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Sherak RAG, Sajjadi H, Khimani N, Tolchin B, Jubanyik K, Taylor RA, Schulz W, Mortazavi BJ, Haimovich AD. SOFA score performs worse than age for predicting mortality in patients with COVID-19. PLoS One 2024; 19:e0301013. [PMID: 38758942 PMCID: PMC11101117 DOI: 10.1371/journal.pone.0301013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/09/2024] [Indexed: 05/19/2024] Open
Abstract
The use of the Sequential Organ Failure Assessment (SOFA) score, originally developed to describe disease morbidity, is commonly used to predict in-hospital mortality. During the COVID-19 pandemic, many protocols for crisis standards of care used the SOFA score to select patients to be deprioritized due to a low likelihood of survival. A prior study found that age outperformed the SOFA score for mortality prediction in patients with COVID-19, but was limited to a small cohort of intensive care unit (ICU) patients and did not address whether their findings were unique to patients with COVID-19. Moreover, it is not known how well these measures perform across races. In this retrospective study, we compare the performance of age and SOFA score in predicting in-hospital mortality across two cohorts: a cohort of 2,648 consecutive adult patients diagnosed with COVID-19 who were admitted to a large academic health system in the northeastern United States over a 4-month period in 2020 and a cohort of 75,601 patients admitted to one of 335 ICUs in the eICU database between 2014 and 2015. We used age and the maximum SOFA score as predictor variables in separate univariate logistic regression models for in-hospital mortality and calculated area under the receiver operator characteristic curves (AU-ROCs) and area under precision-recall curves (AU-PRCs) for each predictor in both cohorts. Among the COVID-19 cohort, age (AU-ROC 0.795, 95% CI 0.762, 0.828) had a significantly better discrimination than SOFA score (AU-ROC 0.679, 95% CI 0.638, 0.721) for mortality prediction. Conversely, age (AU-ROC 0.628 95% CI 0.608, 0.628) underperformed compared to SOFA score (AU-ROC 0.735, 95% CI 0.726, 0.745) in non-COVID-19 ICU patients in the eICU database. There was no difference between Black and White COVID-19 patients in performance of either age or SOFA Score. Our findings bring into question the utility of SOFA score-based resource allocation in COVID-19 crisis standards of care.
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Affiliation(s)
- Raphael A. G. Sherak
- Yale Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Hoomaan Sajjadi
- Department of Computer Science and Engineering, Center for Remote Health Technologies and Systems, Texas A&M Univ, College Station, TX, United States of America
| | - Naveed Khimani
- Department of Computer Science and Engineering, Center for Remote Health Technologies and Systems, Texas A&M Univ, College Station, TX, United States of America
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
- Yale New Haven Health Center for Clinical Ethics, New Haven, CT, United States of America
| | - Karen Jubanyik
- Yale Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - R. Andrew Taylor
- Yale Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Wade Schulz
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, United States of America
| | - Bobak J. Mortazavi
- Department of Computer Science and Engineering, Center for Remote Health Technologies and Systems, Texas A&M Univ, College Station, TX, United States of America
- Center for Outcomes Research and Evaluation, Yale University, New Haven, CT, United States of America
| | - Adrian D. Haimovich
- Yale Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
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2
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Liu X, Shen M, Lie M, Zhang Z, Liu C, Li D, Mark RG, Zhang Z, Celi LA. Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Sex, and Primary Language in the United States: A Retrospective Multicenter Study. Crit Care Explor 2024; 6:e1033. [PMID: 38239408 PMCID: PMC10796141 DOI: 10.1097/cce.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Although illness severity scoring systems are widely used to support clinical decision-making and assess ICU performance, their potential bias across different age, sex, and primary language groups has not been well-studied. DESIGN SETTING AND PATIENTS We aimed to identify potential bias of Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores via large ICU databases. SETTING/PATIENTS This multicenter, retrospective study was conducted using data from the Medical Information Mart for Intensive Care (MIMIC) and eICU Collaborative Research Database. SOFA and APACHE IVa scores were obtained from ICU admission. Hospital mortality was the primary outcome. Discrimination (area under receiver operating characteristic [AUROC] curve) and calibration (standardized mortality ratio [SMR]) were assessed for all subgroups. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS A total of 196,310 patient encounters were studied. Discrimination for both scores was worse in older patients compared with younger patients and female patients rather than male patients. In MIMIC, discrimination of SOFA in non-English primary language speakers patients was worse than that of English speakers (AUROC 0.726 vs. 0.783, p < 0.0001). Evaluating calibration via SMR showed statistically significant underestimations of mortality when compared with overall cohort in the oldest patients for both SOFA and APACHE IVa, female patients (1.09) for SOFA, and non-English primary language patients (1.38) for SOFA in MIMIC. CONCLUSIONS Differences in discrimination and calibration of two scores across varying age, sex, and primary language groups suggest illness severity scores are prone to bias in mortality predictions. Caution must be taken when using them for quality benchmarking and decision-making among diverse real-world populations.
