Promoting Equity via Change In Practice for Respiratory Failure (PRECIPICE)

PRECIPICE is a 4-year, NIH funded study aiming to improve outcomes for Hispanic patients with respiratory failure by reducing inequitable delivery of ICU care. We believe disproportionate exposure to specific care processes for respiratory failure —such as use of

deep sedation and limited physical therapy —produce disparities in survival and long-term function for Hispanic patients.

Deep Sedation

Our preliminary work, a secondary analysis of the same multi-center trial for respiratory failure, showed Hispanic patients had twice the odds of receiving deep sedation as non-Hispanic patients. Deep sedation has been associated with 1-year mortality and worse function after critical illness.

Several key knowledge gaps must be addressed in order to eliminate this disparity. We propose to integrate the following three complementary approaches:

Our Aims

1) Evaluate trajectories of long-term function for Hispanic and non-Hispanic survivors of respiratory failure

2) Characterize care delivery for respiratory failure by ethnicity

3) Refine and pilot an intervention targeting inequitable care delivery

Using clinical data on 96 Hispanic and 96 matched non-Hispanic control patients with respiratory failure from BLUE-CORAL, an NHLBI-funded, multi-center observational study of COVID-19, we will examine trajectories of functional outcomes (activities of daily living and health-related quality of life) by ethnicity.

We will test associations among ethnicity, financial strain, and change in function, controlling for age, sex, comorbidities, and severity of illness.

Using a parallel-convergent mixed methods design, we will

1) Perform detailed site visits at 10 U.S. hospitals to understand organizational characteristics and culture

2) Collect parallel survey data on clinical practice, resources, beliefs about health disparities, and cognitive biases

3) Ask 80 physicians, nurses, and other ICU staff to describe care delivery using clinical vignettes that differ by patient ethnicity.

We will refine our preliminary intervention using the Capability, Opportunity, Motivation, and Behavior (COM-B) model for specifying barriers and facilitators to behavior change.

We will use an iterative, participatory strategy to pilot the intervention at two ICUs—engaging clinicians, patients, and families. Process data will be collected to evaluate mechanisms of action, acceptability, and scalability.

Inequities in respiratory failure are created by interlocking and reinforcing mechanisms, operating across multiple levels—patient, clinician, and ICU organization

Funding

This work is supported by the National Institutes of Health under Award R01HL157361-01A1. The content on this website is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health.