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

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 PARTICIPANTSThis 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.

Silent Hypoxemia in the Emergency Department: A Retrospective Cohort of Two Clinical Phenotypes in Critical COVID-19

“…Emergency and critical care systems were overwhelmed by surges of critically ill, deteriorating patients in need of adequate triage and intensive care. However, the resources were inadequate, forcing hospitals to undergo a structural reorganization to accommodate a time of crisis [ 24 , 25 ]. In uncharted medical territory, the shortage of reserves during the peak stages of the pandemic created vital dilemmas about ideal rationing and timely treatment.…”

Commentary: The Changing Face of Dentistry

“…Health care is no exception. For example, a recent study (Riviello et al 2022) examined instruments used to prioritize care in situations where health care resources are not sufficient to meet demand (Crisis Standards of Care-CSOC). These instruments were designed to optimize overall survival and life years.…”

Inequitable Resource Allocation Amidst a Pandemic—A Crisis Within a Crisis

“…Finally, we need to ensure that any CSOC policy is feasible, useful, and acceptable to all stakeholders. In the study by Riviello and colleagues, priority scores were assigned by redeployed nurses, whereas in my hospitals, medical students sidelined from clinical roles took on this task . It is notable that Riviello and colleagues had to exclude 17.6% of their initial cohort because scores were incomplete.…”

“…Absent such policies, 1 of 3 things will surely happen if resources become scarce: an unweighted lottery will occur; resources will be offered on a first-come, first-served basis; or, those with greater means (eg, money, connections) will be prioritized. Riviello and colleagues found that an unweighted lottery would result in more excess deaths than the evaluated CSOC policy. Health care workers and lay people alike are known to prefer strategies based on survivability, life stages lived, and value to others over unweighted lotteries or triage by arrival order .…”

“…Elsewhere in JAMA Network Open , Riviello and colleagues investigate the differential impact of the Massachusetts Department of Public Health’s CSOC guidelines regarding resource allocation for patients of varying races and ethnicities. They used data from 498 critically ill adults in 6 greater Boston hospitals during the spring 2020 COVID-19 surge for whom, in preparation for possible triage, nurses had prospectively assigned priority scores based on estimates of short-term mortality (using Sequential Organ Failure Assessment [SOFA] score) and longer-term mortality (initially from comorbidity burden and later using attending physicians’ estimates of expected 1- and 5-year survival).…”