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In this podcast, host Kyle B. Enfield, MD, FSHEA, FCCM, is joined by Samuel K. McGowan, MD, to discuss a systematic review that found significant differences in care and outcomes, including mortality rates, among intensive care unit (ICU) patients of different races (McGowan S, et al. Crit Care Med. 2022 Jan;50:1-20). Dr. McGowan is a first-year fellow in pulmonary and critical care at University of California in San Francisco, California, USA. This podcast is sponsored by Sound Physicians.
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Category: CCM Podcast
This podcast is sponsored by Sound Physicians, the employer of choice for critical care physicians, where we seek to transform acute episodes of care. At Sound Physicians, we ensure physicians have the time and resources needed to deliver compassionate care that measurably improves quality and lowers the cost of healthcare for patients in the communities we serve. For more information, please visit careers.soundphysicians.com.
Kyle B. Enfield, MD, FSHEA, FCCM: Hello and welcome to the Society of Critical Care Medicine’s iCritical Care podcast. I’m your host, Dr. Kyle Enfield. Today, I’m excited to speak with Sammy K. McGowen, MD, on the article “Racial Disparities in ICU Outcomes: A Systematic Review,” published in the January 2022 issue of Critical Care Medicine. To access the full article, visit ccmjournal.org. Dr. McGowan is a first-year fellow in pulmonary and critical care at the University of California in San Francisco. I want to start off by saying congratulations on this article. It was a lot of fun to read and I think it’s a great start to your fellowship. Welcome, Dr. McGowan. Before we start, do you have any disclosures to report?
Sammy K. McGowan, MD: Thank you so much. It’s such a pleasure being here. I do not have any disclosures.
Dr. Enfield: Systemic racism and racial disparities in critical care environments have really been highlighted with the COVID-19 pandemic. Why was this study important for you to do?
Dr. McGowan: I got interested in this as a resident and had formative experiences in the intensive care unit, as so many do during training and, pre-pandemic, thinking that there were differences in how patients were cared for based on their race. From a complete novice perspective, I went to the literature to try and learn more and was really surprised that, while racial disparities in medicine are so well described in so many different clinical care settings, whether it’s in primary care or the emergency room or on the medicine wards, there was a lot less research in the intensive care unit than I was expecting. That started me on this journey of trying to systematically look through the literature to understand what racial disparities exist specifically in the intensive care unit.
Dr. Enfield: You got to where I was going to lead, which is why did you choose to do a systematic review to start this process, given what was being reported in the news at the time when you were taking this on and also what was beginning to come out in the literature? Why a systematic review?
Dr. McGowan: I saw that there are attempts at summarizing the literature as it relates to racial disparities, both in the intensive care unit and elsewhere, but when we don’t use a systematic approach, I think that the interjection of bias is a lot stronger. Through the mentorship team that I assembled for this project, and especially talking with the librarians at my institution, there are so many benefits to using a systematic approach and being thoughtful about what question you’re answering and what the studies that come back from asking that question actually show. I started the whole project sitting down with a librarian. Just from opening up PubMed and typing in your search criteria, there’s so much that can go wrong when you look into the literature if you’re not thinking about things systematically. So, starting from that position, we were able to make sure we captured as many studies as possible and had a diligent step-by-step process to make sure we didn’t leave anything out and to make sure that we’re not prioritizing some studies that might match a bias that we had going in.
Dr. Enfield: That’s great. I think a lot of readers are going to be comfortable with the systematic review and some of the importance of that as we think about how we approach our research studies. Could you talk a little bit about the Newcastle-Ottawa Scale and why you included that in your methods section and how it influenced the interpretation of the results?
Dr. McGowan: That’s a really good question. Assessing the risk of bias within each study I think is a really incredible tool to have that enhances the validity of the results. This review is a qualitative look at multiple different studies, but if you’re not assessing the methodological quality of each paper, you might end up placing more emphasis on one study that has a certain particular finding. But if their methodologic quality isn’t as good as other studies, you might place undue influence on that study. There are multiple different scales that can be used in a systematic review. We chose the Newcastle-Ottawa Scale because there are different scales that you can use within the Newcastle-Ottawa System.
