Race, Class, and Place Modify Mortality Rates for the Leading Causes of Death in the United States, 1999-2021.

BACKGROUND: Race and ethnicity, socioeconomic class, and geographic location are well-known social determinants of health in the US. Studies of population mortality often consider two, but not all three of these risk factors. OBJECTIVES: To disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US. DESIGN: We conducted a retrospective analysis of death certificate data. Bayesian regression models, adjusted for age and race/ethnicity from the American Community Survey and the county Area Deprivation Index, were used for inference. MAIN MEASURES: County-level mortality for 11 leading causes of death (1999-2019) and COVID-19 (2020-2021). KEY RESULTS: County "whiteness" and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5-8% increase in death from three causes and 4-15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Patterns of residual risk, measured by spatial county effects, varied by cause of death; for example: cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths. CONCLUSIONS: There are important independent contributions from race, class, and geography to risk of death in the US.

Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19.

Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao2 to the Fio2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo2 to the Fio2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven. OBJECTIVES: Measure overt and occult hypoxemia using ePFR. DESIGN SETTING AND PARTICIPANTS: We retrospectively studied COVID-19 hospital encounters (n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University). MAIN OUTCOMES AND MEASURES: We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test. RESULTS: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p < 0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA]; 0.65 [Emory]) and similar to S/F ratio (0.76 [UVA]; 0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory]; p < 0.01). CONCLUSIONS AND RELEVANCE: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.

Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19

IMPORTANCE: Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao2 to the Fio2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo2 to the Fio2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven. OBJECTIVES: Measure overt and occult hypoxemia using ePFR. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively studied COVID-19 hospital encounters (n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University). MAIN OUTCOMES AND MEASURES: We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test. RESULTS: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA];1.7 [Emory];p < 0.01) with better discrimination (AUROC: 0.76 [UVA];0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA];0.65 [Emory]) and similar to S/F ratio (0.76 [UVA];0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites];p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA];1.2 [Emory];p < 0.01). CONCLUSIONS AND RELEVANCE: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.

Coronavirus Disease 2019 Calls for Predictive Analytics Monitoring-A New Kind of Illness Scoring System.

Coronavirus disease 2019 can lead to sudden and severe respiratory failure that mandates endotracheal intubation, a procedure much more safely performed under elective rather than emergency conditions. Early warning of rising risk of this event could benefit both patients and healthcare providers by reducing the high risk of emergency intubation. Current illness severity scoring systems, which usually update only when clinicians measure vital signs or laboratory values, are poorly suited for early detection of this kind of rapid clinical deterioration. We propose that continuous predictive analytics monitoring, a new approach to bedside management, is more useful. The principles of this new practice anchor in analysis of continuous bedside monitoring data, training models on diagnosis-specific paths of deterioration using clinician-identified events, and continuous display of trends in risks rather than alerts when arbitrary thresholds are exceeded.