Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Abstract

Background Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies. The novel coronavirus disease (COVID-19) has disproportionately affected Black and Latinx populations in the USA. No literature exists comparing state-level CSC. It is unknown how equitably CSC would allocate resources. Methods The authors identified all publicly available state-level CSC through online searches and communication with state governments. Publicly available CSC were systematically reviewed for content including ethical framework and prioritization strategy. Results CSC were identified for 29 states. Ethical principles were explicitly stated in 23 (79.3%). Equity was listed as a guiding ethical principle in 15 (51.7%); 19 (65.5%) said decisions should not factor in race, ethnicity, disability, and other identity-based factors. Ten states (34.4%) allowed for consideration of societal value, which could lead to prioritization of health care workers and other essential personnel. Twenty-one (72.4%) CSC provided a specific strategy for prioritizing patients for critical care resources, e.g., ventilators. All incorporated Sequential Organ Failure Assessment scores; 15 (71.4%) of these specific CSC considered comorbid conditions (e.g., cardiac disease, renal failure, malignancy) in resource allocation decisions. Conclusion There is wide variability in the existence and specificity of CSC across the USA. CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism.

Assessment of Disparities Associated With a Crisis Standards of Care Resource Allocation Algorithm for Patients in 2 US Hospitals During the COVID-19 Pandemic

“…Evidence for higher comorbidity burdens among individuals from underrepresented minority groups is robust 26,27 and has been the focus of many concerns regarding possible disparities related to CSC policies. 3,8,9 There is also evidence that acuity of non-COVID-19 illness on ICU presentation 28 patients with triage scoring strengthens our findings. Finally, our results may be affected by residual confounding, specifically socioeconomic factors.…”

“…Patients only received 1 allotment of comorbidity points based the highest point value appropriate without a sum of scores from multiple comorbidities (ie, someone with 2 comorbidities with reduced 5-year survival and 3 comorbidities with reduced 1-year survival received 4 points for having at least 1 comorbidity that reduced 1-year survival). If needed, resource allocation would be based on priority groups (1)(2)(3) with ties within groups broken by comorbidities known to affect short-term recovery, then age (ie, younger patients receiving priority), followed by provision of an essential function within health care, then actual priority score (1)(2)(3)(4)(5)(6)(7)(8), and, finally, lottery. If we were ever to implement this process, all…”

“…Most regional and institutional CSC policies incorporate some measure of estimated short-term survival (eg, based on Sequential Organ Failure Assessment [SOFA] scores 7 ), and many, although not all, also include an assessment of likely longer-term prognosis (eg, based on comorbidities). 3 , 4 …”

“…Significant concern has been raised that CSC policies—especially those that consider longer-term prognosis in triage scoring—may systematically deprioritize patients from underrepresented minority groups given the higher incidence of comorbidities among these populations resulting from systemic racism. 3 , 8 , 9 In fact, compared with White lay people, Black individuals were significantly more likely to prefer a triage algorithm based on the principle of first come, first served and less likely to prefer one aimed at saving the most life-years, 5 which may be a reflection of this very real concern.…”

COVID-19 ventilator rationing protocols: why we need to know more about the views of those with most to lose

“…In the wake of the initial US surge of the COVID-19 pandemic, numerous hospitals and states developed plans for how to allocate ventilators. [1][2][3][4] We seek to determine what is known about the views of historically and structurally disadvantaged populations on guiding rationing principles. This analysis matters practically for designing and reviewing triage models in the ongoing epidemic, and conceptually for assessing their underlying values.…”