Overestimation of Sequential Organ Failure Assessment scores in Black populations may lead to deprioritization during public health emergencies

1. Black patients demonstrated lower in-hospital mortality than White patients with equivalent Sequential Organ Failure Assessment (SOFA) scores.

2. This overestimatation of Black patient mortality might lead to deprioritization of this population during public health crises based on the current Crisis Standards of Care guidelines.

Evidence Rating Level: 2 (Good)

Study Rundown: The Crisis Standards of Care (CSC) guidelines provide ethical guidance on allocating health resources when healthcare systems are overwhelmed. The Sequential Organ Failure Assessment (SOFA) score is used to assess mortality risk among intensive care unit (ICU) patients; those with the lowest SOFA score (greatest chance of survival) are the highest priority to receive resources when they are limited. Racial variations exist among some of the variables measured in the SOFA score; however, the exact variance of SOFA scores between Black and White patient populations has not yet been well-explored. CSC has multiple different systems (A, B, and C) of categorizing SOFA scores into levels of priorities. This retrospective cohort study compared survival between Black and White patients with equivalent SOFA scores to assess whether variations in SOFA scores lead to misrepresentation within the CSC framework. Adjusted analysis demonstrated significantly lower mortality among Black patients compared to White patients with equal SOFA scores. Furthermore, in the highest priority group for all three CSC systems, Black patients had significantly lower mortality than White patients, leading to an inaccurate and disproportionate evaluation in the CSC system. Additionally, significantly more Black patients were deprioritized in the CSC system due to comorbidities compared to equivalent White patients. Overall, this study demonstrated that Black patients may have lower mortality than their SOFA score indicates and, therefore, may not be reasonably prioritized for supplies when limited. It also questions the overall utility of SOFA as a triage tool, something of concern that has been brought up in recent years. One limitation of this study, however, is whether there were differences in the etiologies of death between Black and White patients and if it is a confounding factor for the study’s results.

Click to read the study in JAMA Network Open

Relevant Reading: Serial evaluation of the SOFA score to predict outcome in critically ill patients

In-Depth [retrospective cohort]: This study included 111 885 patient encounters (95 197 White, 16 688 Black) from 233 ICUs across the United States in 2014 and 2015. Patients were included if they were admitted to the ICU, and at least 1 SOFA variable was recorded within 24 hours of admission. The primary outcome was in-hospital mortality. The odds of death for Black patients were 2% lower than that of white patients with equivalent SOFA scores (OR: 0.98 [95% CI: 0.97-0.99], p<0.001). The odds ratio of mortality for Black compared to White patients with equal kidney SOFA scores was 0.91 (95% CI: 0.88-0.95, p<0.001) and with equal hematologic SOFA scores was 1.09 (95% CI: 1.01-1.16, p= 0.02). Furthermore, there were significant differences when White vs Black patients were categorized into tiers for all three SOFA systems. Black patients had lower mortality than White patients in the highest priority category of all SOFA systems (system A: OR: 0.65 [95% CI: 0.58-0.74], p<0.001; system B: OR: 0.70 [95% CI: 0.64-0.78], p<0.001; system C: 0.73 [95% CI: 0.67-0.80], p<0.001). Black patients had lower morality than White patients in the lowest priority category of all systems (system A: OR: 0.78 [95% CI: 0.66-0.92], p= 0.004; system B: OR: 0.79 [95% CI: 0.67-0.94], p= 0.006; system C: OR: 0.65 [95% CI: 0.46-0.91], p= 0.01). Adjusted odds of death for both cohorts who were in the high priority tier of all 3 CSC systems were equalized if SOFA thresholds for Black patients were increased by 2 points.

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