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Affiliation(s)
- Xiaoli Liu
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Max Shen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Margaret Lie
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Zhongheng Zhang
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Liu
- Department of Critical Care Medicine, The First Medical Center, The General Hospital of PLA, Beijing, China
| | - Deyu Li
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Roger G Mark
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Zhengbo Zhang
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
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Walsh BC, Zhu J, Feng Y, Berkowitz KA, Betensky RA, Nunnally ME, Pradhan DR. Simulation of New York City's Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge. JAMA Netw Open 2023; 6:e2336736. [PMID: 37796499 PMCID: PMC10556967 DOI: 10.1001/jamanetworkopen.2023.36736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/25/2023] [Indexed: 10/06/2023] Open
Abstract
Importance The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented. Objectives To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities. Design, Setting, and Participants This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized. Exposures The NYVAG protocol for triage ventilators. Main Outcomes and Measures Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing. Results The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities. Conclusions and Relevance In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.
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Affiliation(s)
- B. Corbett Walsh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Los Angeles David Geffen School of Medicine, Los Angeles
- Section of Palliative Medicine, Department of Medicine, University of Los Angeles David Geffen School of Medicine, Los Angeles
| | - Jianan Zhu
- Department of Biostatistics, New York University School of Global Public Health, New York
| | - Yang Feng
- Department of Biostatistics, New York University School of Global Public Health, New York
| | - Kenneth A. Berkowitz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York
- National Center for Ethics in Health Care, Veterans Health Administration
- Division of Medical Ethics, Department of Population Health, New York University Grossman School of Medicine, New York
| | - Rebecca A. Betensky
- Department of Biostatistics, New York University School of Global Public Health, New York
| | - Mark E. Nunnally
- New York University Langone Health, New York
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York
| | - Deepak R. Pradhan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York
- New York University Langone Health, New York
- Bellevue Hospital Center, NYC Health & Hospitals, New York, New York
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Goyal P, Schenck E, Wu Y, Zhang Y, Visaria A, Orlander D, Xi W, Díaz I, Morozyuk D, Weiner M, Kaushal R, Banerjee S. Influence of social deprivation index on in-hospital outcomes of COVID-19. Sci Rep 2023; 13:1746. [PMID: 36720999 PMCID: PMC9887560 DOI: 10.1038/s41598-023-28362-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 01/17/2023] [Indexed: 02/01/2023] Open
Abstract
While it is known that social deprivation index (SDI) plays an important role on risk for acquiring Coronavirus Disease 2019 (COVID-19), the impact of SDI on in-hospital outcomes such as intubation and mortality are less well-characterized. We analyzed electronic health record data of adults hospitalized with confirmed COVID-19 between March 1, 2020 and February 8, 2021 from the INSIGHT Clinical Research Network (CRN). To compute the SDI (exposure variable), we linked clinical data using patient's residential zip-code with social data at zip-code tabulation area. SDI is a composite of seven socioeconomic characteristics determinants at the zip-code level. For this analysis, we categorized SDI into quintiles. The two outcomes of interest were in-hospital intubation and mortality. For each outcome, we examined logistic regression and random forests to determine incremental value of SDI in predicting outcomes. We studied 30,016 included COVID-19 patients. In a logistic regression model for intubation, a model including demographics, comorbidity, and vitals had an Area under the receiver operating characteristic curve (AUROC) = 0.73 (95% CI 0.70-0.75); the addition of SDI did not improve prediction [AUROC = 0.73 (95% CI 0.71-0.75)]. In a logistic regression model for in-hospital mortality, demographics, comorbidity, and vitals had an AUROC = 0.80 (95% CI 0.79-0.82); the addition of SDI in Model 2 did not improve prediction [AUROC = 0.81 (95% CI 0.79-0.82)]. Random forests revealed similar findings. SDI did not provide incremental improvement in predicting in-hospital intubation or mortality. SDI plays an important role on who acquires COVID-19 and its severity; but once hospitalized, SDI appears less important.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Edward Schenck
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Yiyuan Wu
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Yongkang Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Aayush Visaria
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ, USA
| | - Duncan Orlander
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Wenna Xi
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Iván Díaz
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Dmitry Morozyuk
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Mark Weiner
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Rainu Kaushal
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA.,Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Samprit Banerjee
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA. .,, New York, USA.
