Analysis of Discrepancies Between Pulse Oximetry and Arterial Oxygen Saturation Measurements by Race and Ethnicity and Association With Organ Dysfunction and Mortality

• Type of Material: Article
• Authors: An-Kwok Ian Wong, Emory University; Marie Charpignon, MIT; Han Kim, Johns Hopkins University; Christopher Josef, Emory University; Anne AH de Hond, Leiden University; Jhalique J Fojas, Harvard Medical School; Azade Tabaie, Emory University; Xiaoli Liu, Beihang University; Eduardo Mireles-Cabodevila, Beihang University; Leandro Carvalho, Cleveland Clinic; Rishikesan Kamaleswaran, Emory University; RWMA Madushani, Boston Medical Cente; Lasith Adhikari, Philips Res North Amer; Andre Holder, Emory University; Ewout W Steyerberg, Leiden University; Timothy Buchman, Emory University; Mary E Lough, Stanford University; Leo Anthony Celi, Massachusetts Institute of Technology
• Language: English
• Date: 2021-11-03
• Publisher: AMER MEDICAL ASSOC
• Publication Version: Final Published Version
• Copyright Statement: 2021 Wong AKI et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1001/jamanetworkopen.2021.31674
• Title of Journal or Parent Work: JAMA NETWORK OPEN
• Volume: 4
• Issue: 11
• Start Page: e2131674
• End Page: e2131674
• Grant/Funding Information: Dr Buchman is supported by the Society of Critical Care Medicine and the Biomedical Advanced Research and Development Authority.; Dr Wong is supported by grant 2T32GM095442 from the National Institute of General Medical Sciences and the clinical and translational science award pilot informatics grant by the National Center for Advancing Translation Science under award UL1TR002378.; Dr Holder is supported by the National Institute for General Medical Sciences under award number K23GM137182 and the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR002378.; Dr Tabaie was funded by the Surgical Critical Care Initiative (SC2i), the Department of Defense’s Defense Health Program Joint Program Committee 6/Combat Casualty Care (grants USUHS HT9404-13-1-0032 and HU0001-15-2-0001).; Dr Josef is supported by grant 2T32GM095442 from the National Institute of General Medical Sciences.; Dr Kamaleswaran is supported by grant 17267 from the Michael J. Fox Foundation.; Dr Celi is funded by the National Institute of Health through grant NIBIB R01 EB017205.
• Keywords: Life Sciences & Biomedicine; ACCURACY; Science & Technology; General & Internal Medicine; Medicine, General & Internal; HYPOXIA

Abstract

Importance: Discrepancies in oxygen saturation measured by pulse oximetry (Spo2), when compared with arterial oxygen saturation (Sao2) measured by arterial blood gas (ABG), may differentially affect patients according to race and ethnicity. However, the association of these disparities with health outcomes is unknown. Objective: To examine racial and ethnic discrepancies between Sao2and Spo2measures and their associations with clinical outcomes. Design, Setting, and Participants: This multicenter, retrospective, cross-sectional study included 3 publicly available electronic health record (EHR) databases (ie, the Electronic Intensive Care Unit-Clinical Research Database and Medical Information Mart for Intensive Care III and IV) as well as Emory Healthcare (2014-2021) and Grady Memorial (2014-2020) databases, spanning 215 hospitals and 382 ICUs. From 141600 hospital encounters with recorded ABG measurements, 87971 participants with first ABG measurements and an Spo2of at least 88% within 5 minutes before the ABG test were included. Exposures: Patients with hidden hypoxemia (ie, Spo2≥88% but Sao2<88%). Main Outcomes and Measures: Outcomes, stratified by race and ethnicity, were Sao2for each Spo2, hidden hypoxemia prevalence, initial demographic characteristics (age, sex), clinical outcomes (in-hospital mortality, length of stay), organ dysfunction by scores (Sequential Organ Failure Assessment [SOFA]), and laboratory values (lactate and creatinine levels) before and 24 hours after the ABG measurement. Results: The first Spo2-Sao2pairs from 87971 patient encounters (27713 [42.9%] women; mean [SE] age, 62.2 [17.0] years; 1919 [2.3%] Asian patients; 26032 [29.6%] Black patients; 2397 [2.7%] Hispanic patients, and 57632 [65.5%] White patients) were analyzed, with 4859 (5.5%) having hidden hypoxemia. Hidden hypoxemia was observed in all subgroups with varying incidence (Black: 1785 [6.8%]; Hispanic: 160 [6.0%]; Asian: 92 [4.8%]; White: 2822 [4.9%]) and was associated with greater organ dysfunction 24 hours after the ABG measurement, as evidenced by higher mean (SE) SOFA scores (7.2 [0.1] vs 6.29 [0.02]) and higher in-hospital mortality (eg, among Black patients: 369 [21.1%] vs 3557 [15.0%]; P <.001). Furthermore, patients with hidden hypoxemia had higher mean (SE) lactate levels before (3.15 [0.09] mg/dL vs 2.66 [0.02] mg/dL) and 24 hours after (2.83 [0.14] mg/dL vs 2.27 [0.02] mg/dL) the ABG test, with less lactate clearance (-0.54 [0.12] mg/dL vs -0.79 [0.03] mg/dL). Conclusions and Relevance: In this study, there was greater variability in oxygen saturation levels for a given Spo2level in patients who self-identified as Black, followed by Hispanic, Asian, and White. Patients with and without hidden hypoxemia were demographically and clinically similar at baseline ABG measurement by SOFA scores, but those with hidden hypoxemia subsequently experienced higher organ dysfunction scores and higher in-hospital mortality..