An Algorithmic Approach for Causal Health Equity: A Look at Race Differentials in Intensive Care Unit (ICU) Outcomes

The new era of large-scale data collection and analysis presents an opportunity for diagnosing and understanding the causes of health inequities. In this study, we describe a framework for systematically analyzing health disparities using causal inference. The framework is illustrated by investigating racial and ethnic disparities in intensive care unit (ICU) outcome between majority and minority groups in Australia (Indigenous vs. Non-Indigenous) and the United States (African-American vs. White). We demonstrate that commonly used statistical measures for quantifying inequity are insufficient, and focus on attributing the observed disparity to the causal mechanisms that generate it. We find that minority patients are younger at admission, have worse chronic health, are more likely to be admitted for urgent and non-elective reasons, and have higher illness severity. At the same time, however, we find a protective direct effect of belonging to a minority group, with minority patients showing improved survival compared to their majority counterparts, with all other variables kept equal. We demonstrate that this protective effect is related to the increased probability of being admitted to ICU, with minority patients having an increased risk of ICU admission. We also find that minority patients, while showing improved survival, are more likely to be readmitted to ICU. Thus, due to worse access to primary health care, minority patients are more likely to end up in ICU for preventable conditions, causing a reduction in the mortality rates and creating an effect that appears to be protective. Since the baseline risk of ICU admission may serve as proxy for lack of access to primary care, we developed the Indigenous Intensive Care Equity (IICE) Radar, a monitoring system for tracking the over-utilization of ICU resources by the Indigenous population of Australia across geographical areas.