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5
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Advani SD, Sickbert-Bennett E, Moehring R, Cromer A, Lokhnygina Y, Dodds-Ashley E, Kalu IC, DiBiase L, Weber DJ, Anderson DJ. The Disproportionate Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Healthcare-Associated Infections in Community Hospitals: Need for Expanding the Infectious Disease Workforce. Clin Infect Dis 2022; 76:e34-e41. [PMID: 35997795 PMCID: PMC9452131 DOI: 10.1093/cid/ciac684] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/26/2022] [Accepted: 08/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. However, a comprehensive assessment of the impact on healthcare-associated infections (HAIs) across different hospitals with varying level of infectious disease (ID) physician expertise, resources, and infrastructure is lacking. METHODS This retrospective longitudinal multicenter cohort study included central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), Clostridioides difficile infections (CDIs), and ventilator-associated events (VAEs) from 53 hospitals (academic and community) in Southeastern United States from 1 January 2018 to 31 March 2021. Segmented negative binomial regression generalized estimating equations models estimated changes in monthly incidence rates in the baseline (01/2018-02/2020) compared to the pandemic period (03/2020-03/2021, further divided into three pandemic phases). RESULTS CLABSIs and VAEs increased by 24% and 34%, respectively, during the pandemic period. VAEs increased in all phases of the pandemic, while CLABSIs increased in later phases of the pandemic. CDI trend increased by 4.2% per month in the pandemic period. On stratifying the analysis by hospital characteristics, the impact of the pandemic on healthcare-associated infections was more significant in smaller sized and community hospitals. CAUTIs did not change significantly during the pandemic across all hospital types. CONCLUSIONS CLABSIs, VAEs, and CDIs increased significantly during the pandemic, especially in smaller community hospitals, most of which lack ID physician expertise. Future efforts should focus on better understanding challenges faced by community hospitals, strengthening the infection prevention infrastructure, and expanding the ID workforce, particularly to community hospitals.
