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. 2022 Jul 1;182(7):730-738.
doi: 10.1001/jamainternmed.2022.1906.

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

Ashraf Fawzy  1 , Tianshi David Wu  2   3 , Kunbo Wang  4 , Matthew L Robinson  5 , Jad Farha  6 , Amanda Bradke  7 , Sherita H Golden  8 , Yanxun Xu  4 , Brian T Garibaldi  1
Affiliations

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19

Ashraf Fawzy et al. JAMA Intern Med. .

Erratum in

  • Error in Figure 3.
    [No authors listed] [No authors listed] JAMA Intern Med. 2022 Oct 1;182(10):1108. doi: 10.1001/jamainternmed.2022.3817. JAMA Intern Med. 2022. PMID: 35994278 Free PMC article. No abstract available.

Abstract

Importance: Pulse oximetry guides triage and therapy decisions for COVID-19. Whether reported racial inaccuracies in oxygen saturation measured by pulse oximetry are present in patients with COVID-19 and associated with treatment decisions is unknown.

Objective: To determine whether there is differential inaccuracy of pulse oximetry by race or ethnicity among patients with COVID-19 and estimate the association of such inaccuracies with time to recognition of eligibility for oxygen threshold-specific COVID-19 therapies.

Design, setting, and participants: This retrospective cohort study of clinical data from 5 referral centers and community hospitals in the Johns Hopkins Health System included patients with COVID-19 who self-identified as Asian, Black, Hispanic, or White.

Exposures: Concurrent measurements (within 10 minutes) of oxygen saturation levels in arterial blood (SaO2) and by pulse oximetry (SpO2).

Main outcomes and measures: For patients with concurrent SpO2 and SaO2 measurements, the proportion with occult hypoxemia (SaO2<88% with concurrent SpO2 of 92%-96%) was compared by race and ethnicity, and a covariate-adjusted linear mixed-effects model was produced to estimate the association of race and ethnicity with SpO2 and SaO2 difference. This model was applied to identify a separate sample of patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation. Cox proportional hazards models were used to estimate differences by race and ethnicity in time to recognition of eligibility for guideline-recommended COVID-19 therapies, defined as an SpO2 level of 94% or less or oxygen treatment initiation. The median delay among individuals who ultimately had recognition of eligibility was then compared.

Results: Of 7126 patients with COVID-19, 1216 patients (63 Asian [5.2%], 478 Black [39.3%], 215 Hispanic [17.7%], and 460 White [37.8%] individuals; 507 women [41.7%]) had 32 282 concurrently measured SpO2 and SaO2. Occult hypoxemia occurred in 19 Asian (30.2%), 136 Black (28.5%), and 64 non-Black Hispanic (29.8%) patients compared with 79 White patients (17.2%). Compared with White patients, SpO2 overestimated SaO2 by an average of 1.7% among Asian (95% CI, 0.5%-3.0%), 1.2% among Black (95% CI, 0.6%-1.9%), and 1.1% among non-Black Hispanic patients (95% CI, 0.3%-1.9%). Separately, among 1903 patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation, compared with White patients, Black patients had a 29% lower hazard (hazard ratio, 0.71; 95% CI, 0.63-0.80), and non-Black Hispanic patients had a 23% lower hazard (hazard ratio, 0.77; 95% CI, 0.66-0.89) of treatment eligibility recognition. A total of 451 patients (23.7%) never had their treatment eligibility recognized, most of whom (247 [54.8%]) were Black. Among the remaining 1452 (76.3%) who had eventual recognition of treatment eligibility, Black patients had a median delay of 1.0 hour (95% CI, 0.23-1.9 hours; P = .01) longer than White patients. There was no significant median difference in delay between individuals of other racial and ethnic minority groups and White patients.

Conclusions and relevance: The results of this cohort study suggest that racial and ethnic biases in pulse oximetry accuracy were associated with greater occult hypoxemia in Asian, Black, and non-Black Hispanic patients with COVID-19, which was associated with significantly delayed or unrecognized eligibility for COVID-19 therapies among Black and Hispanic patients. This disparity may contribute to worse outcomes among Black and Hispanic patients with COVID-19.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Robinson reported grants from Fisher Center Discovery Program, Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, and Johns Hopkins University during the conduct of the study as well as grants from Rapid Acceleration of Diagnostics of the National Institutes of Health (NIH), Critical Path Institute, and US Food and Drug Administration (FDA) outside the submitted work. Dr Golden reported advisory board service for Abbott and Medtronic outside the submitted work. Dr Garibaldi reported personal fees from the FDA, Janssen, Gilead Sciences Inc, and Atea Pharmaceuticals during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flow Diagram Detailing Patients Included in the Pulse Oximetry Inaccuracy Analysis and Analysis of Unrecognized or Delayed Treatment Eligibility
JHHS indicates Johns Hopkins Health System; SaO2, oxygen saturation levels in arterial blood; SpO2, pulsatile flow of arterial blood.
Figure 2.
Figure 2.. Difference Between Arterial Blood Oxygen Saturation and Noninvasive Oxygen Saturation Levels
Median, IQR, and range of difference between arterial blood oxygen saturation levels (SaO2) and noninvasive oxygen saturation levels measured by pulse oximetry (SpO2) by SpO2 level among 950 patients (15 984 measurements) with an SpO2 between 88% and 96%.
Figure 3.
Figure 3.. Relative Mean Differences With 95% CIs of SaO2-SpO2 for Patients of Racial and Ethnic Minority Groups Based on the Adjusted Parsimonious Linear Mixed-Effects Model
Figure 4.
Figure 4.. Cumulative Incidence of Treatment Eligibility Recognition Based on Pulse Oximetry (SpO2) of 94% or Less or Oxygen Treatment Initiation Since Predicted Arterial Oxygen Saturation (SaO2) of 94% or Less Among Patients Diagnosed With COVID-19
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Comment in

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