By Elaine Chen, MD
Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago
This special feature begins with a representative intensive care unit (ICU) patient. This patient has chronic obstructive pulmonary disease (COPD) and lung cancer, the latter of which was diagnosed several months ago. The patient is admitted to the ICU with pneumonia, sepsis, and acute hypoxemic respiratory failure requiring high-flow oxygen.
Now, let us consider two different demographic profiles for this patient. The first is a 90-year-old white female who is a former smoker who quit 30 years ago. She worked many years in an accounting office and retired at age 65 years. She is widowed; her husband also was an accountant and died 10 years ago. She lives in a retirement community and is frequently visited by her children and grandchildren.
In contrast, the second is a 50-year-old Black male who was actively smoking until he presented to the emergency department. He had been working in construction but had to stop last year because he was too short of breath. His wife is working two jobs to try to make ends meet. His daughter and her three children live in the home together with him, and he has three other adult children who live nearby.
I present these scenarios as common social situations that I see juxtaposed in my own ICU, but also as representative of communities and entire hospitals comprised of more homogeneous populations. Our hospital is located on the near west side of Chicago, on the cusp of the transition between wealth and poverty.1 In our ICU, these patients might be in adjacent rooms. In other hospitals, the entire ICU might be filled with patients of similar socioeconomic backgrounds.
In our city, across the nation, and around the world, disparities abound in healthcare. The U.S. Centers for Disease Control and Prevention (CDC) defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.2 The differences in opportunity are due to societal inequity, unfairness, or injustice. In the United States, race often is considered a primary issue when considering social determinants of health, disparity, and inequity. Structural inequities have faced the Black/African American community for centuries, manifesting in policies, social issues, and overt and occult racism. Race is studied less often in other regions of the world. Race is a social construct, particularly in the United States, and serves as a marker for social class and a proxy for socioeconomic status, along with cultural and environmental factors. Gender, education, and income also are significant sources of disparity.
In Chicago, this results in a substantial life expectancy gap. A 2019 report from New York University (NYU) reported the nation’s largest mortality gap of 30.1 years between neighborhoods in Chicago.3 This is reflected by a life expectancy of approximately 90 years in Streeterville compared to a life expectancy of approximately 60 years in Englewood.4 Streeterville is a neighborhood in downtown Chicago filled with high-rises, is predominantly white, and has a median household income of approximately $126,000. Englewood is a predominantly Black neighborhood on the south side of Chicago, with a poverty rate of more than 40% and a median household income of $30,000.5 Another report about Chicago reported a life expectancy of 80.6 years for white individuals and 71.5 years for Black individuals, regardless of neighborhood. The gap was larger for men (10.5 years) than women (8.2 years), which was attributed to rates of homicide and heart disease for men, and cancer and heart disease for women.6
This “death gap” is not unique to Chicago. The NYU report also detailed a life expectancy gap of 27.5 years in Washington, DC; 27.4 years in New York City; and 25.8 years in New Orleans and Buffalo, NY.3 Life expectancy gaps vary among nations around the world. Japan, for example, has one of the highest life expectancies in the world at 84 years and the narrowest mortality gap, whereas Europe and Australia have wider gaps.7,8 Strikingly, the gaps within the cities in the United States mirror the gaps between developed and developing nations elsewhere in the world.9
Disparities and inequity are everywhere, including in the ICU. This article will review some of the disparities that are present in the ICU, provide a reflection on possible root causes, and identify ideas to combat these inequities.
PREVALENCE AND PRESENTATION
In 2013, Soto et al published a review summarizing healthcare disparities in the ICU in the United States.10 They concluded that the disparities are multifactorial, resulting from individual, community, and hospital-level factors. They note that literature in this arena tends to be descriptive, with few interventional studies. Regarding prevalence of disease, males were found to have a greater prevalence of sepsis and acute hypoxic respiratory failure. African Americans and other non-whites were found to have a greater prevalence of sepsis compared with white patients. African Americans were found to have a greater prevalence of cardiac arrest, acute lung injury, acute hypoxic respiratory failure, and venous thromboembolic disease compared with other races. The authors concluded that genetics were insufficient to explain the differences, but that an increase in chronic comorbid conditions increased susceptibility to these acute illnesses. Socioeconomic status, insurance coverage, access to preventive health and primary care, poverty, low levels of education, unmeasurable structural racism, and environmental toxins all were studied as contributors.
In terms of clinical presentation, African American men with sepsis were younger and more likely to require ICU care. Men presented more frequently with pulmonary infection compared to women with genitourinary infection. African Americans were more likely to have gram-positive infections, which tend to be less responsive to antibacterials, and thus end up with more organ failure. Contributors include lack of pneumococcal vaccination leading to an increase in gram-positive infections (reflecting a lack of access to preventive and primary care), alcohol use, chronic kidney disease, and uncontrolled diabetes.