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Affiliation(s)
- Sonali D Advani
- Corresponding Author: Sonali D. Advani MBBS, MPH, Assistant Professor of Medicine, Division of Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC, 27710, United States,
| | - Emily Sickbert-Bennett
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - Rebekah Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Andrea Cromer
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, US
| | - Elizabeth Dodds-Ashley
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Ibukunoluwa C Kalu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, NC, US
| | - Lauren DiBiase
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - David J Weber
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - Deverick J Anderson
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
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Walsh BC, Pradhan D, Mukherjee V, Uppal A, Nunnally ME, Berkowitz KA. How Common SOFA and Ventilator Time Trial Criteria Would Have Performed During the COVID-19 Pandemic: An Observational Simulated Cohort Study. Disaster Med Public Health Prep 2022; 17:e225. [PMID: 35678391 PMCID: PMC9353237 DOI: 10.1017/dmp.2022.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/18/2022] [Accepted: 06/04/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate how key aspects of New York State Ventilator Allocation Guidelines (NYSVAG)-Sequential Organ Failure Assessment score criteria and ventilator time trials -might perform with respect to the frequency of ventilator reallocation and survival to hospital discharge in a simulated cohort of coronavirus disease (COVID-19) patients. METHODS Single center retrospective observational and simulation cohort study of 884 critically ill COVID-19 patients undergoing ventilator allocation per NYSVAG. RESULTS In total, 742 patients (83.9%) would have had their ventilator reallocated during the 11-day observation period, 280 (37.7%) of whom would have otherwise survived to hospital discharge if provided with a ventilator. Only 65 (18.1%) of the observed surviving patients would have survived by NYSVAG. Extending ventilator time trials from 2 to 5 days resulted in a 49.2% increase in simulated survival to discharge. CONCLUSIONS In the setting of a protracted respiratory pandemic, implementation of NYSVAG or similar protocols could lead to a high degree of ventilator reallocation, including withdrawal from patients who might otherwise survive. Longer ventilator time trials might lead to improved survival for COVID-19 patients given their protracted respiratory failure. Further studies are needed to understand the survival of patients receiving reallocated ventilators to determine whether implementation of NYSVAG would improve overall survival.
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Affiliation(s)
- B. Corbett Walsh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Deepak Pradhan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Health, New York, NY, USA
- Bellevue Hospital Center, NYC Health & Hospitals, New York, NY, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Bellevue Hospital Center, NYC Health & Hospitals, New York, NY, USA
| | - Amit Uppal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Bellevue Hospital Center, NYC Health & Hospitals, New York, NY, USA
| | - Mark E. Nunnally
- New York University Langone Health, New York, NY, USA
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Kenneth A. Berkowitz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
- Division of Medical Ethics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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7
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Riviello ED, Dechen T, O’Donoghue AL, Cocchi MN, Hayes MM, Molina RL, Moraco NH, Mosenthal A, Rosenblatt M, Talmor N, Walsh DP, Sontag DN, Stevens JP. Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19. JAMA Netw Open 2022; 5:e221744. [PMID: 35289860 PMCID: PMC8924715 DOI: 10.1001/jamanetworkopen.2022.1744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. OBJECTIVE To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. EXPOSURES Race, ethnicity, Social Vulnerability Index. MAIN OUTCOMES AND MEASURES The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. RESULTS Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. CONCLUSIONS AND RELEVANCE In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.
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Affiliation(s)
- Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley L. O’Donoghue
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael N. Cocchi
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rose L. Molina
- Harvard Medical School, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicole H. Moraco
- Division of General Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Anne Mosenthal
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Michael Rosenblatt
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Noa Talmor
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel P. Walsh
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Critical Care, Beth Israel Deaconess Hospital–Plymouth, Plymouth, Massachusetts
| | - David N. Sontag
- Harvard Medical School, Boston, Massachusetts
- Office of the General Counsel, Beth Israel Lahey Health, Cambridge, Massachusetts
- Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P. Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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8
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Gershengorn HB. Inequitable Resource Allocation Amidst a Pandemic-A Crisis Within a Crisis. JAMA Netw Open 2022; 5:e221751. [PMID: 35289866 DOI: 10.1001/jamanetworkopen.2022.1751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
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9
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White D, Lo B. Promoting equity with a multi-principle framework to allocate scarce ICU resources. JOURNAL OF MEDICAL ETHICS 2022; 48:133-135. [PMID: 34099542 PMCID: PMC8649043 DOI: 10.1136/medethics-2021-107456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
We wholeheartedly agree with Schmidt and colleagues' efforts to promote equity in intensive care unit (ICU) triage. We also take issue with their characterisation of the New Jersey (NJ) allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim-without evidence-that it will 'compound disadvantage for black patients'. However, the NJ triage framework-like the model allocation policy we developed-actually contains four allocation criteria: the two criteria that the authors mentioned (chances for survival and near-term prognosis) and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage.
