Abstract
Background
A multicenter RCT showed that displaying a heart rate characteristics index (HRCi) predicting late-onset sepsis reduced mortality for VLBW infants. We aimed to assess whether HRCi display had a differential impact for Black versus White infants.
Methods
We performed secondary data analysis of Black and White infants enrolled in the HeRO RCT. We evaluated the predictive performance of the HRCi for infants with Black or White maternal race. Using models adjusted for birth weight, we assessed outcomes and interventions for a race × randomization interaction.
Results
Among 2607 infants, Black infants had lower birth weight, gestational age, length of stay, and ventilator days, while sepsis and mortality were similar. The HRCi performed equally for sepsis prediction in Black and White infants. We found no differential effect of randomization by race on sepsis, mortality, antibiotic days, length of stay, or ventilator days. However, there was a differential randomization effect by race for blood cultures per patient: White RR 1.11 (95% CrI 1.04–1.18), Black RR 1.00 (0.93–1.07).
Conclusions
The HRCi performed similarly for sepsis prediction in Black and White infants. Randomization to HRCi display increased blood cultures in White but not in Black infants, while the impact on other outcomes or interventions was similar.
Impact
-
Predictive analytics, such as heart rate characteristics (HRC) monitoring for late-onset neonatal sepsis, should have equal impact among patients of different race. Infants with Black or White maternal race randomized to HRC display had similar outcomes, but randomization to the study arm increased a related clinical intervention, blood cultures, in White but not in Black infants.
-
This study provides evidence of a differential effect of predictive models on clinical care by race.
-
The work will promote consideration and analysis of equity in the implementation of predictive analytics.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 14 print issues and online access
$259.00 per year
only $18.50 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
Data availability
Data are available upon reasonable request.
References
Beck, A. F. et al. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr. Res. 87, 227–234 (2020).
Hamilton, B., Martin, J. & Osterman, M. Births: Provisional Data for 2020 (Centers for Disease Control and Prevention, 2021)
DeSisto, C. L., Hirai, A. H., Collins, J. W. & Rankin, K. M. Deconstructing a disparity: explaining excess preterm birth among U.S.-born black women. Ann. Epidemiol. 28, 225–230 (2018).
Travers, C. P. et al. Prematurity and race account for much of the interstate variation in infant mortality rates in the United States. J. Perinatol. 40, 767–773 (2020).
Anderson, J. G. et al. Racial and ethnic disparities in preterm infant mortality and severe morbidity: a population-based study. Neonatology 113, 44–54 (2018).
Travers, C. P. et al. Racial/ethnic disparities among extremely preterm infants in the united states from 2002 to 2016. JAMA Netw. Open 3, e206757 (2020).
Profit, J. et al. Racial/ethnic disparity in NICU quality of care delivery. Pediatrics 140, e20170918 (2017).
Stoll, B. J. et al. Late-onset sepsis in very low birth weight neonates: a report from the National Institute of Child Health and Human Development Neonatal Research Network. J. Pediatr. 129, 63–71 (1996).
Stoll, B. J. et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 110, 285–291 (2002).
Hornik, C. P. et al. Early and late onset sepsis in very-low-birth-weight infants from a large group of neonatal intensive care units. Early Hum. Dev. 88(Suppl. 2), S69–S74 (2012).
Sullivan, B. A. et al. Clinical and vital sign changes associated with late-onset sepsis in very low birth weight infants at 3 NICUs. J. Neonatal Perinat. Med. 14, 553–561 (2021).
Wallace, M. E. et al. Racial/ethnic differences in preterm perinatal outcomes. Am. J. Obstet. Gynecol. 216, 306.e1–306.e12 (2017).
Greenberg, R. G. et al. Late-onset sepsis in extremely premature infants: 2000-2011. Pediatr. Infect. Dis. J. 36, 774–779 (2017).
Griffin, M. P. & Moorman, J. R. Toward the early diagnosis of neonatal sepsis and sepsis-like illness using novel heart rate analysis. Pediatrics 107, 97–104 (2001).
Griffin, M. P. et al. Abnormal heart rate characteristics preceding neonatal sepsis and sepsis-like illness. Pediatr. Res. 53, 920–926 (2003).
Moorman, J. R. et al. Mortality reduction by heart rate characteristic monitoring in very low birth weight neonates: a randomized trial. J. Pediatr. 159, 900.e1–906.e1 (2011).
Fairchild, K. D. et al. Septicemia mortality reduction in neonates in a heart rate characteristics monitoring trial. Pediatr. Res. 74, 570–575 (2013).
