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Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care.

Publication ,  Journal Article
Miller, WD; Han, X; Peek, ME; Charan Ashana, D; Parker, WF
Published in: JAMA Netw Open
June 1, 2021

IMPORTANCE: Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality. OBJECTIVE: To investigate whether reliance on SOFA is associated with bias against Black patients in CSC. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021. EXPOSURE: SOFA scores at ICU admission. MAIN OUTCOMES AND MEASURES: Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion). RESULTS: Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions. CONCLUSIONS AND RELEVANCE: This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.

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Published In

JAMA Netw Open

DOI

EISSN

2574-3805

Publication Date

June 1, 2021

Volume

4

Issue

6

Start / End Page

e2113891

Location

United States

Related Subject Headings

  • Standard of Care
  • Racial Groups
  • Prognosis
  • Organ Dysfunction Scores
  • Middle Aged
  • Male
  • Logistic Models
  • Humans
  • Hospital Mortality
  • Female
 

Citation

APA
Chicago
ICMJE
MLA
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Miller, W. D., Han, X., Peek, M. E., Charan Ashana, D., & Parker, W. F. (2021). Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open, 4(6), e2113891. https://doi.org/10.1001/jamanetworkopen.2021.13891
Miller, William Dwight, Xuan Han, Monica E. Peek, Deepshikha Charan Ashana, and William F. Parker. “Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care.JAMA Netw Open 4, no. 6 (June 1, 2021): e2113891. https://doi.org/10.1001/jamanetworkopen.2021.13891.
Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open. 2021 Jun 1;4(6):e2113891.
Miller, William Dwight, et al. “Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care.JAMA Netw Open, vol. 4, no. 6, June 2021, p. e2113891. Pubmed, doi:10.1001/jamanetworkopen.2021.13891.
Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open. 2021 Jun 1;4(6):e2113891.

Published In

JAMA Netw Open

DOI

EISSN

2574-3805

Publication Date

June 1, 2021

Volume

4

Issue

6

Start / End Page

e2113891

Location

United States

Related Subject Headings

  • Standard of Care
  • Racial Groups
  • Prognosis
  • Organ Dysfunction Scores
  • Middle Aged
  • Male
  • Logistic Models
  • Humans
  • Hospital Mortality
  • Female