Evaluating equitable care in the ICU:Creating a causal inference template to assess the impact of life-sustaining interventions across racial and ethnic groups

Abstract

Background

Variability in the provision of intensive care unit (ICU)-interventions may lead to disparities between socially defined racial-ethnic groups.

Objectives

We aimed to study the use of invasive mechanical ventilation (IMV), renal replacement therapy (RRT), and vasopressor agents (VP) to identify disparities in outcomes across race-ethnicity in patients with sepsis.

Methods

Retrospective analysis of treatment effect with a target trial design with treatment assignment within the first 24 h in MIMIC-IV (2008–2019) using targeted maximum likelihood estimation. Of 76,943 ICU stays in MIMIC-IV, 32,971 adult stays fulfilled sepsis-3 criteria. Primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days, and occurrence of nosocomial infection stratified by predicted mortality probability and self-reported race-ethnicity. Average treatment effects by treatment type and race-ethnicity, Racial-ethnic group (REG) or White group (WG), were estimated.

Results

Of 19,419 admissions that met inclusion criteria, median age was 68 years, 57.4 % were women, 82 % were White, and mortality was 18.2 %. There was no difference in mortality benefit associated with the administration of IMV, RRT, or VP between the REG and the WG. There was also no difference in hospital-free days or nosocomial infections. These findings are unchanged with different eligibility periods.

Conclusion

There were no differences in the treatment outcomes from three life-sustaining interventions in the ICU according to race-ethnicity. While there was no discernable harm from the treatments across mortality risk, on average there was also no measurable benefit. These findings highlight the need for research to better understand the risk-benefit ratio of interventions in the ICU.