Does unconscious socioeconomic bias influence tele-evaluation of obstructive sleep apnea? An exploratory analysis

We examined the association between a patient's income and a provider's ability to identify risk for obstructive sleep apnea (OSA) when assessed in-person versus via telemedicine.

We utilized data from a randomized interrater reliability study of 58 patients who were referred to a university sleep center. Participants volunteered their annual income bracket as part of data collection, although raters were blinded to these data. We assessed the inter-method reliability between the clinical impressions of a telemedicine rater and those of an in-person rater for pretest probability of OSA, stratified by income levels.

Inter-method reliabilities, assessed using weighted kappa, were 0.83, 0.24, and 0.66 for subjects with low (<$50,000/year), moderate ($50,000-$100,000/year) and high (>$100,000) incomes, respectively. The kappa statistics were significantly different (p = 0.005) between the low and moderate income groups.

There was a significant difference in the reliability values of telemedicine versus in-person assessments between the low and middle income brackets. This is despite the raters being unaware of the patients' income levels. This association might suggest possible unconscious bias in evaluating for OSA. With telemedicine in early development, it is important to create processes that will minimize bias that might result from patients' economic disparities.