The potential impact of triage protocols on racial disparities in clinical outcomes among COVID-positive patients in a large academic healthcare system

Abstract

Background The COVID-19 pandemic has had a devastating impact in the United States, particularly for Black populations, and has heavily burdened the healthcare system. Hospitals have created protocols to allocate limited resources, but there is concern that these protocols will exacerbate disparities. The sequential organ failure assessment (SOFA) score is a tool often used in triage protocols. In these protocols, patients with higher SOFA scores are denied resources based on the assumption that they have worse clinical outcomes. The purpose of this study was to assess whether using SOFA score as a triage tool among COVID-positive patients would exacerbate racial disparities in clinical outcomes. Methods We analyzed data from a retrospective cohort of hospitalized COVID-positive patients in the Yale-New Haven Health System. We examined associations between race/ethnicity and peak overall/24-hour SOFA score, in-hospital mortality, and ICU admission. Other predictors of interest were age, sex, primary language, and insurance status. We used one-way ANOVA and chi-square tests to assess differences in SOFA score across racial/ethnic groups and linear and logistic regression to assess differences in clinical outcomes by sociodemographic characteristics. Results Our final sample included 2,554 patients. Black patients had higher SOFA scores compared to patients of other races. However, Black patients did not have significantly greater in-hospital mortality or ICU admission compared to patients of other races. Conclusion While Black patients in this sample of hospitalized COVID-positive patients had higher SOFA scores compared to patients of other races, this did not translate to higher in-hospital mortality or ICU admission. Results demonstrate that if SOFA score had been used to allocate care, Black COVID patients would have been denied care despite having similar clinical outcomes to white patients. Therefore, using SOFA score to allocate resources has the potential to exacerbate racial inequities by disproportionately denying care to Black patients and should not be used to determine access to care. Healthcare systems must develop and use COVID-19 triage protocols that prioritize equity.

Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study

“…Specifically, the SOFA score has shown poor accuracy in the context of COVID-19 and confers limited ability to clinically differentiate between prognostic categories ( 17 ). Further, this score may perpetuate biases against underserved racial groups ( 18 ). For these reasons, the SOFA score has been removed from many triage algorithms, including for Washington State.…”

What Should Be Roles of Federal Clinician Governors in Motivating Equity in Locally Coordinated Triage Protocols?

“…Roy et al found that Black patients had higher mean peak and mean 24-hour SOFA scores than patients of other races despite not having significantly greater ICU admission and in-hospital mortality rates. 5 Although Gershengorn and colleagues found SOFA accuracy to be consistent among racial and ethnic groups, 6 accuracy does not guarantee equitable treatment. In a large multisite cohort study, Miller et al found that Black patients' odds of dying were 2% lower than those of White patients with equivalent SOFA scores.…”

Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19

“…Even if we had access to data from COVID-19 patients who did not require ICU admission, this design would still condition sick patients who nevertheless were healthy enough to survive hospital admission or presentation to a healthcare provider. Our study was conducted during the first wave of the COVID-19 pandemic when there was a rise in excess out-of-hospital sudden deaths (41)(42)(43).…”