Aluko A. Hope

Background: Racial and ethnic disparities exist in critical illness outcomes in the United States. Objectives: To identify research priorities for reducing disparities in U.S. critical illness outcomes. Methods: A 22-member multidisciplinary committee participated in virtual workshops to appraise the literature and discuss opportunities for structural changes to reduce disparities in critical illness outcomes. The co-chairs conducted content analysis of workshop recordings to identify research priorities, then committee members completed a survey to rate the feasibility and potential impact on health outcomes of each priority. Research priorities were classified as highly feasible and/or highly impactful if ≥85% of responses indicated agreement or strong agreement. Results: The committee identified 35 research priorities to reduce U.S. critical care disparities in the following categories: mechanisms of disparities, research outcomes, data sources, and research methods. Nearly all priorities related to data sources and research methods were considered highly impactful. Research priorities considered both highly impactful and highly feasible were as follows: 1) mechanisms: examining variability in a) evidence-based care and b) clinician communication; 2) research outcomes: the use of hierarchical outcomes that evaluate patient-relevant trade-offs; and 3) research methods: the use of a) multicenter studies to address center-level variation and structural barriers to equity, b) qualitative and mixed methods to center the patient and family voice, c) interdisciplinary research teams that incorporate the broad expertise necessary to address complex social problems, d) directed acyclic graphs to promote causal inference, and e) quality improvement collaboratives comprising multiple stakeholders working together to achieve equitable outcomes. Conclusions: These results offer a roadmap for future critical illness health equity research.

Background: Identifying potentially modifiable factors that mediate adverse outcomes in frail adults with critical illness may facilitate development of interventions to improve intensive care unit (ICU) survivorship. Objectives: To estimate the relationship between frailty, acute brain dysfunction (as reflected by delirium or persistent coma), and 6-month disability outcomes. Methods: Older adults (aged ≥50 years) admitted to the ICU were enrolled prospectively. Frailty was identified with the Clinical Frailty Scale. Delirium and coma were assessed daily with the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale, respectively. Disability outcomes (death and severe physical disability [defined as new dependence in 5 or more activities of daily living]) were assessed by telephone within 6 months after discharge. Results: In 302 older adults (mean [SD] age, 67.2 [10.8] y), both frail and vulnerable patients had a higher risk for acute brain dysfunction (adjusted odds ratio [AOR], 2.9 [95% CI, 1.5-5.6], and 2.0 [95% CI, 1.0-4.1], respectively) compared with fit patients. Both frailty and acute brain dysfunction were independently associated with death or severe disability at 6 months (AOR, 3.3 [95% CI, 1.6-6.5] and 2.4 [95% CI, 1.4 -4.0], respectively). The average proportion of the frailty effect mediated by acute brain dysfunction was estimated to be 12.6% (95% CI, 2.1%-23.1%; P = .02). Conclusion: Frailty and acute brain dysfunction were important independent predictors of disability outcomes in older adults with critical illness. Acute brain dysfunction may be an important mediator of increased risk for physical disability outcomes after critical illness.