ICU MANAGEMENT
Regarding ICU management, studies have shown that non-whites and African Americans were less likely to be admitted to an ICU or a cardiac care unit, and less likely to receive dialysis, tracheostomy, and central venous catheterization, among other critical care procedures. Non-whites were less likely than whites to be discharged to another facility or a long-term acute care hospital. While treatment bias is a concern in these situations, prevalence of disease, clinical need, personal preference, age of patients, and insurance access all are potential contributors that need further granular investigation. Safety net hospitals located in poorer areas with a less favorable payer mix tend to have substantially more financial constraints and less ability to focus on quality improvement initiatives.10
In 2010, Mayr et al reported a prospective cohort study on community-acquired pneumonia and sepsis.11 The study was undertaken because of reported lower quality of care for Black patients compared with white patients with pneumonia. It is well-known that faster time to antibiotic administration improves outcomes in pneumonia and sepsis. The authors found that Black patients were less likely than white patients to receive their antibiotics within the four-hour recommended window and less likely to receive guideline-concordant antibiotics. However, a notable finding was that within the same hospital, there were no differences. The differences were between hospitals, with Black-predominant hospitals struggling more. Thus, this racial disparity was more prominent at the hospital level, and policies should be directed to these hospitals to improve access and opportunities.
A systematic review published in 2010 by the American Thoracic Society showed that lack of health insurance was associated with receiving fewer critical care services and resulted in worse clinical outcomes.12 The publication of this article coincided with the passing of the Affordable Care Act, which has improved upstream access to care for many Americans.13 Overall, disparities in ICU management appear to be at the hospital level and above (e.g., neighborhood and regional), rather than at the individual clinician level, although as bedside clinicians, we should continue to do our best to offer the most appropriate evidence-based practices to all of our patients.
ICU OUTCOMES
Disparities in critical care outcomes have been conflicting because of study design methodologies, population differences, and case mix. Almost all studies relating to health disparity and critical care outcomes are cohort studies, which limit generalizability.
Outside the United States, Mullany et al studied short-term ICU mortality as it related to the average socioeconomic status of patients in Australia and New Zealand.14 Notably, Australia and New Zealand have universal healthcare, and insurance status does not factor into healthcare access. Furthermore, race is not routinely collected by government census or for research purposes in Australia and New Zealand. This study used de-identified data from a large multinational critical care database. Patients were divided into deciles of relative socioeconomic advantage or disadvantage based on postal code, and mortality was compared. The authors found higher hospital mortality for those in the most disadvantaged socioeconomic deciles compared to the most advantaged socioeconomic deciles. However, they also noted that the most advantaged patients were more frequently admitted to the ICU following elective surgery. After all elective surgery admissions were excluded, there was no difference in hospital mortality between the most disadvantaged and most advantaged groups.
In the United States, Soto et al found that African American males have a higher mortality from sepsis.10 African Americans also were shown to have higher mortality with venous thromboembolism and less successful survival following cardiopulmonary resuscitation. However, there does not appear to be a disparity in case fatality, suggesting that the contributors to these disparities are upstream due to prevalence of chronic disease, access to care, and chronic outpatient care. Additionally, issues such as census undercount of minorities leading to an incorrectly low denominator could contribute to an incorrectly increased mortality rate.10
In contrast, Lusk et al published a retrospective cohort study using Medicare claims data from 2017 to 2019 that showed neighborhood socioeconomic deprivation, as measured by the validated Area Deprivation Index, was strongly associated with higher 30-day mortality for critically ill patients after adjustment for demographics, comorbidities, individual poverty level, and hospital characteristics.15 They did not find an association with 30-day hospital readmission rates. They noted that their data contrasts with a French study that found no association between socioeconomic deprivation and three-month mortality following ICU admission.
Jones et al published a systematic review in 2019 that assessed socioeconomic position (SEP) and health outcomes following critical illness.16 While this review was completed by authors in the United Kingdom, it included 10 studies from Australia, Europe, and the United Kingdom, as well as North America. They defined SEP to include socioeconomic status or deprivation, and the review evaluated issues including survival, health-related quality of life, insurance status, alcohol-related admissions, racial disparities, and acute illness severity. In summary, the majority of studies showed increased mortality (whether ICU, in-hospital, 30-day, or long-term) with lower SEP. The authors concluded that a lower pre-admission SEP is associated with higher mortality across the critical care continuum and that a social gradient exists leading to a gradual accumulation of behavioral, environmental, and psychosocial risk factors. One study reported an association between lower SEP and worse mental health outcomes at six months that did not persist to 12 months, noting that multiple factors may make these populations more vulnerable in the immediate post-acute and early recovery phase.17
A systematic review published in 2022 by McGowan et al (which I co-authored) focused on racial disparities in ICU outcomes.18 We found that while non-white (primarily Black and Hispanic) patients had higher crude mortality than white patients, these differences did not persist after adjusting for confounders such as age, socioeconomic status, severity of illness at admission, and hospital type. However, palliative care outcomes were noted to be significantly different among racial groups. Black patients were less likely to have engaged in advance care planning prior to admission, and were noted to prefer life-extending care and increased intensity of care, even if it led to familial economic hardship. Non-white patients were less likely to undergo withdrawal of life-sustaining therapies. Overall, racial minorities are more likely to receive higher intensity of care at the end of life, a difference that is only partially explained by socioeconomic status. This mirrors findings by Soto et al that Black patients have a preference for more “aggressive” care.10
Regarding post-ICU outcomes and survivorship, Howard et al reviewed associations between socioeconomic position and critical illness survivor outcomes, often showing poorer outcomes in less affluent populations.19 The severity of post-intensive care syndrome may be worse, caregiver burden may be more intense, and financial sequelae may be more debilitating. This editorial emphasizes the importance of critical care survivorship research, as well as dedicating resources and policies to reduce survivorship disparities and help tackle systemic and structural oppression.
