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Disparities in Hypoxemia Detection by Pulse Oximetry Across Self-Identified Racial Groups and Associations With Clinical Outcomes*

Henry, Nicole R. DO, MPH¹; Hanson, Andrew C. MS²; Schulte, Phillip J. PhD²; Warner, Nafisseh S. MD³; Manento, Megan N. MD⁴; Weister, Timothy J. MS⁵; Warner, Matthew A. MD⁴

Author Information

¹ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

² Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.

³ Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

⁴ Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

⁵ Anesthesia Clinical Research Unit, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

*See also p. 335.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. N. S. Warner’s institution received funding from the National Institute on Aging (K23 Grant 1 K23 AG070113-01). Drs. N. S. Warner and M. A. Warner received support for article research from the National Institutes of Health. Dr. M. A. Warner’s institution received funding from a Clinical and Translational Science Awards KL2 grant (TR002379) from the National Center for the Advancing Translational Science and K23HL153310 from the National Heart, Lung, and Blood Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest.

The contents of this article are solely the responsibility of the authors and do not represent the official view of the National Institute on Aging, National Center for the Advancing Translational Science, National Heart, Lung, and Blood Institute, or the National Institutes of Health.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 50(2):p 204-211, February 2022. | DOI: 10.1097/CCM.0000000000005394

Abstract

OBJECTIVES:

To assess disparities in hypoxemia detection by pulse oximetry across self-identified racial groups and associations with clinical outcomes.

DESIGN:

Observational cohort study from May 5, 2018, to December 31, 2020.

SETTING:

Three academic medical centers in the United States.

PATIENTS:

Adults greater than or equal to 18 years who self-identified as White, Black, Asian, or American Indian admitted to the ICU or undergoing surgery during inpatient hospitalization with simultaneous measurements of pulse oximetry-estimated oxygen saturation and arterial blood gas-derived oxygen saturation.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Multivariable models were employed to assess the relationships between race, occult hypoxemia (i.e., arterial blood gas-derived oxygen saturation < 88% despite pulse oximetry-estimated oxygen saturation ≥ 92%), and clinical outcomes of hospital mortality and hospital-free days. One-hundred twenty-eight–thousand two-hundred eighty-five paired pulse oximetry-estimated oxygen saturation–arterial blood gas-derived oxygen saturation measurements were included from 26,603 patients. Pulse oximetry-estimated oxygen saturation on average overestimated arterial blood gas-derived oxygen saturation by 1.57% (1.54–1.61%). Black, Asian, and American Indian patients were more likely to experience occult hypoxemia during hospitalization (estimated probability 6.2% [5.1–7.6%], 6.6% [4.9–8.8%], and 6.6% [4.4–10.0%], respectively) compared with White patients (3.6% [3.4–3.8%]). Black patients had increased odds of occult hypoxemia compared with White patients after adjustment (odds ratio, 1.65; 1.28–2.14; p < 0.001). Differences in occult hypoxemia between Asian and American Indian patients compared with White patients were not significant after adjustment (odds ratio, 1.53; 0.95–2.47; p = 0.077 and odds ratio, 1.31; 0.80–2.16; p = 0.288, respectively). Occult hypoxemia was associated with increased odds of mortality in surgical (odds ratio, 2.96; 1.20–7.28; p = 0.019) and ICU patients (1.36; 1.03–1.80; p = 0.033). Occult hypoxemia was associated with fewer hospital-free days in surgical (–2.5 d [–3.9 to –1.2 d]; p < 0.001) but not ICU patients (0.4 d [–0.7 to 1.4 d]; p = 0.500).

CONCLUSIONS:

Occult hypoxemia is more common in Black patients compared with White patients and is associated with increased mortality, suggesting potentially important outcome implications for undetected hypoxemia. It is imperative to validate pulse oximetry with expanded racial inclusion.

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Disparities in Hypoxemia Detection by Pulse Oximetry Across Self-Identified Racial Groups and Associations With Clinical Outcomes*