This study, which is one of the first large-scale investigations of over 100,000 hospitalized patients evaluating the influence of healthcare inequities on PIVC outcomes, demonstrated significant disparities among sex and race. Specifically, female gender and Black race were key predictors of adverse outcomes. Some of the differences in PIVC functionality were quite substantial and disproportionately impacted these vulnerable groups. In the context of PIVC dwell time compared to the patient’s hospitalization length of stay, our model demonstrated that Black females had 19.6% lesser ratio of PIVC dwell time to hospital length of stay compared to White males. In other words, after our machine learning model accounts for confounding factors, and with an overall average length of stay of 135 hours, Black females have reliable PIVC access for over one full day less than White males.
Regrettably, numerous studies and review articles on PIVC failure often omit or neglect to report race in their findings, a trend consistent with broader patterns in medical research.25 However, this oversight is being addressed by recent updates in guidelines for reporting race/ethnicity, indicating a shift towards greater inclusivity in medical research.26,27 Some articles investigating risk factors for difficult intravenous access in patients (DIVA) have identified darker skin as a potential risk factor, given the diminished visibility of veins.28–30 Previous literature establishes a link between darker skin pigmentation and reduced vein visibility, increasing the difficulty of PIVC placement.31 Given the crucial role of vein visualization in standard venous assessment and its correlation with PIVC placement ease, it is unsurprising that Black patients with darker skin face a heightened risk of encountering challenging venous access. The same logic can also be applied to women as they tend to have different venous anatomy compared to men.32,33 Naturally, smaller target vessels create an anatomical disadvantage leading to difficult access. The well-established association between DIVA patients and increased insertion attempts, as well as poor functionality outcomes, often necessitates escalation to ultrasound-guided PIVC insertion—a skill not universally available among clinical staff. In the absence of ultrasound, PIVCs are frequently placed in suboptimal locations, leading to elevated complications and early failures. Consequently, our study underscores that Black individuals and females experience a higher incidence of suboptimal site placement, resulting in shorter PIVC dwell times. Despite recognized anatomical and physiological disparities contributing to multiple puncture attempts and failures, comprehensive solutions or escalation strategies targeting PIVC outcomes for Black individuals and females remain limited.
While much of a PIVC’s predictability of its survival lies within the first 24 hours, regular care and maintenance of the PIVC is crucial. First, certain skin pigmentations may make identifying signs of PIVC complications, such as phlebitis, more difficult for the untrained eye.28,31 Next, perhaps it is related to poor health outcomes in non-white populations as a whole. Our study also demonstrated Black patients lived in areas with higher levels of poverty and previous research has shown low socioeconomic status may result in fewer diagnostic tests and medications for chronic illnesses.34 Or, perhaps it is even more complex than we can imagine and the answer lies among a multifaceted biopsychosocial factor that still needs to be uncovered.
The disparities unveiled in our study are also indicative of broader systemic issues in healthcare delivery. This discrepancy could be attributed to factors such as differential access to quality care, potential biases in patient treatment, or differences in health literacy and patient advocacy.
Historically, medical textbooks have predominantly featured illustrations of light-skinned individuals, a bias that could inadvertently impact the preparedness of healthcare professionals in performing PIVC placement on patients with darker skin tones.35,36 This reality highlights the critical necessity for more comprehensive and inclusive educational materials and training programs that address the needs of a diverse patient demographic.
Nevertheless, in light of these findings, our study urges a reevaluation of PIVC placement protocols to account for the disparities identified. Tailoring interventions to address the unique challenges faced by different demographic groups is imperative for improving overall PIVC success rates and reducing complications. The implications extend beyond immediate patient care, encompassing potential reductions in hospital stays and more efficient delivery of critical treatments. This research advances our understanding of the intersection between routine medical procedures and healthcare disparities, emphasizing the need for targeted strategies to enhance equity in PIVC outcomes. As we navigate the complexities of healthcare delivery, addressing disparities in the most common medical procedures is a pivotal step toward a more equitable and effective healthcare system.
LIMITATIONS
This study offers valuable insights into disparities in PIVC outcomes across various demographic groups; however, several limitations warrant consideration. First, its retrospective design limits the ability to establish causality between demographic factors and PIVC outcomes, and the data sourced from a single healthcare system may not be representative of other settings, potentially affecting the generalizability of our findings. Second, the possibility of unmeasured confounders, such as individual clinician skill or patient-specific anatomical variations, alongside the reliance on administrative data, which may not capture all relevant clinical details, could influence outcomes. Third, the categorization of race and ethnicity into broad groups may oversimplify their complex interplay with healthcare outcomes and not fully represent individuals with multiple racial or ethnic identities. Fourth, inherent biases in the data collection process, including selection and information bias, must be considered.
It's important to contextualize these findings within our healthcare setting, which features a robust PIVC training program, including early escalation to ultrasound for patient care.37–39 This aspect of our practice suggests that the disparities observed in our study might be even more significant in environments with less developed escalation protocols for PIVC placement. While this study sheds light on important disparities in PIVC outcomes, these limitations highlight the need for cautious interpretation of the findings and underscore the importance of further research to develop more comprehensive and effective strategies to reduce healthcare disparities in PIVC outcomes and beyond.