Another Piece of Equipment with Racial Bias

Background: Medical equipment that gives clinicians vital signs or other objective information must be reliable across populations as this data drives medical decisions. Many of these tools were not developed or validated in a racially diverse group of patients.  We have already covered issues with pulse oximetry potentially missing hypoxemia in Black patients on REBEL EM (Link is HERE). Inaccuracies with infrared technology with pulse oximeters raises questions about accuracy in other diagnostic tools like temporal (forehead) thermometers.

Paper: Bhavani SV et al. Racial Differences in Detection of Fever Using Temporal vs Oral Temperature Measurements in Hospitalized Patients. JAMA 2022. PMID: 36066526

 Clinical Question: Is there a discrepancy in fever identification between oral and temporal thermometers in Black vs white patients presenting with suspected infection?

What They Did:

  • Retrospective, cross-sectional study
  • Adult patients admitted to 4 Emory hospitals between 2014 and 2021
  • First pair of oral and temporal temperatures measured within 1 hour of each other with the 1st day of hospitalization were included

Outcomes:

  • Association between route of measurement and fever (≥38.0C)
    • Also evaluated at varying fever cutoffs of 37.8C, 38.3C, and 38.5C 

Inclusion:

  • Suspected infection
    • Defined as a combination of body fluid cultures and antibiotics within 24 hours of hospital presentation 

Exclusion:

  • Patients identifying as Asian, Hispanic, or other (due to small sample sizes)
  • Measurements after receipt of acetaminophen

Results:

  • 2031 African American Patients
  • 2344 White patients
  • Temporal Temperature vs Oral Temperature (Black patients)
    • Temporal Temp: 36.98C
    • Oral Temp: 37.05C
    • Diff -0.07C; 95% CI -0.10 to 0.04C; p<0.001
  • Temporal Temperature vs Oral Temperature (White patients)
    • Temporal Temp: 36.97C
    • Oral Temp: 36.95C
    • Diff 0.02; 95% CI 0.01 to 0.05C; p = 0.18
  • Prevalence of fever in Black was 10.1% with a temporal thermometer and 13.2% with an oral thermometer
  • Prevalence of fever in White patients was 10.8% with a temporal thermometer and 10.2% with oral measurement
  • Logistic regression showed:
    • Temporal compared with oral measurement associated with a significantly lower odds ratio of fever in Black patients: OR 0.74; 95% CI 0.61 to 0.90; p = 0.002
    • This was not the case in white patients: OR 1.07/95% CI 0.89 to 1.29; p = 0.47
  • This association was significant in Black Patients at multiple fever cutoffs as well

Strengths:

  • Asks a clinically important question that affects decisions in management and treatment of patients
  • Study was appropriately designed to answer the question posed

Limitations:

  • Absolute differences between oral and temporal temperatures were small
  • Unclear what patient-oriented outcomes would be based on this trial alone
  • Retrospective analysis
  • Inadequate power to evaluate differences in Asian and Hispanic patients
  • Baseline characteristics were unbalanced

Discussion:

  • Using temporal thermometers in darker skinned ethnicities in combination with fever cutoffs will lead to fever going undetected in many of these patients. This could lead to delays in antibiotics and medical care all of which could be associated with worsened patient outcomes
  • Race is a social construct and patients self-identified to race (which is appropriate). It’s important to note that identifying as Black does not necessarily mean that the patient has darker skin. Skin tone of Black patients is a spectrum; not a homologous characteristic.

Author Conclusion: “Differences in detection of fever could lead to delays in antibiotics and medical care for Black patients.”

Clinical Take Home Point: Temporal thermometers are more likely to underestimate temperature in Black patients than in White patients. As a result, the equipment we rely on will under-detect fever in Black patients. 

References:

  1. Bhavani SV et al. Racial Differences in Detection of Fever Using Temporal vs Oral Temperature Measurements in Hospitalized Patients. JAMA 2022. PMID: 36066526

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

Cite this article as: Salim Rezaie, "Another Piece of Equipment with Racial Bias", REBEL EM blog, September 22, 2022. Available at: https://rebelem.com/another-piece-of-equipment-with-racial-bias/.

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