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Affiliation(s)
- Douglas White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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10
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Schmidt H, Roberts DE, Eneanya ND. Sequential organ failure assessment, ventilator rationing and evolving triage guidance: new evidence underlines the need to recognise and revise, unjust allocation frameworks. JOURNAL OF MEDICAL ETHICS 2022; 48:136-138. [PMID: 34635502 DOI: 10.1136/medethics-2021-107696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/15/2021] [Indexed: 06/13/2023]
Abstract
We respond to recent comments on our proposal to improve justice in ventilator triage, in which we used as an example New Jersey's (NJ) publicly available and legally binding Directive Number 2020-03. We agree with Bernard Lo and Doug White that equity implications of triage frameworks should be continually reassessed, which is why we offered six concrete options for improvement, and called for monitoring the consequences of adopted triage models. We disagree with their assessment that we mis-characterised their Model Guidance, as included in the NJ Directive, in ways that undermine our conclusions. They suggest we erroneously described their model as a two-criterion allocation framework; that recognising other operant criterion reveals it 'likely mitigate[s] rather than exacerbate[s] racial disparities during triage', and allege that concerns about inequitable outcomes are 'without evidence'. We highlight two major studies robustly demonstrating why concerns about disparate outcomes are justified. We also show that White and Lo seek to retrospectively-and counterfactually-correct the version of the Model Guideline included in the NJ Directive. However, as our facsimile reproductions show, neither the alleged four-criteria form, nor other key changes, such as dropping the Sequential Organ Failure Assessment score, are found in the Directive. These points matter because (1) our conclusions hence stand, (2) because the public version of the Model Guidance had not been updated to reduce the risk of inequitable outcomes until June 2021 and (3) NJ's Directive still does not reflect these revisions, and, hence, represents a less equitable version, as acknowledged by its authors. We comment on broader policy implications and call for ways of ensuring accurate, transparent and timely updates for users of high-stakes guidelines.
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Affiliation(s)
- Harald Schmidt
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dorothy E Roberts
- Penn Law, Departments of Africana Studies and Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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Piscitello GM, Siegler M, Parker WF. Ethics of Extracorporeal Membrane Oxygenation under Conventional and Crisis Standards of Care. THE JOURNAL OF CLINICAL ETHICS 2022; 33:13-22. [PMID: 35100174 PMCID: PMC9648099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of life support for cardiac and/or pulmonary failure with unique ethical challenges compared to other forms of life support. Ethical challenges with ECMO exist when conventional standards of care apply, and are exacerbated during periods of absolute ECMO scarcity when "crisis standards of care" are instituted. When conventional standards of care apply, we propose that it is ethically permissible to withhold placing patients on ECMO for reasons of technical futility or when patients have terminal, short-term prognoses that are untreatable by ECMO. Under crisis standards of care, it is ethically permissible to broaden exclusionary criteria to also withhold ECMO from patients who have a low likelihood of recovery, to maximize the overall number of lives saved. Unilateral withdrawal of ECMO against a patient's preferences is unethical under conventional standards of care, but is ethical under crisis standards of care to increase access to ECMO to others in society. ECMO should only be rationed when true scarcity exists, and allocation protocols should be transparent to the public. When rationing must occur under crisis standards of care, it is imperative that oversight bodies assess for inequities in the allocation of ECMO and make frequent changes to improve any inequities.
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Affiliation(s)
- Gina M Piscitello
- Assistant Professor, Department of Internal Medicine, Section of Palliative Medicine; and Division of Hospital Medicine at Rush Medical College, Rush University, Chicago, Illinois USA.
| | - Mark Siegler
- Lindy Bergman Distinguished Service Professor of Medicine and Surgery, University of Chicago; Founding Director, University of Chicago's MacLean Center for Clinical Medical Ethics; and Executive Director of the Bucksbaum Institute for Clinical Excellence, Chicago, Illinois USA.
| | - William F Parker
- Assistant Professor of Medicine, Section of Pulmonary/Critical Care, University of Chicago Department of Medicine; and Assistant Director, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois USA.
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12
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Frydman JL, Aldridge M, Moreno J, Singer J, Zeng L, Chai E, Morrison RS, Gelfman LP. Access to Palliative Care Consultation for Hospitalized Adults with COVID-19 in an Urban Health System: Were There Disparities at the Peak of the Pandemic? J Palliat Med 2022; 25:124-129. [PMID: 34637349 PMCID: PMC8721492 DOI: 10.1089/jpm.2021.0313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1-June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.
