Importance: Differential use of therapies for respiratory failure according to patient race/ethnicity may represent health inequity and could impact patient survival. Objective: Measure the association between patient race/ethnicity and the use of invasive ventilation, and the impact of any association on survival. Design: Retrospective cohort analysis using a Bayesian multistate model that adjusted for baseline covariates and time-varying severity. Setting: Multicenter study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) and Phillips eICU (eICU) databases from the USA. Participants: Non-intubated adults receiving oxygen within the first 24 hours of ICU admission. Exposure: Patient race/ethnicity (Asian, Black, Hispanic, white). Main outcomes and measures: Primary output was the cause-specific hazard ratio (HR) of invasive ventilation for patient race/ethnicity. Secondary output was change in 28-day survival mediated by differences in invasive ventilation rate. We reported posterior means and 95% credible intervals (CrI). Results: We studied 38,263 patients, 52% (20,033) from MIMIC-IV and 48% (18,230) from eICU, 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,923). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The rate of invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, lower rates of invasive ventilation did not mediate differences in survival. For a reference patient with inspired oxygen (FiO2) varied from 0.5 to 1.0, the change in survival mediated by lower rates of invasive ventilation ranged from probable benefit (probability 0.82 for Asian patients, 0.91 for Black patients, and 0.93 for Hispanic patients) at FiO2 0.5 to probable harm (probability 0.87 for Asian patients, 0.92 for Black patients, and 0.97 for Hispanic patients) at FiO2 1.0, although the mean absolute changes in mortality were all less than 1.5%. Conclusions: Asian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. The changes in 28-day survival mediated by this difference ranged from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0, and there was no difference in survival for the average patient.

The authors have declared no competing interest.

The study did not receive any funding. Dr Yarnell was funded by the Canadian Institutes for Health Research Vanier Scholar program, the Eliot Phillipson Clinician Scientist Training Program, and the Clinician Investigator Program of the University of Toronto.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Use of the MIMIC IV database for research has been approved by institutional review board of Massachusetts Institute of Technology (number 0403000206). The eICU database has been deemed to meet safe harbour standards by an independent privacy expert (Privacert, Cambridge, MA, USA; Health Insurance Portability and Accountability Act Certification number 1031219 2).

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