Racial Disparities Linked to Length of Sepsis and Respiratory Failure Stays

Racial disparities appeared to be impacting hospital stay durations for sepsis and acute respiratory failure (ARF), a retrospective study found.

Black patients had significantly longer hospital stays than their white counterparts in regards to both sepsis (difference in median 1.26 days, 95% CI 0.68-1.84) and ARF (difference 0.97 days, 95% CI 0.05-1.89), reported Christopher F. Chesley, MD, MSCE, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, and co-authors.

However, compared with white patients, shorter hospital stays were seen among Hispanic patients for both sepsis (mean difference −0.22 days, 95% CI −0.39 to −0.05) and ARF (−0.47, 95% CI −0.73 to −0.20) and among Asian American and Pacific Islander patients who had ARF (−0.61, 95% CI −0.88 to −0.34), according to the study published in JAMA Network Open.

Those results were fully adjusted for commonly implicated factors, including clinical presentation characteristics, hospital capacity strain, initial ICU admission, and the occurrence of inpatient death.

"Our results revealed that previously identified factors incompletely accounted for LOS [length of stay] disparities and suggest that other underappreciated factors may play important roles," Chesley's group concluded, pointing to socioeconomic factors relevant to presentation and discharge care coordination as likely candidates.

Their study population of patients who were critically ill but did not immediately received advanced life support is an "understudied population in the disparities field who may be most susceptible to cognitively biased care delivery," they noted.

Yet the findings fit with other recent results showing that sepsis patients presenting to hospitals serving racial and ethnic minority patients had about 1 day longer median hospital LOS compared with white patients.

Chesley's study included a total of 102,362 adult participants (average age 76, 51.5% males) seen at 27 acute care teaching and community hospitals in Philadelphia and northern California from January 2013 through December 2018. Sepsis accounted for 84,685 of the emergency department visits, while ARF accounted for 42,008. Of the participants, 5.7% self-identified as multiracial, 9.7% as Hispanic, 10.2% as Asian American or Pacific Islander, 13.7% as Black, and 60.7% as white.

The researchers matched racial and ethnic minority patients with white patients with similar clinical characteristics for comparison.

Insurance status was also measured as part of the study. Medicare coverage was most common among Black patients (22.6%), followed by white patients (12.9%), Hispanic patients (5.9%), multiracial patients (2.4%), and lastly Asian or Pacific Islander patients (1.7%). Medicaid was most common among Black patients (10.7%), then Hispanic patients (4.4%), multiracial patients (2.5%), Asian or Pacific Islander patients (2.3%), then white patients (2%). Private insurance was the most common payor among all groups, but particularly for multiracial (91.9%) and Asian or Pacific Islander patients (84.4%), followed by Hispanic (79.4%) and white patients (78.9%), compared with 53.8% among Black patients.

Sensitivity analyses consistently turned up longer LOS among Black patients compared with their white counterparts.

"However, differences were mildly (but not completely) attenuated by DNR code status, suggesting that comprehensively characterizing advanced care planning differences between Black and white patients should be a priority for future studies," the researchers suggested.

Limitations to their study included possible misclassification bias, a lack of information analysis regarding a patient's possible need for future vasopressors or invasive mechanical ventilation, and the fact that the scope of the study included some factors such as patient insurance status, but not other factors like financial status, that may influence results.

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