences in lung function would become a major focus of medical research soon after his writing to justify the system of slavery 4,5 . Nearly a century later, Samuel Cartwright, a physician and slave owner, was the first to report differences between Black enslaved people and White people using spirometry.…”

Section: Historical Context For Race-correction and Spirometrymentioning

confidence: 99%

“…His published writings reported a 20% deficiency in the pulmonary capacity of Black enslaved people, spawning the idea that forced labor improved the pulmonary function of enslaved individuals and building the foundation of what would become the normalization of race-correction in pulmonary tests. 4,5…”

Section: Historical Context For Race-correction and Spirometrymentioning

confidence: 99%

The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications

Bonner

Wakeam

2022

Annals of Surgery

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“…22 Some early biological explanations leaned on baseless centuries-old notions of genetic differences in lung function across racial and ethnic groups. [23][24][25] For instance, early in the pandemic there were false notions of COVID-19 immunity among Black Americans, and currently most medical facilities in the United States use different standards and race-adjusted algorithms to measure various health functions and outcomes for Black patients versus others, potentially affecting COVID-19 detection and STRUCTURAL RACISM AND COVID-19 IN THE UNITED STATES care. 26,27 Others have pointed to behavioral explanations.…”

Section: Structural Racism and Covid-19 Racial Health Disparitiesmentioning

confidence: 99%

Structural Racism and the COVID-19 Experience in the United States

et al. 2021

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The long, fallacious history of attributing racial disparities in public health outcomes to biological inferiority or poor decision making persists in contemporary conversations about the COVID-19 pandemic. Given the disproportionate impacts of this pandemic on communities of color, it is essential for scholars, practitioners, and policymakers to focus on how structural racism drives these disparate outcomes. In May and June 2020, we conducted a 6-state online survey to examine racial/ethnic differences in exposure to COVID-19, risk mitigation behaviors, risk perceptions, and COVID-19 impacts. Results show that Black and Hispanic individuals were more likely than White respondents to experience factors associated with structural racism (eg, living in larger households, going to work in person, using public transportation) that, by their very nature, increase the likelihood of exposure to COVID-19. Controlling for other demographic and socioeconomic characteristics, non-White respondents were equally or more likely than White respondents to take protective actions against COVID-19, including keeping distance from others and wearing masks. Black and Hispanic respondents also perceived higher risks of dying of the disease and of running out of money due to the pandemic, and 40% of Black respondents reported knowing someone who had died of COVID-19 at a time when the US death toll had just surpassed 100,000 people. To manage the current pandemic and prepare to combat future health crises in an effective, equitable, and antiracist manner, it is imperative to understand the structural factors perpetuating racial inequalities in the COVID-19 experience.

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Could routine race-adjustment of spirometers exacerbate racial disparities in COVID-19 recovery?

Cited by 27 publications

References 8 publications

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications

Structural Racism and the COVID-19 Experience in the United States

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