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Affiliation(s)
- Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Julia L. Frydman, MD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Singer
- Enterprise Reporting, Mount Sinai Health System, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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13
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Protocol to assess performance of crisis standards of care guidelines for clinical triage. STAR Protoc 2021; 2:100943. [PMID: 34786562 PMCID: PMC8580414 DOI: 10.1016/j.xpro.2021.100943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
During the COVID-19 pandemic, US states developed Crisis Standards of Care (CSC) algorithms to triage allocation of scarce resources to maximize population-wide benefit. While CSC algorithms were developed by ethical debate, this protocol guides their quantitative assessment. For CSC algorithms, this protocol addresses (1) adapting algorithms for empirical study, (2) quantifying predictive accuracy, and (3) simulating clinical decision-making. This protocol provides a framework for healthcare systems and governments to test the performance of CSC algorithms to ensure they meet their stated ethical goals. For complete details on the use and execution of this protocol, please refer to Jezmir et al. (2021). Scoring with Crisis Standards of Care (CSC) triage algorithms Assessing the predictive accuracy of triage algorithms Simulating clinical decision-making by triage algorithms Troubleshooting disease severity, comorbidity scoring, and ties
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14
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Predictive Value of Sequential Organ Failure Assessment Score across Patients with and without COVID-19 Infection. Ann Am Thorac Soc 2021; 19:790-798. [PMID: 34784497 PMCID: PMC9116345 DOI: 10.1513/annalsats.202106-680oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rationale Sequential organ failure assessment (SOFA) scores are commonly used in crisis standards of care policies to assist in resource allocation. The relative predictive value of SOFA by coronavirus disease (COVID-19) infection status and among racial and ethnic subgroups within patients infected with COVID-19 is unknown. Objectives To evaluate the accuracy and calibration of SOFA in predicting hospital mortality by COVID-19 infection status and across racial and ethnic subgroups. Methods We performed a retrospective cohort study of adult admissions to the University of Miami Hospital and Clinics inpatient wards (July 1, 2020–April 1, 2021). We primarily considered maximum SOFA within 48 hours of hospitalization. We assessed accuracy using the area under the receiver operating characteristic curve (AUROC) and created calibration belts. Considered subgroups were defined by COVID-19 infection status (by severe acute respiratory syndrome coronavirus 2 polymerase chain reaction testing) and prevalent racial and ethnic minorities. Comparisons across subgroups were made with DeLong testing for discriminative accuracy and visualization of calibration belts. Results Our primary cohort consisted of 20,045 hospitalizations, of which 1,894 (9.5%) were COVID-19 positive. SOFA was similarly accurate for COVID-19–positive (AUROC, 0.835) and COVID-19–negative (AUROC, 0.810; P = 0.15) admissions but was slightly better calibrated in patients who were positive for COVID-19. For those with critical illness, maximum SOFA score accuracy at critical illness onset also did not differ by COVID-19 status (AUROC, COVID-19 positive vs. negative: intensive care unit admissions, 0.751 vs. 0.775; P = 0.46; mechanically ventilated, 0.713 vs. 0.792, P = 0.13), and calibration was again better for patients positive for COVID-19. Among patients with COVID-19, SOFA accuracy was similar between the non-Hispanic White population (AUROC, 0.894) and racial and ethnic minorities (Hispanic White population: AUROC, 0.824 [P vs. non-Hispanic White = 0.05]; non-Hispanic Black population: AUROC, 0.800 [P = 0.12]; Hispanic Black population: AUROC, 0.948 [P = 0.31]). This similar accuracy was also found for those without COVID-19 (non-Hispanic White population: AUROC, 0.829; Hispanic White population: AUROC, 0.811 [P = 0.37]; Hispanic Black population: AUROC, 0.828 [P = 0.97]; non-Hispanic Black population: AUROC, 0.867 [P = 0.46]). SOFA was well calibrated for all racial and ethnic groups with COVID-19 but estimated mortality more variably and performed less well across races and ethnicities without COVID-19. Conclusions SOFA accuracy does not differ by COVID-19 status and is similar among racial and ethnic groups both with and without COVID-19. Calibration is better for COVID-19–infected patients and, among those without COVID-19, varies by race and ethnicity.