Sullivan, B. A. & Fairchild, K. D. Vital signs as physiomarkers of neonatal sepsis. Pediatr. Res. https://doi.org/10.1038/s41390-021-01709-x (2021)
Sullivan, B. A., Grice, S. M., Lake, D. E., Moorman, J. R. & Fairchild, K. D. Infection and other clinical correlates of abnormal heart rate characteristics in preterm infants. J. Pediatr. 164, 775–780 (2014).
Johnson, G. M. Algorithmic bias: on the implicit biases of social technology. Synthese https://doi.org/10.1007/s11229-020-02696-y (2020)
Gianfrancesco, M. A., Tamang, S., Yazdany, J. & Schmajuk, G. Potential biases in machine learning algorithms using electronic health record data. JAMA Intern. Med. 178, 1544–1547 (2018).
Vehtari, A., Gelman, A. & Gabry, J. Practical Bayesian model evaluation using leave-one-out cross-validation and WAIC. Stat. Comput. 27, 1413–1432 (2017).
Bürkner, P.-C. brms: an R package for bayesian multilevel models using stan. J. Stat. Softw. 80, 1–28 (2017).
Ryan, R. M. et al. Black race is associated with a lower risk of bronchopulmonary dysplasia. J. Pediatr. 207, 130.e2–135.e2 (2019).
Burris, H. H., Hwang, S. S., Collins, J. W., Kirpalani, H. & Wright, C. J. Re-conceptualizing associations between race and morbidities of extreme prematurity. J. Pediatr. 207, 10.e1–14.e1 (2019).
Howell, E. A. et al. Differences in morbidity and mortality rates in black, white, and hispanic very preterm infants among new york city hospitals. JAMA Pediatr. 172, 269–277 (2018).
Fairchild, K. D. et al. Endotoxin depresses heart rate variability in mice: cytokine and steroid effects. Am. J. Physiol. Regul. Integr. Comp. Physiol. 297, R1019–R1027 (2009).
Fairchild, K. D., Srinivasan, V., Moorman, J. R., Gaykema, R. P. A. & Goehler, L. E. Pathogen-induced heart rate changes associated with cholinergic nervous system activation. Am. J. Physiol. Regul. Integr. Comp. Physiol. 300, R330–R339 (2011).
Hill, L. K., Watkins, L. L., Hinderliter, A. L., Blumenthal, J. A. & Sherwood, A. Racial differences in the association between heart rate variability and left ventricular mass. Exp. Physiol. 102, 764–772 (2017).
Lombardi, F. & Stein, P. K. Origin of heart rate variability and turbulence: an appraisal of autonomic modulation of cardiovascular function. Front. Physiol. 2, 95 (2011).
Fonkoue, I. T., Schwartz, C. E., Wang, M. & Carter, J. R. Sympathetic neural reactivity to mental stress differs in black and non-Hispanic white adults. J. Appl. Physiol. 124, 201–207 (2018).
Carnethon, M. R. et al. Cardiovascular health in african americans: a Scientific Statement from the American Heart Association. Circulation 136, e393–e423 (2017).
Whitehill, L. et al. Socio-demographic factors related to parent engagement in the NICU and the impact of the SENSE program. Early Hum. Dev. 163, 105486 (2021).
Ioannidis, J. P. A., Powe, N. R. & Yancy, C. Recalibrating the use of race in medical research. JAMA 325, 623–624 (2021).
Kaplan, J. B. & Bennett, T. Use of race and ethnicity in biomedical publication. JAMA 289, 2709–2716 (2003).
Funding
This study was supported by the National Institutes of Health (K23 HD 097254 [PI B.A.S.] and R01 HD 092071 [PI K.D.F.].
Author information
Authors and Affiliations
Contributions
All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; B.A.S. wrote the first draft of the manuscript and all other authors revised it critically for important intellectual content; and all authors gave final approval of the version to be published.
Corresponding author
Ethics declarations
Competing interests
W.E.K. is Chief Executive Officer of Medical Predictive Science Corporation. The other authors declare no competing interests.
Ethics approval and consent to participate
This study analyzed data from a randomized clinical trial that required informed consent from a parent of every patient prior to enrollment.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Sullivan, B.A., Hochheimer, C.J., Chernyavskiy, P. et al. Impact of race on heart rate characteristics monitoring in very low birth weight infants. Pediatr Res 94, 575–580 (2023). https://doi.org/10.1038/s41390-023-02470-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41390-023-02470-z