Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care.
Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care.
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DOI：
10.1001/jamanetworkopen.2021.13891
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发表时间：
2021-06-01
影响因子：
13.8
通讯作者：
Parker WF
中科院分区：
文献类型：
--
作者：
Miller WD;Han X;Peek ME;Charan Ashana D;Parker WF
本队列研究比较了具有相同序贯器官衰竭评估（SOFA）评分的黑人和白色患者的死亡率，以及在危机护理标准中具有相同优先级的死亡几率。依赖序贯器官衰竭评估（SOFA）评分来估计院内死亡风险是否与危机护理标准（CSC）中对黑人患者的偏倚相关？在这项对重症监护室95549例患者的队列研究中，与SOFA评分相同的白色患者相比，黑人患者的院内死亡率较低。这种对黑人患者死亡风险的高估与CSC中黑人患者的优先级降低有关。这项研究的结果表明，与白色患者相比，SOFA与黑人患者的高估死亡率有关，这表明CSC与黑人患者的系统性降低优先级有关。危机护理标准（CSC）是在公共卫生紧急情况下配给卫生保健资源的指导方针。美国采用的CSC使用序贯器官衰竭评估（SOFA）评分来定量重症监护病房（ICU）的入院，该评分用于比较符合条件的患者的预期住院死亡率。然而，尚不清楚具有相同SOFA评分的黑人和白色患者是否具有相同的住院死亡率。调查对SOFA的依赖是否与CSC对黑人患者的偏倚有关。这项队列研究使用了2014年至2015年入住233个美国ICU的患者的eICU协作研究数据库的数据。纳入个体为ICU中的黑人和白色成人患者，随访至出院。分析了2020年5月至2021年4月的数据。ICU入院时的SOFA评分。采用医院固定效应的分层logistic回归分析，测量种族和SOFA之间的相互作用，作为与住院死亡率相关的因素，以及根据3个州CSC基于SOFA的排名规则，具有同等资源分配优先级的黑人和白色患者的死亡几率。（表示为A、B和C）在严重短缺条件下（即，只有最高优先级的患者才有资格分配），中间（即，最高2层的患者有资格分配）或低（即，只有最低优先级的患者有排除风险）。在111 885次ICU就诊中（95 549例患者），有16 688例黑人患者（14.9%）和51 464例女性患者（46.0%），平均（SD）年龄为63.3（16.9）岁。黑人和白色患者的SOFA评分中位数（四分位距）无统计学显著差异（两组均为4 [2-6]; P = 0.19），但黑人个体的死亡率低于SOFA评分相同的白色个体（比值比[OR]，0.98; 95%CI，0.97-0.99; P <0.001）。在严重短缺的情况下，这与3例CSC中优先分配资源的白色患者相比，黑人患者的死亡率较低有关（系统A：OR，0.65; 95% CI，0.58-0.74; P <0.001;系统B：OR，0.70; 95% CI，0.64-0.78; P <0.001;系统C：OR，0.73; 95% CI，0.67-0.80; P < .001），中间（系统A：OR，0.73; 95% CI，0.67-0.80; P <0.001;系统B：OR，0.83; 95% CI，0.77-0.89; P <0.001;系统C：OR，0.82; 95% CI，0.77-0.89; P <0.001）和低（系统A：OR，0.83; 95% CI，0.77-0.89; P <0.001;系统C：OR，0.86; 95% CI，0.81-0.92; P <0.001;不适用于系统B，其层级较少）。当基于SOFA的排名规则进行调整，以模拟公平分配的基础上观察到的死亡率，黑人患者的比例升级到更高的优先级范围从379黑人患者遇到（2.3%）在低短缺的条件下，2601黑人患者遇到（15.6%）在严重短缺的条件。这项研究发现，与白色患者相比，SOFA评分与黑人患者的高估死亡率相关，这与黑人患者在CSC分配系统中的结构性劣势相关。这些研究结果表明，应修订指导方针，以纠正这种不公平和替代方法，应制定更公平的分流。
This cohort study compares mortality among Black and White patients with equivalent Sequential Organ Failure Assessment (SOFA) Scores and their odds of death with equivalent priority in Crisis Standards of Care. Is reliance on the Sequential Organ Failure Assessment (SOFA) score to estimate the risk of in-hospital mortality associated with bias against Black patients in Crisis Standards of Care (CSC)? In this cohort study of 95 549 patients in the intensive care unit, in-hospital mortality was lower among Black patients compared with White patients who had equivalent SOFA scores. This overestimation of mortality risk for Black patients was associated with deprioritization of Black patients in CSC. This study's findings that SOFA is associated with overestimated mortality among Black patients compared with White patients suggest that CSC are associated with systematic deprioritization of Black patients. Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality. To investigate whether reliance on SOFA is associated with bias against Black patients in CSC. This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021. SOFA scores at ICU admission. Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion). Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions. This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.
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DOI：
10.15585/mmwr.mm6915e3
发表时间：
2020-04-17
期刊：
MMWR. Morbidity and mortality weekly report
影响因子：
--
作者：
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通讯作者：
Fry A
影响因子：
14.6
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影响因子：
38.9
作者：
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通讯作者：
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影响因子：
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通讯作者：
for Southeast Asia Infectious Disease Clinical Research Network
DOI：
10.1164/rccm.201905-0917oc
发表时间：
2020-04-01
影响因子：
24.7
作者：
Machado, Flavia R.;Cavalcanti, Alexandre B.;Azevedo, Luciano C. P.
通讯作者：
Azevedo, Luciano C. P.