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15
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Bhavani SV, Luo Y, Miller WD, Sanchez-Pinto LN, Han X, Mao C, Sandıkçı B, Peek ME, Coopersmith CM, Michelson KN, Parker WF. Simulation of Ventilator Allocation in Critically Ill Patients with COVID-19. Am J Respir Crit Care Med 2021; 204:1224-1227. [PMID: 34499587 PMCID: PMC8759315 DOI: 10.1164/rccm.202106-1453le] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | - Yuan Luo
- Northwestern University Fienberg School of MedicineChicago, Illinois
| | | | | | - Xuan Han
- University of Chicago Pritzker School of MedicineChicago, Illinois
| | - Chengsheng Mao
- Northwestern University Fienberg School of MedicineChicago, Illinois
| | | | - Monica E. Peek
- University of Chicago Pritzker School of MedicineChicago, Illinois
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16
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Ross-Driscoll K, Esper G, Kinlaw K, Lee YTH, Morris A, Murphy DJ, Pentz RD, Robichaux C, Vong G, Wack K, Dickert N. Evaluating Approaches to Improve Equity in Critical Care Resource Allocation in the COVID-19 Pandemic. Am J Respir Crit Care Med 2021; 204:1481-1484. [PMID: 34624203 PMCID: PMC8865705 DOI: 10.1164/rccm.202106-1462le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katherine Ross-Driscoll
- Emory University School of Medicine, 12239, Department of Surgery, Atlanta, Georgia, United States
| | - Gregory Esper
- Emory University School of Medicine, 12239, Department of Neurology, Atlanta, Georgia, United States.,Emory Healthcare, 14360, Office of Quality and Risk, Atlanta, Georgia, United States
| | - Kathy Kinlaw
- Emory University, 1371, Center for Ethics, Atlanta, Georgia, United States.,Emory University School of Medicine, 12239, Department of Pediatrics , Atlanta, Georgia, United States
| | - Yi-Ting Hana Lee
- Emory University School of Medicine, 12239, Health Services Research Center, Atlanta, Georgia, United States
| | - Alanna Morris
- Emory University School of Medicine, 12239, Department of Medicine, Atlanta, Georgia, United States
| | - David J Murphy
- Emory University School of Medicine, 12239, Department of Pulmonology, Allergy, and Critical Care, Atlanta, Georgia, United States
| | - Rebecca D Pentz
- Emory University, 1371, Winship Cancer Institute , Atlanta, Georgia, United States
| | - Chad Robichaux
- Emory University School of Medicine, 12239, Department of Biomedical Informatics, Atlanta, Georgia, United States.,Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States
| | - Gerard Vong
- Emory University, 1371, Center for Ethics, Atlanta, Georgia, United States.,Emory University School of Medicine, 12239, Department of Medicine, Atlanta, Georgia, United States
| | - Kevin Wack
- Emory Healthcare, 14360, Clinical Ethics, Atlanta, Georgia, United States
| | - Neal Dickert
- Emory University School of Medicine, 12239, Division of Cardiology, Atlanta, Georgia, United States;
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17
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Gandhi R, Piscitello GM, Parker WF, Michelson K. Variation in COVID-19 Resource Allocation Protocols and Potential Implementation in the Chicago Metropolitan Area. AJOB Empir Bioeth 2021; 12:266-275. [PMID: 34596474 DOI: 10.1080/23294515.2021.1983667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Scarce resource allocation policies vary across the United States. Little is known about regional variation in resource allocation protocols and variation in their application. We sought to evaluate how Covid-19 scarce resource allocation policies vary throughout the Chicago metropolitan area and whether there are differences in policy application within hospitals when prioritizing hypothetical patients who need critical care resources. METHODS Two cross-sectional surveys were distributed to Chicago metropolitan area hospital representatives and triage officers. Survey responses and categorical variables are described by frequency of occurrence. Intra- and interhospital variation in ranking of hypothetical patients was assessed using Fleiss's Kappa coefficients. RESULTS Eight Chicago-area hospitals responded to the survey assessing scarce resource allocation protocols (N = 8/18, response rate 44%). For hospitals willing to describe their ventilator allocation protocol (N = 7), most used the sequential organ failure assessment (SOFA) score (N = 6/7, 86%) and medical comorbidities (N = 4/7, 57%) for initial scoring of patients. A majority gave priority in initial scoring to pre-defined groups (N = 5/7, 71%), all discussed withdrawal of mechanical ventilation for adult patients (N = 7/7, 100%), and a minority had exclusion criteria (N = 3/7, 43%). Forty-nine triage officers from nine hospitals responded to the second survey (N = 9/10 hospitals, response rate 