Minorities Disproportionately Cared for in ICU

John Danziger, MD

African American patients in the intensive care unit (ICU) are disproportionately cared for in minority-serving hospitals.

Although non-minority hospitals have seen steady declines in death rates over the last decade, minority hospitals have seen significantly less improvement. The findings of a recent study highlighted the disparities facing minorities and minority-serving hospitals in the US and emphasized the need for additional support and appropriate resources to meet their clinical demand.

Lead author John Danziger, MD, a physician at Beth Israel Deaconess Medical Center in Boston, and a team of investigators analyzed nearly 1.1 million patients hospitalized at more than 200 hospitals. Danziger and colleagues used the Philips Health Care electronic ICU Research Institute Database—which contained data from participating hospitals that used Philips Health Care’s telehealth ICU platform—to identify minority-serving hospitals with an African American or Hispanic ICU census more than twice its regional mean.

The investigators found that over a decade, ICU deaths at non-minority hospitals saw a steady decline of about 2% each year, and no decline after the first few years at minority hospitals.

The primary outcome was death during critical illness hospitalization, while secondary outcomes included length of ICU and hospital stay.

Among the almost 1.1 million critically ill patients, 10% were cared for in 1 of 14 minority-serving hospitals. In those hospitals, there was a significant ethnic variation, with 25% of African Americans and 48% of Hispanic patients receiving care there. Only 5.2% of white patients received critical care in such hospitals.

Patients who received care in a minority-serving hospital tended to be younger with a lower comorbidity burden and higher level of illness severity on ICU presentation. The minority-serving hospitals had higher ICU admissions for trauma, myocardial infarction, and heart failure, and a lower rate for sepsis and drug and alcohol complications.

Morality was higher in minority than non-minority hospitals (10.5% vs 9.5%, P <.001) across ethnic groups. In non-minority hospitals, there was a steady decline in critical illness mortality between 2006—2016 (HR, .98; 95% CI, .97–.98; P <.001), which was not seen in minority hospitals.

Inequality was seen most among African American patients, where each year was associated with 3% lower mortality (HR, .97; 95% CI, .96—.97) in non-minority hospitals, compared to no change in minority hospitals (HR, .99; 95% CI, .97–1.01). P values were .002, .007, and .004 among African American, Hispanic, and white patients, respectively.

Danziger and the team used a threshold of >25% African American or Hispanic ICU census to define a minority hospital. Patients in 1 of the 26 minority-serving hospitals, which served 177,186 patients, had higher mortality rates and less temporal improvement. Length of ICU stay and critical illness hospitalization were also higher in minority hospitals compared to non-minority (3.1±3.9 and 7.3±6.9 days vs 2.9±3.6 and 6.4±6.2 days).

The difference existed during an analysis that included mortality [.03 (95% CI, .02—.04; P <.001) and .21 (95% CI, .2—.23; P <.001) longer ICU days and hospital stays in minority hospitals.] Lengths of stay steadily decreased in non-minority hospitals [-.08 (95% CI, -.08 to -.07; P <.001) and -.16 (95% CI, -16 to -.15; P <.001) days per additional calendar year].

Patients in minority hospitals also tended to wait longer to be admitted to the ICU than those in non-minority hospitals.

It is unclear whether the disparity in care for minorities, especially African Americans, was due to an increasingly disadvantaged population or differences in the way hospitals used their resources, investigators noted. The data highlights the need for additional support for minority hospitals.

The study, “Temporal trends in critical care outcomes in United States minority serving hospitals,” was published online in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.