CONCLUSION
Healthcare disparities are present in the ICU and exist across the spectrum of healthcare because of multiple systemic inequities. These inequities may present differently in various nations based on the different population makeups of each country. Racial differences are studied more in the United States than elsewhere and serve as a surrogate marker for SEP or deprivation. Since the ICU does not exist in a vacuum, these disparities are reflected in ICU patient presentations and outcomes. As individual clinicians, we must try to provide the most equitable care while being mindful of our potential unconscious biases. However, multiple systemic and structural factors affect outcomes in the ICU, and as a society, we should work on targeting those inequities to narrow the life expectancy gap. Education, social support, and insurance access must be addressed. Primary care, such as improving vaccination rates, diabetes, and blood pressure control, can improve comorbidities that affect ICU presentation. Nutritional options and choices can help with obesity and diabetes control. Alcohol and tobacco use also contribute to disparities. Additionally, improving communication and trust between the healthcare institution and communities with different cultural communication styles is important for advancing trust, health literacy, and advance care planning. In summary, structural inequities that exist prior to the ICU are primarily responsible for the disparities in outcomes seen in the ICU.
REFERENCES
- Ansell DA. The Death Gap: How Inequality Kills. The University of Chicago Press; 2017.
- Centers for Disease Control and Prevention. Health disparities. Last reviewed May 26, 2023. https://www.cdc.gov/healthyyouth/disparities/index.htm
- NYU Langone Health. Large life expectancy gaps in U.S. cities linked to racial & ethnic segregation by neighborhood. NYU Langone News. June 5, 2019. https://nyulangone.org/news/large-life-expectancy-gaps-us-cities-linked-racial-ethnic-segregation-neighborhood
- Goudie C, Markoff B, Fagg J. The challenge to cut Chicago’s 30-year life expectancy gap in half by 2030. ABC7 Chicago. Nov. 20, 2019. https://abc7chicago.com/life-expectancy-average-us-in/5710399/
- U.S. Census Bureau. QuickFacts: Chicago city, Illinois. https://www.census.gov/quickfacts/chicagocityillinois
- Bishop-Royse J, Saiyed NS, Schober DJ, et al. Cause-specific mortality and racial differentials in life expectancy, Chicago 2018-2019. J Racial and Ethnic Health Disparities 2024;11:846-852.
- World Health Organization. Japan data. http://data.who.int/countries/392
- Tanaka H, Nusselder WJ, Bopp M, et al. Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: A national register-based study, 1990-2015. J Epidemiol Community Health 2019;73:750-758.
- World Health Organization. Life expectancy at birth (years). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/life-expectancy-at-birth-(years)
- Soto GJ, Martin GS, Gong MN. Healthcare disparities in critical illness. Crit Care Med 2013;41:2784.
- Mayr FB, Yende S, D’Angelo G, et al. Do hospitals provide lower quality of care to Black patients for pneumonia? Crit Care Med 2010;38:759.
- Fowler RA, Noyahr LA, Thornton JD, et al. An official American Thoracic Society systematic review: The association between health insurance status and access, care delivery, and outcomes for patients who are critically ill. Am J Respir Crit Care Med 2010;181:1003-1011.
- U.S. Department of Health and Human Services. Fact Sheet: Celebrating the Affordable Care Act. Published March 18, 2022. https://www.hhs.gov/about/news/2022/03/18/fact-sheet-celebrating-affordable-care-act.html
- Mullany DV, Pilcher DV, Dobson AJ. Associations between socioeconomic status, patient risk, and short-term intensive care outcomes. Crit Care Med 2021;49:e849.
- Lusk JB, Blass B, Mahoney H, et al. Neighborhood socioeconomic deprivation, healthcare access, and 30-day mortality and readmission after sepsis or critical illness: Findings from a nationwide study. Crit Care 2023;27:287.
- Jones JRA, Berney S, Connolly B, et al. Socioeconomic position and health outcomes following critical illness: A systematic review. Crit Care Med 2019;47:e512.
- Griffith DM, Salisbury LG, Lee RJ, et al. Determinants of health-related quality of life after ICU: Importance of patient demographics, previous comorbidity, and severity of illness. Crit Care Med 2018;46:594.
- McGowan SK, Sarigiannis KA, Fox SC, et al. Racial disparities in ICU outcomes: A systematic review. Crit Care Med 2022;50:1-20.
- Howard AF, Li H, Lynch K, Haljan G. Health equity: A priority for critical illness survivorship research. Crit Care Explor 2022;4:e0783.
Disparities and inequity are everywhere, including in the ICU. This article will review some of the disparities that are present in the ICU, provide a reflection on possible root causes, and identify ideas to combat these inequities.
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