Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care

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 PARTICIPANTSThis 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 MEASURESHierarchical 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

Sequential organ failure assessment, ventilator rationing and evolving triage guidance: new evidence underlines the need to recognise and revise, unjust allocation frameworks

“…where only the top priority tier would receive treatment, 15.6% of black patients were misclassified from the highest to the second priority. 4 Second, White and Lo claim that our conclusions are at best limited, due to a perceived erroneous description of their model. For example: 'Although it is plausible-but uncertainthat using the two-criterion framework they inaccurately described as the NJ framework may worsen disparities the actual four-criterion framework we developed is unlikely to worsen disparities and would probably mitigate them'.…”

“…We, therefore accurately characterised the multiprinciple strategy and its consequences, and more robust (including broadly concurrent) data than presented by White and Lo show that the Model Guidance as integrated into the NJ Directive indeed exacerbates black patients' disadvantage. [3][4][5] In a broader perspective, this situation raises critical questions about the obligations of authors of high-stake guidelines to inform users about important updates in an accurate, transparent and timely manner as well as regarding other structures that avoid triage decisions being based on outdated frameworks.…”

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

“…16 Another large retrospective study of ICU patients admitted prior to the COVID-19 pandemic also found that the SOFA score overestimated mortality among Black patients. 18 Another study that looked at 3 priority groupings of critically ill patients in 2 hospitals in Florida during the pandemic found no difference in priority groupings between patients in different racial categories. 7 The Massachusetts Department of Public Health published guidelines for the allocation of scarce resources on April 7, 2020, using the SOFA score as a proxy for likelihood of acute survival and a comorbidities score as a proxy for likelihood of long-term survival.…”

“…Crisis Standards of Care and Estimated Excess Mortality by Race and Ethnicity During COVID-19 length of stay of 13(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) days. A total of 119 patients (23.9%) died during the hospitalization, and 165 (45.3%) were discharged home without hospice.…”

“…Patients residing in socially vulnerable areas were more likely to be COVID-19 positive than others (79 [62.2%] vs 146 [39.4%];Patient OutcomesOverall, 244 patients (49.5%) received mechanical ventilation, with a median (IQR) of 10 (4-19) days of ventilation (Table2). Median (IQR) ICU length of stay was 6 (3-17) days, with median (IQR) hospital JAMA Network Open | Critical Care Medicine[4][5][6][7][8][9][10][11][12][13][14][15][16][17] days; P = .005), have longer median (IQR) ICU stays(12 [3-26] days vs 5[3][4][5][6][7][8][9][10][11][12][13][14] days; P < .001), and longer median (IQR) hospital stays(19 [9-35] days vs 11[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] days, P < .001) (eTable 4 in the Supplement).…”