The scale that we used was specifically for cohort studies, when pretty much every study that we looked at was a retrospective cohort. There are different categories within the scale that allow you to look at each study in a systematic way and say, What kind of bias might be present in this study? Is it just a one-center study or is it multi-center? Does the cohort match the cohort that our hypothesis is hoping to answer? And it gives you a numerical score that you can then use to compare across studies and say, Is the risk of bias higher or is the risk of bias low? I can say overall the majority of our papers were pretty good and our scores were pretty high. I think that gives us a higher degree of confidence at the end, when we make certain claims about collating all of these data and trying to synthesize them, that the validity of our claims are there.
Dr. Enfield: When I first picked up your paper, I was really struck by the sheer number of tables that are in it. I think table three, which is your outcomes and conclusions, spans four pages. I think it can be a little overwhelming to the reader. You ended up including 25 studies. When you started going through theirs, were there any of them that surprised you at what they looked at and what their outcomes were?
Dr. McGowan: Yeah, I think I separated out the papers in my mind into three basic categories. One were the papers that looked specifically at mortality differences based off of race. Number two were other outcomes that weren’t mortality based. Number three were outcomes in the realm of palliative care. Going into this study, I had a sense that palliative care outcomes, where at least in my personal experience and in what I had read in the literature previously, there were differences that were described.
I wasn’t sure what to expect as it relates to mortality. I was surprised at how many articles followed a similar pathway of taking a cohort, separating out the demographics, looking at the differences between White and non-White or Black and Hispanic and White and seeing differences and then comparing those based off of confounders and then ultimately concluding that, even though in raw numbers there was a difference in mortality based off of race, after looking at all these confounders, we saw that that difference was quote-unquote explained or could be accounted for by these other demographics. That led me to try and think a little bit more critically about how we report data, especially in these multivariate logistical regression models.
Dr. Enfield: I would love to dig in with that a little bit because I was struck by that finding as well in a couple of areas. But when we think about the things that are being adjusted for there, we also know that there are determinants that are within that group that are structural in nature and not up to the individual. What did you conclude when you started looking at how studies adjusted for differences in outcomes, and how did you interpret the results after you thought about it that way?
Dr. McGowan: I think that the basic way you start out is looking at race as a demographic variable that is similar to all the other variables that are in table 1 of every study. What I found coming up again and again is that often when we try to control for zip code or socioeconomic status, a huge part of the effect of that variable is co-explained by race because race is so constitutive of every facet of life, particularly in the United States, that it’s almost impossible to disentangle somebody’s race from their zip code because of the way that our society is structured. You might actually underestimate the effect of race on that outcome if you try and separate the two and then compare them against each other. I think that, as a result, it might end up with us making claims about mortality in the ICU, for example, that don’t take into account the complexity of race and how much it can affect outcomes in different parts of the clinical process.
Dr. Enfield: One of the factors that you mentioned that was highlighted in one of the studies that you talk about in your discussion was the article by Merchant et al that looked at cardiac arrest outcomes. They reported that Black patients had the worst outcomes but that largely got explained by the hospitals that the Black patients were going to, which primarily cared for other Black patients and that White patients going to those hospitals had similar outcomes. How did you reflect on that finding in their paper, and what do you think it means for this larger context of research?
Dr. McGowan: I think that’s such a perfect example of what I’m trying to describe. It’s something that I found in a lot of different studies where you heard that Black patients had worse outcomes but it could be explained by a hospital type. It might lead you to make the conclusion that it’s not a problem of the ICU doing something wrong, it’s just a problem of the patient going to the wrong ICU. But I think what I come away from that realization is that what a large structural inequality exists if Black patients are more likely to present to ICUs that are lower quality. And what is it about those hospitals that provide that lower quality of care?
That is something that I think we need further research on and something that could drive future study because that’s still a disparity. Even though you’re explaining the mechanism, you’re not explaining the mechanism away, you’re helping us to get further at the root cause of why that disparity exists. To me that just gets at what is fascinating about looking at race and the intensive care unit in that everything that we experience in society as it relates to race doesn’t stop at the doors of the ICU. It continues on and is reflected in the care that we provide. Shining a light on that and thinking about strategies going forward, I think that just makes it all the more important.
