Why Did It Take So Long?

By Nick van Terheyden aka Dr Nick, Principal, ECG Management Consulting
Twitter: @drnic1
Host of Healthcare Upside Down#HCupsidedown

Remember the toilet paper shortage of 2020? Or maybe like me, you were surprised by the shortage of wood in the home improvement stores. Panic buying and supply chain shortages only added to the daily challenges of the COVID-19 pandemic.

But for the healthcare world, there were significant problems getting access to ventilators and oxygen supplies, and this extended into the community as we learned more about the disease and its biomarkers—in particular, blood oxygenation.

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Before we had clear treatments for COVID-19, healthcare facilities instituted lockdowns to keep most people out of the hospital unless they needed emergency care. But that inhibited screening and monitoring, making it harder to identify people with worsening symptoms.

Enter the pulse oximeter—that little device that clips over your finger and produces a reading of your blood oxygenation. It also disappeared off store shelves amid a rash of panic buying, adding further challenges.

The pulse oximeter is a useful tool that estimates blood oxygen levels by transmitting infrared light through the finger. Unfortunately, its deployment during the pandemic exposed another inequity in healthcare—skin color affects its accuracy.

Despite studies from years ago that clearly showed these devices overestimated arterial oxygen saturation in dark-skinned individuals, we continued to rely on them to guide therapy and intervention. The renewed focus that emerged during the pandemic has prompted the FDA to take a specific interest in the accuracy of these devices.

The precision of such technology is of particular interest to Victoria Reinhartz, CEO of Mobile Health Consultants. On this episode she talks about the value of screening devices, their limitations, and the need to treat the patient—not the number. Below are a few excerpts.

Evolution of the pulse ox.

“Historically, the most accurate way to assess oxygen saturation was to put a needle in the patient through an arterial line or through the wrist. But who wants to go to the hospital every time they need to get oxygen assessed? That’s where the pulse oximetry devices are so helpful—they’re non-invasive, they’re not painful, they can be done in any setting, and there’s less infection risk. But there’s new data showing us how significant the inaccuracies of these devices can be.”

How it works…and when it doesn’t.

“Essentially, the device sends a light through your finger, and the light gets absorbed by the hemoglobin in the blood. The percentage of the light that gets absorbed can tell us a lot about how much oxygen is in the blood. The problem is that hemoglobin is not the only component that absorbs the light. Darker skin pigments also absorb the light, and the darker a patient’s skin, the [more the] pulse oximeter overestimates the amount of oxygen in the blood. If arterial oxygen is less than 88%, a patient would be deemed to be in hypoxemia and eligible for supplemental oxygen. [A 2022 study published in JAMA found] three times as many Black patients had readings that were 90% to 96% on the pulse ox, when in actuality they were below 88%. That’s a significant impact to health outcomes. And the finding from this study was that those patients did end up receiving less supplemental oxygen.”

Treating the patient, not the number.

“As clinicians, we’re always looking for objective data to help us treat our patients. But this is a perfect example of that old adage that you need to treat the patient, not the number. My industry is the mobile integrated health and community paramedicine industry. We have in every community underserved patients who are unable to access the healthcare system—they can’t drive, or they don’t have insurance, or they have dementia—and they end up in a cycle of calling 911 and being transported to the ER. We mobilize paramedics, partnered with a team of nurses, social workers, pharmacists, and physicians, to visit patients in the home to help prevent that next 911 call. And as more information like the inaccuracy of pulse ox comes out, mobilizing these types of teams can allow us to treat the patient, not the number, and really is also a much more personable way to deliver care.”

This article was originally published on the ECG Management Consulting blog and is republished here with permission.

About the Show
The US spends more on healthcare per capita than any other country on the planet. So why don’t we have superior outcomes? Why haven’t the principles of capitalism prevailed? And why do American consumers have so much trouble accessing and paying for healthcare? Dive into these and other issues on Healthcare Upside/Down with ECG principal Dr. Nick van Terheyden and guest panelists as they discuss the upsides and downsides of healthcare in the US, and how to make the system work for everyone.

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