Evaluating equitable care in the ICU: Creating a causal inference framework to assess the impact of life-sustaining interventions across racial and ethnic groups

BackgroundVariability in the provision of intensive care unit (ICU)-interventions may lead to disparities between socially defined racial-ethnic groups. Research QuestionWe used causal inference to examine the use of invasive mechanical ventilation (IMV), renal replacement therapy (RRT), and vasopressor agents (VP) to identify disparities in outcomes across race-ethnicity in patients with sepsis. Study Design and MethodsSingle-center, academic referral hospital in Boston, Massachusetts, USA. Retrospective analysis of treatment effect with a targeted trial design categorized by treatment assignment within the first 24 hours in the MIMIC-IV dataset (2008- 2019) using targeted maximum likelihood estimation. Of 76,943 ICU stays in MIMIC-IV, 32,971 adult stays fulfilling sepsis-3 criteria were included. The primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days, and occurrence of nosocomial infection stratified by predicted mortality probability ranges and self-reported race-ethnicity. Average treatment effects by treatment type and race-ethnicity, Racial-ethnic group (REG) or White group (WG), were estimated. ResultsOf 19,419 admissions that met inclusion criteria, median age was 68 years, 57.4% were women, 82% were White, and mortality was 18.2%. There was no difference in mortality benefit associated with the administration of IMV, RRT, or VP between the REG and the WG. There was also no difference in hospital-free days or nosocomial infections. These findings are unchanged with different eligibility periods. InterpretationThere were no differences in the treatment outcomes from three life-sustaining interventions in the ICU according to race-ethnicity. While there was no discernable harm from the treatments across mortality risk, there was also no measurable benefit. These findings highlight the need for research to understand better the risk-benefit of life-sustaining interventions in the ICU.