The Impact of Black Race on Pneumonia Severity Scoring Systems

Racial disparities disproportionately affect the morbidity and mortality of Black patients with community-acquired pneumonia (CAP). Some scoring systems used in the ICU (eg, Sequential Organ Failure Assessment, APACHE IVa) overpredict mortality in Black patients. However, to our knowledge, the performance of pneumonia severity scoring systems in White and Black adult patients has never been comprehensively evaluated.

Does Black race differentially impact the ability of pneumonia severity scoring systems to predict in-hospital mortality, direct ICU admission, or identify severe CAP?

This was a secondary analysis of 2 prospective cohorts of patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP from 8 adult hospitals in Louisville, Kentucky. The following pneumonia severity scores were assessed: Pneumonia Severity Index; CURB-65; Confusion, Oxygenation, Respiratory Rate, and Blood Pressure scale; American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) 2007 criteria; SMART-COP; Severe Community-Acquired Pneumonia (SCAP) score; and Risk of Early Admission to ICU Index.

For Black and White patients with CAP, the in-hospital mortality rate was 5.6% vs 7.5% (P = .007), and the direct ICU admission rate was 15.2% vs 17.0% (P = .082). All pneumonia severity scores predicted in-hospital mortality equally in White and Black patients except the ATS/IDSA 2007 criteria, which performed better in Black patients than White patients (area under the curve, 0.873; 95% CI, 0.836-0.907 vs area under the curve, 0.809; 95% CI, 0.788-0.830). All pneumonia severity scores predicted direct ICU admission equally well in White and Black patients. Compared with White patients, Black patients had decreased incidence of severe CAP as defined by all pneumonia severity scores except the Severe Community-Acquired Pneumonia score (11.5% in White patients vs 10.0% in Black patients; P = .146).

Our results show that most pneumonia severity scores perform equally well for predicting in-hospital mortality and direct ICU admission in White and Black patients except the ATS/IDSA 2007 criteria, which showed superior performance in Black patients when predicting in-hospital mortality. Before implementation in clinical practice, it is important to consider the limitations of pneumonia severity scores and their subsequent impact on equitable care delivery.