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Original Investigation
July 11, 2022

Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit

Author Affiliations
  • 1Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge
  • 4Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
  • 5Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 6Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 7Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2022;182(8):849-858. doi:10.1001/jamainternmed.2022.2587
Key Points

Question  Are there differences in supplemental oxygen administration among patients of different races and ethnicities associated with pulse oximeter performance discrepancies?

Findings  In this cohort study of 3069 patients in the intensive care unit, Asian, Black, and Hispanic patients had a higher adjusted time-weighted average pulse oximetry reading and were administered significantly less supplemental oxygen for a given average hemoglobin oxygen saturation compared with White patients.

Meaning  There were differences in supplemental oxygen administration between Asian, Black, and Hispanic patients and White patients that were associated with pulse oximeter performance and may contribute to racial and ethnic disparities in care.


Importance  Pulse oximetry (SpO2) is routinely used for transcutaneous monitoring of blood oxygenation, but it can overestimate actual oxygenation. This is more common in patients of racial and ethnic minority groups. The extent to which these discrepancies are associated with variations in treatment is not known.

Objective  To determine if there are racial and ethnic disparities in supplemental oxygen administration associated with inconsistent pulse oximeter performance.

Design, Setting, and Participants  This retrospective cohort study was based on the Medical Information Mart for Intensive Care (MIMIC)-IV critical care data set. Included patients were documented with a race and ethnicity as Asian, Black, Hispanic, or White and were admitted to the intensive care unit (ICU) for at least 12 hours before needing advanced respiratory support, if any. Oxygenation levels and nasal cannula flow rates for up to 5 days from ICU admission or until the time of intubation, noninvasive positive pressure ventilation, high-flow nasal cannula, or tracheostomy were analyzed.

Main Outcomes and Measures  The primary outcome was time-weighted average supplemental oxygen rate. Covariates included race and ethnicity, sex, SpO2–hemoglobin oxygen saturation discrepancy, data duration, number and timing of blood gas tests on ICU days 1 to 3, partial pressure of carbon dioxide, hemoglobin level, average respiratory rate, Elixhauser comorbidity scores, and need for vasopressors or inotropes.

Results  This cohort included 3069 patients (mean [SD] age, 66.9 [13.5] years; 83 were Asian, 207 were Black, 112 were Hispanic, 2667 were White). In a multivariable linear regression, Asian (coefficient, 0.602; 95% CI, 0.263 to 0.941; P = .001), Black (coefficient, 0.919; 95% CI, 0.698 to 1.140; P < .001), and Hispanic (coefficient, 0.622; 95% CI, 0.329 to 0.915; P < .001) race and ethnicity were all associated with a higher SpO2 for a given hemoglobin oxygen saturation. Asian (coefficient, −0.291; 95% CI, −0.546 to −0.035; P = .03), Black (coefficient, −0.294; 95% CI, −0.460 to −0.128; P = .001), and Hispanic (coefficient, −0.242; 95% CI, −0.463 to −0.020; P = .03) race and ethnicity were associated with lower average oxygen delivery rates. When controlling for the discrepancy between average SpO2 and average hemoglobin oxygen saturation, race and ethnicity were not associated with oxygen delivery rate. This discrepancy mediated the effect of race and ethnicity (−0.157; 95% CI, −0.250 to −0.057; P = .002).

Conclusions and Relevance  In this cohort study, Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, and this was associated with differences in pulse oximeter performance, which may contribute to known race and ethnicity–based disparities in care.

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