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Cited by 268Non-Invasive Vital Sign MonitoringHemodynamic Monitoring and TherapySepsis Diagnosis and Treatment

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

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Wong, An-Kwok Ian, Charpignon, Marie, Kim, Han, Josef, Christopher, de Hond, Anne A. H., Fojas, Jhalique Jane, Tabaie, Azade, Liu, Xiaoli, Mireles-Cabodevila, Eduardo, Carvalho, Leandro, Kamaleswaran, Rishikesan, Madushani, R. W. M. A., Adhikari, Lasith, Holder, Andre L., Steyerberg, Ewout W., Buchman, Timothy G., Lough, Mary E., Celi, Leo Anthony·2021·JAMA Network Open
DOI 10.1001/jamanetworkopen.2021.31674PMC PMC9178439
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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 Sao2 and Spo2 measures 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 141 600 hospital encounters with recorded ABG measurements, 87 971 participants with first ABG measurements and an Spo2 of 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 Sao2 for 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-Sao2 pairs from 87 971 patient encounters (27 713 [42.9%] women; mean [SE] age, 62.2 [17.0] years; 1919 [2.3%] Asian patients; 26 032 [29.6%] Black patients; 2397 [2.7%] Hispanic patients, and 57 632 [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 Spo2 level 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.

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Figure 1. Flow Diagram Aggregate flow diagram for all data sets. ABG indicates arterial blood gas; Sao2, arterial oxygen saturation; Spo2, oxygen saturation by pulse oximetry.
Figure 1. Flow Diagram Aggregate flow diagram for all data sets. ABG indicates arterial blood gas; Sao2, arterial oxygen saturation; Spo2, oxygen saturation by pulse oximetry.CC BY · PubMed Central
Figure 2. Modified Bland-Altman Plots by Race and Ethnicity On each plot, the bold horizontal lines represent the mean bias (defined as the difference between the oxygen saturation measured by pulse oximetry [Spo2] and arterial blood gas value [Sao2]) for each of the 2 Spo2 groups. The blue lines, with dashed blue lines indicating 95% CIs, are for the group with Spo2 of 88% to 92%, and the orange lines, with dashed orange lines indicating 95% CIs, for the group with Spo2 of 93% to 96%. The solid black line indicates the absence of bias (ie, Spo2 − Sao2 = 0). When the mean bias is above the black line, there is positive bias in the pulse oximetry measurement (ie, the observed Spo2 is greater than the true Sao2). In contrast, when the mean bias is below the black line, there is negative bias in the pulse oximetry measurement (ie, the observed Spo2 is below the true Sao2).
Figure 2. Modified Bland-Altman Plots by Race and Ethnicity On each plot, the bold horizontal lines represent the mean bias (defined as the difference between the oxygen saturation measured by pulse oximetry [Spo2] and arterial blood gas value [Sao2]) for each of the 2 Spo2 groups. The blue lines, with dashed blue lines indicating 95% CIs, are for the group with Spo2 of 88% to 92%, and the orange lines, with dashed orange lines indicating 95% CIs, for the group with Spo2 of 93% to 96%. The solid black line indicates the absence of bias (ie, Spo2 − Sao2 = 0). When the mean bias is above the black line, there is positive bias in the pulse oximetry measurement (ie, the observed Spo2 is greater than the true Sao2). In contrast, when the mean bias is below the black line, there is negative bias in the pulse oximetry measurement (ie, the observed Spo2 is below the true Sao2).CC BY · PubMed Central

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Metadata

Authors
Wong, A.-K. I., Charpignon, M., Kim, H., Josef, C., de Hond, A. A. H., Fojas, J. J., Tabaie, A., Liu, X., Mireles-Cabodevila, E., Carvalho, L., Kamaleswaran, R., Madushani, R. W. M. A., Adhikari, L., Holder, A. L., Steyerberg, E. W., Buchman, T. G., Lough, M. E., & Celi, L. A.
Affiliations
  • Emory University (US)
  • Massachusetts Institute of Technology (US)
  • Johns Hopkins University (US)
  • Leiden University Medical Centre, Department of Biomedical Data Sciences, Leiden, the Netherlands
  • Beth Israel Deaconess Medical Center (US)
  • Beihang University (CN)
  • School of Biological Science and Medical Engineering, Beihang University, Beijing, China
  • Cleveland Clinic (US)
  • Boston Medical Center (US)
  • Philips (United States) (US)
  • Leiden University Medical Center (NL)
  • Stanford Health Care (US)
Corresponding author
Wong, An-Kwok Ian
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2021-11-03
Volume
4
Issue
11
Pages
e2131674
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2021.31674
PMC
PMC9178439
OpenAlex
W3210241905
Cited by
268
References
25
Citations by year
2026: 26 · 2025: 53 · 2024: 62 · 2023: 67 · 2022: 60
FWCI
14.36
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Leiden Repository (Leiden University) (submittedVersion, cc-by)
  • Data Archiving and Networked Services (DANS) (submittedVersion, cc-by)
  • DSpace@MIT (Massachusetts Institute of Technology) (submittedVersion, cc-by-nc)
Funders
  • U.S. Department of Defense
  • National Institutes of Health (5r01eb017205-07, R01-EB017205, EB017205, NIBIB R01 EB017205, UL1TR002378)
  • Uniformed Services University of the Health Sciences (HT9404-13-1-0032, HU0001, USUHS HT9404-13-1-0032, HU0001-15-2-0001)
  • Biomedical Advanced Research and Development Authority
  • National Institute of General Medical Sciences (K23GM137182, T32GM095442, R01GM139967)
  • National Institute of Biomedical Imaging and Bioengineering (NIBIB R01 EB017205, R01-EB017205, EB017205)
  • National Center for Advancing Translational Sciences
Topics
  • Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Sepsis Diagnosis and Treatment
Keywords
pulse oximetry, arterial oxygen saturation, racial and ethnic disparities, arterial blood gases, intensive care unit patients, organ dysfunction, SOFA score, in-hospital mortality, length of hospital stay, lactate, creatinine, Black patients, Hispanic patients, health disparities, hypoxemia detection
MeSH terms
Oxygen Saturation, Aged, Hypoxia, Creatinine, Cross-Sectional Studies, Ethnicity, Female, Georgia, Humans, Male, Middle Aged, Multiple Organ Failure, Oximetry, Retrospective Studies, Racial Groups

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