Teasing apart the multifaceted relationships between patient characteristics and outcomes in the critically ill patient can be quite complex, and coronavirus disease 2019 (COVID-19) has been no exception (1,2). It has been recently described in the medical literature that certain racial and ethnic groups are suffering a disproportionate burden of disease with regards to COVID-19 (3–5). Yet, the results for the critically ill patient are less clear (6,7). In this issue of Critical Care Medicine, Lazar et al (8) attempt to elucidate the delicate and impactful issue of race and COVID-19 in the ICU. We would like to share with you our perspective on what they did, what they found, what it means, and where we go from here.
WHAT DID THEY DO?
The investigators are from Henry Ford Hospital, an academic medical center located in Detroit, MI—a U.S. city that is almost 70% Black. They performed a single-center retrospective, cohort study, describing outcomes of patients who had laboratory-confirmed COVID-19 and were treated in their ICU between March 13, and July 31, 2020. Their primary focus was to look at racial differences in certain outcomes such as ICU length of stay, need for mechanical ventilation (MV) during their ICU stay, and mortality. Race was dichotomized into a binary variable: White (Caucasian) and People of Color (POC) (Black, Arab, Hispanic/Latinx, and Asian), although most of the POC in their study sample were Black or African Americans. In addition to standard descriptive techniques, they performed a logistic regression model to identify independent risk factors for MV, as well as a Cox proportional hazards model to estimate survival and risk of remaining in the ICU.
WHAT DID THEY FIND?
Three hundred sixty-five patients treated in the ICU were included in the study by Lazar et al (8): 64.7% were categorized as POC, and 35.3% were White. The investigators highlighted some important differences in baseline characteristics by race/ethnicity in their study sample. POC were significantly younger than Whites (63 vs 67 yr; p = 0.007), and POC reported less coronary artery disease (14% vs 27%; p = 0.003); no other significant differences in comorbidities by race/ethnicity were notable in their sample.
The authors also found no difference between the POC and White groups in number of days of symptoms prior to presentation (5 in POC, 4 in White; p = 0.14), as well as median ICU LOS (18 d in both groups; p = 0.979). The frequency of MV was similar between the two groups (approximately 72%), as was the frequency and severity of acute respiratory distress syndrome. In-hospital mortality was 47.9% in the POC group and was 58% for the White group (p = 0.061). This lack of statistical difference remained after adjusting for confounders. Finally, the authors found that 28-day mortality was actually lower in the POC group compared with the White group (45.3% vs 56.6%; p = 0.034), which also remained significant after adjusting for potential confounders.
The investigators found the following statistically significant predictors of MV: male gender, age greater than or equal to 65 years old, and having chronic kidney disease. Of note, being a POC was “not” a predictor of MV. In terms of predictors of hospital mortality, as with MV, being a POC was “not” a risk factor for in-hospital mortality, whereas the following variables were: age greater than or equal to 65 years old, chronic kidney disease, and coronary artery disease. Being a POC was actually a negative risk factor for 28-day mortality (p = 0.034).
WHAT DOES IT MEAN?
These data are from a single academic center in the United States, and the study by Lazar et al (8) extends the literature on COVID-19 and racial disparities. A key strength of this article is the fairly large number of patients they were able to analyze. In addition, their two major groups (POC and White) were actually reasonably well matched in terms of comorbidities, which may be an important mediator of racial disparities in outcomes in COVID-19. That having been said, there was no explicit discussion of body mass index or obesity in the two groups. Given that other studies have emphasized the crucial and complex relationship between obesity and COVID-19 with regard to outcomes (specifically in certain ethnic groups), we feel this is an area for further investigation (9). Regarding the analysis of socioeconomic status (SES) of the two groups, the authors leave it to a single sentence describing that “there was no difference in median income by zip code of residence.” This is an absolutely crucial element of their article, specifically because there are more detailed techniques available to document that the two groups were matched in terms of their SES other than simply the median income of the zip code, and it is critical that issues of SES be carefully and clearly delineated between the POC and White groups (10,11). One other strength was their analysis of median time to death for those patients who died during the admission. As it was found to be longer in the POC group, they hypothesized that this could be related to the documented lack of interest in a palliative approach or request to withhold or withdraw care in certain racial and ethnic groups.
WHERE DO WE GO FROM HERE?
We believe that one can reconcile the data from Lazar et al (8) with the other data from the medical literature indicating that the burden of COVID-19 disease is increased in patients from certain racial and ethnic backgrounds (11–13). This article suggests that in a cohort of critically ill adults treated for severe COVID-19 in a large urban hospital’s ICU, POC did not appear to be at higher mortality risk compared with Whites. This report (8) would support the fact that the case-fatality rate may not be different for POC than for any other people with COVID-19. Therefore, it remains an urgent and important question whether the disproportionate burden of disease of COVID-19 demonstrated in certain communities could be explained by the increased prevalence of relevant comorbidities as well as important socioeconomic factors, such as lack of access to adequate healthcare.
There are physicians whose primary role is to keep people from going over the waterfall (e.g., primary care providers), and there are others where their primary responsibility is to remove people from the water once they have gone over in an attempt to save them (e.g., intensivists). The clinicians who will facilitate a clear-cut victory in the war against COVID-19 will be the former, not the latter. Although we do not wish to diminish the importance of our chosen field, we believe that the best solutions for the COVID-19 war lie in “prevention,” rather than treatment after the disease has set in (10,14,15).
In order for preventive strategies to be successful against COVID-19, the scale of implementation will need to be much larger than what is usually discussed for solutions in the ICU. Some techniques will apply to all people, and others need to be aimed at areas with disproportionate socioeconomic needs. First, there are approaches that we are all familiar with and are already practicing (with some varying degree of success): examples of this category would include “social distancing, hand hygiene, and the aggressive wearing of masks.” Second, crushing the virus will require the rapid—but scientifically verified—implementation of vaccines. Third, since this virus seems to hit patients with certain comorbidities particularly hard (e.g., those with metabolic syndrome, obesity, diabetes, and hypertension), a critical component of the solution will be effective outreach and educational initiatives specifically designed to improve health through the ability to curb, minimize, and prevent these afflictions. Finally, the data by Lazar et al (8) fully support the notion that a lack of adequate access to healthcare is a key factor in the etiology of the disproportionate disease burden shouldered by certain ethnic and racial communities throughout the country. The patients in the study by Lazar et al (8) (by definition) had access to their hospital, and once they did, POC received appropriate, high-quality healthcare like any other group of people, as it rightly should be!
Dr. L. Ebony Boulware delivers a powerful and eloquent summary of the relevant issues in her recent article providing noteworthy insight into the nature of COVID-19 and other race-based healthcare disparities:
These … factors reflect broader social and environmental conditions that are the result of long-standing systemically racist social policies and practices that have permeated US life since the founding of the nation, leading to generations of wealth inequality, poorer safety, housing segregation, and poorer life opportunities for Black US residents compared with White US residents. In addition to their association with poor health, these policies and practices have resulted in Black US residents experiencing unemployment … persistently lower access to health-promoting environments (such as healthy grocery stores or venues for safe exercise), poorer health literacy, and poorer access to health care services than White US residents (10).
Unless and until our federal government begins to move forward with a concerted effort to make healthcare a right for all, rather than a privilege, the aforementioned healthcare inequalities and disparate outcomes will remain a scourge we will likely continue to be fighting for many years to come.
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