90%). Their rankings of hypothetical patients showed only slight agreement amongst all hospitals (Kappa 0.158) and fair agreement within two hospitals with the most respondents (Kappa 0.21 and 0.25). Almost half used tiebreakers to rank patients (N = 23/49, 47%). CONCLUSIONS Although most respondents from Chicago-area hospitals described policies for resource allocation during the COVID-19 pandemic, the substance and application of these protocols varied. There was little agreement when prioritizing hypothetical patients to receive scarce resources, even among people from the same hospital. Variations in resource allocation protocols and their application could lead to inequitable distribution of resources, further exacerbating community distrust and disparities in health. Supplemental data for this article is available online at https://doi.org/10.1080/23294515.2021.1983667.
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Affiliation(s)
- Rupali Gandhi
- Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | | | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Kelly Michelson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Bioethics & Medical Humanities, Northwestern University Feinberg School of Medicine Institute for Public Health and Medicine, Chicago, Illinois, USA.,Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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18
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Preston-Suni K, Celedon MA, Cordasco KM. Patient Safety and Ethical Implications of Health Care Sick Leave Policies in the Pandemic Era. Jt Comm J Qual Patient Saf 2021; 47:673-676. [PMID: 34420856 PMCID: PMC8457980 DOI: 10.1016/j.jcjq.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 11/21/2022]
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19
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Abstract
I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid‐19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify “tie‐breaking” criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world.
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20
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White DB, Lo B. Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources. Hastings Cent Rep 2021; 51:42-47. [PMID: 34529848 DOI: 10.1002/hast.1285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.
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21
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Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open 2021; 4:e2113891. [PMID: 34143190 PMCID: PMC8214156 DOI: 10.1001/jamanetworkopen.2021.13891] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality. OBJECTIVE To investigate whether reliance on SOFA is associated with bias against Black patients in CSC. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021. EXPOSURE SOFA scores at ICU admission. MAIN OUTCOMES AND MEASURES Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion). RESULTS Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions. CONCLUSIONS AND RELEVANCE This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.
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Affiliation(s)
- William Dwight Miller
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Xuan Han
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- Center for the Study of Race, Politics, and Culture, University of Chicago, Chicago, Illinois
| | - Deepshikha Charan Ashana
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina
| | - William F. Parker
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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22
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Donadee C, Rudd KE. Mortality Prediction Models: Another Barrier to Racial Equity in a Pandemic. Am J Respir Crit Care Med 2021; 204:120-121. [PMID: 33945776 PMCID: PMC8650786 DOI: 10.1164/rccm.202103-0809ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Chenell Donadee
- Department of Critical Care Medicine University of Pittsburgh Pittsburgh, Pennsylvania
| | - Kristina E Rudd
- Department of Critical Care Medicine University of Pittsburgh Pittsburgh, Pennsylvania.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center University of Pittsburgh Pittsburgh, Pennsylvania
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23
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Cleveland Manchanda EC, Molina MF, Rodriguez RM. Racial Equity in Crisis Standards of Care-Reassuring Data or Reason for Concern? JAMA Netw Open 2021; 4:e214527. [PMID: 33739428 DOI: 10.1001/jamanetworkopen.2021.4527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Emily C Cleveland Manchanda
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Melanie F Molina
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco
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