Dr. Enfield: I can’t agree with you in any other way, but to say, yeah, I’m really struck by that. Your paper highlighted for me how we explain away certain things and in some ways fail to recognize the societal structures that have led to those outcomes. I was also really struck by two other findings in your paper. One was the discussions about palliative care in life differences in how race plays out in those discussions and the decisions that are being made. Could you highlight some of what you found?
Dr. McGowan: This was the part that I think showed the strongest associations in the literature, even with the caveats of how demographics are described. What these articles show pretty overwhelmingly is that Black and Latinx patients in the intensive care unit are more likely to prefer CPR at the end of the life, reverse the DNR status, prefer life-extending care, and some other very upsetting outcomes. There was one study that showed that families of patients who are African-American were more likely to endure economic hardship during their ICU stay. Other quality metrics like consultative palliative care, White patients were more likely to have a palliative care consultation than patients of other races.
That really builds a picture of overall palliative care outcomes being substantially worse for patients of color as opposed to White patients. To me, this shows a real area of potential growth and a place where we could really make a difference in closing this gap by focusing on how we improve these goals-of-care conversations that we’re having. Are we thinking thoughtfully about the differences in the goals-of-care conversations with our patients of color versus our White patients? What effect do we have on those conversations? To me, there’s so much more that needs to be studied in that area to fully understand that.
Dr. Enfield: Where do you think we take that conversation and that research line of thought, both in trying to understand how we’re bringing that conversation to our patients and also what information are they taking in and how are they responding to it? What are the next steps in your mind?
Dr. McGowan: The editorial that was published alongside the paper, I really encourage folks to read. Dr. Curtis and Dr. Brown wrote about a phrase that I hadn’t been acquainted with called public health critical race practice. They outline a conceptual framework for thinking about future research that I think is so important, thinking about knowledge production, how to conceptualize research questions as they relate to race. I would definitely point folks in that direction. Other things I think about are how the studies that we looked at often looked at the race of family members. They obviously looked at the race of the patient. The race of the provider was never studied. As a White person in critical care medicine, I don’t think I think enough about my race and the effect that it has on my patients. I wonder if that’s something that’s unexplored. What are we transmitting, both explicitly and implicitly in conversations in the intensive care unit and what effects does what words we use, what assumptions we make about the families of patients, and what effect is that having on the decisions that they’re making? Those are questions that I find really, really fascinating. I think there might be some troubling answers to those questions but so important in improving outcomes in the ICU.
Dr. Enfield: We’ve seen in the medical literature the differences in outcomes for women, particularly in the surgical literature and other studies, and I think it is an important lesson for those of us who are white cisgender males to think about how we approach our patient interactions when the person sitting across from the table may not identify with the same things that we identify with. I appreciate you highlighting that. There was another striking finding in your study that I wanted to highlight because I think it’s important for us to think about because there have been some other recent articles on this; that is the timing of antibiotics, particularly that Black men had slower starts of antibiotics. There’s a recent study that also looked at this same outcome, finding something very similar. That is so different than the palliative care discussion, which is really thinking in a communicated process. This is the application of timing of antibiotics. What do you think may be driving those decisions and those outcomes?
Dr. McGowan: That’s such a good question. In the papers that we looked at there were some differences across the different papers. I think we had two or three that showed that there were lower timely antibiotics administered for both pneumonia and then for all-cause, I think in sepsis, and again, at least in the literature that we looked at, a huge part of difference was quote-unquote explained by hospital type. There might be just an overall quality issue in the hospitals that Black patients are getting admitted to. There was one interesting study that did not show a difference in mortality and a study looking at guideline-directed antibiotics. That was a study that only looked at patients within the VA system. That did lead me to think about how maybe there are systematic barriers to care within certain hospital systems that need to be looked at in the future because hospital type and hospital system seem to be a huge driver of a lot of these disparities.
I have a clinic at the VA every week and I absolutely love the care that we can provide. While there sometimes can be issues with getting folks resources, it also is a very kind of fair system and a completely enclosed care model that might have some benefits and leads me to wonder if a system structured like the VA is a system that is less likely to produce inequalities in care as opposed to a more fee-for-service model. I don’t think our data necessarily show that, but it at least leads me to think about it.
Dr. Enfield: You’ve highlighted some of the challenges with the research you looked at to do this project. When we think about future studies, what do you think researchers need to be aware of as they start to try to untangle structural inequities in our healthcare system and how that influences health outcomes?
Dr. McGowan: I think that any paper that looks at race, which truly is almost any paper in research, is going to report data that have to do with race as a demographic. Going forward, we need to move beyond thinking about race just as a demographic variable that we report in our first table of our study. We need to holistically use the data that we have to make reasonable assumptions about what our data show. The other part of it is that we need to check our own biases as researchers and the assumptions that we have going in about what the data show specifically around race. I think that thoughtful approach is more labor intensive but ultimately more rewarding. There’s so much that we have yet to uncover about the effect that race has in the intensive care unit.
Dr. Enfield: Where does this take you as a fellow in pulmonary critical care? What’s next for you? What are you thinking about, having wrapped up this study?
Dr. McGowan: I’m really motivated by these palliative care questions and thinking about the goals-of-care conversations in the ICU as a subject of research. I think that how we implement goals-of-care conversations in a just way but also an effective way is something that is going to require a lot of research and something that I’m definitely passionate about as it relates to the intensive care unit or anywhere in pulmonary medicine as well.
Dr. Enfield: That’s great. Any words of advice for the third-year resident or new fellow starting a project like this that helped you get through it?
Dr. McGowan: Yeah, I encourage early trainees to think about the systematic review as a way to do robust research with limited resources. As a resident, you might not have access to grants or funding, but you do have access to labor, which is your own labor and the labor of your colleagues. I was able to work on this with two really phenomenal co-residents and some mentors. We went through over a thousand studies; it took over a year to get through all the literature, but I think we were able to do something that hadn’t been done before, in part because it took a lot of time. In residency, you don’t have a ton of time, but you do have the ability to put in the hours when maybe others can’t.
So I highly suggest the systematic review process, but so important at the beginning of starting one of those projects is having really good mentorship, working with a medical librarian and then making sure that you’re registering your review, that you’re using the PRISMA guidelines and the International Perspective Register of Systematic Reviews because if you don’t start out with the right methodology at the beginning, you don’t want to get a year into the process and realize that there were studies that were missing or that you had problems with your methodology. But overall we definitely encourage early-career researchers to think about this as a methodology for their initial study.
Dr. Enfield: That’s great advice. Is there anything that you think we should have highlighted and talked about today that you wish we had talked a little bit more about?
Dr. McGowan: I think that we talked about everything. The mortality differences were somewhat equivocal in our study, and I think we talked a little bit about that. The palliative care outcomes are really my key takeaway. And, like I said before, I’d really encourage folks to check out the editorial from Dr. Curtis and Dr. Brown. I learned a lot reading that and thinking about next steps for research.
Dr. Enfield: I want to thank you. This was an important piece to get out there, as we all begin to think about how racial disparities are influencing our outcomes and some of the biases that have existed in the studies that have come before us.
This concludes another edition of the iCritical Care podcast. For the iCritical air podcast, I’m Dr. Kyle Enfield. Thank you very much.
This podcast is sponsored by Sound Physicians, the employer of choice for critical care physicians, where we seek to transform acute episodes of care. At Sound Physicians, we ensure physicians have the time and resources needed to deliver compassionate care that measurably improves quality and lowers the cost of health care for patients in the communities we serve. For more information, please visit careers.soundphysicians.com.
Kyle B. Enfield MD, FSHEA, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia, where he also serves as associate chief medical officer for critical care. He received his undergraduate degree, master’s degree in epidemiology, and medical doctorate degree from the University of Oklahoma. Prior to his internship, residency, and fellowship at the University of Virginia, he was an intern in communicable diseases at the World Health Organization. His clinical and academic interests include highly transmissible diseases, disaster response, and emergency preparedness, and critical illness recovery.
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