Equitably Allocating Resources during Crises: Racial Differences in Mortality Prediction Models

Ashana, Deepshikha Charan; Anesi, George L; Liu, Vincent X; Escobar, Gabriel J.; Chesley, Christopher F; Eneanya, Nwamaka D.; Weissman, Gary E.; Miller, William; Harhay, Michael O.; Halpern, Scott D.

doi:10.1164/rccm.202012-4383oc

Cited by 76 publications

(102 citation statements)

References 45 publications

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“…(15) These findings ar e also consistent with prior findings that SOFA overestimates mortality among Black patients and underestimates mortality among White patients with sepsis and ARDS prior to the COVID-19 pandemic. (26) The racial disparities in SOFA scores we found among patients with COVID might be due to this systemic overestimation of mortality among Black persons and underestimation of mortality among White persons. Alternatively, Black persons with COVID-19 might have higher SOFA scores in the hospital because COVID-19 affects them more severely, for example because they are subjected to higher levels of discrimination and stress or because they have less access to long-term preventive care.…”

Section: Discussionmentioning

confidence: 79%

“…(24, 25) The potential for triage protocols to exacerbate racial and ethnic health disparities has been documented in patient cohorts with sepsis and acute respiratory distress syndrome (ARDS) but has not previously been examined in patients with COVID-19. (26) There is therefore a lack of evidence as to whether there are disparities by race and ethnicity in SOFA scores amongst patients admitted with COVID-19. We conducted a retrospective cohort study to determine whether SOFA scores are disproportionately elevated among members of racial and ethnic minorities, and specifically Non-Hispanic Black and Hispanic patients, in comparison to Non-Hispanic White patients with COVID-19.…”

Section: Introductionmentioning

confidence: 99%

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Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19

Tolchin

Oladele

Galusha

et al. 2021

Preprint

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Background: Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care use SOFA score to allocate medical resources during the COVID-19 pandemic. Research Question: Are SOFA scores disproportionately elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients? Study Design and Methods: Retrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged ≥18 admitted with COVID-19 from March 29th to August 1st, 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcomes was SOFA score, with peak score within 24 hours of admission dichotomized as <6 or ≥6. Results: Of 2982 patients admitted with COVID-19, 2320 met inclusion criteria and were analyzed, of whom 1058 (45.6%) were Non-Hispanic White, 645 (27.8%) were Hispanic, and 617 (26.6%) were Non-Hispanic Black. Median age was 65.0 and 1226 (52.8%) were female. In univariate logistic screen and in full multivariate model, Non-Hispanic Black patients but not Hispanic patients had greater odds of an elevated SOFA score ≥6 when compared to Non-Hispanic White patients (OR 1.49, 95%CI 1.11-1.99). Interpretation: Crisis standards of care utilizing the SOFA score to allocate medical resources would be more likely to deny these resources to Non-Hispanic Black patients.

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Section: Discussionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19

Tolchin

Oladele

Galusha

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…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.…”

Section: Responsementioning

confidence: 99%

“…The SOFA score without creatinine reduced racial miscalibration. 3 In practice, under severe crisis conditions, these results suggest that the Model Policy would lead to the deaths of large numbers of black patients by inappropriately denying them ICU care despite good prognoses.…”

mentioning

confidence: 97%

“…The team calculated in-hospital mortality of SOFA and another score, 'including categorical SOFA groups recommended in a popular crisis standard of care, and a SOFA score without creatinine to reduce the influence of race'. 3 The standard referred to is the same Model Guidance included in the Directive that we drew on. The authors urge that more equitable mortality prediction scores be developed, since:…”

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confidence: 99%

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

2021

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

Mikell

Hoggard

Schmidt

2023

AMA Journal of Ethics

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This commentary on a case examines racially inequitable outcomes, especially for Black patients, resulting from use of Sequential Organ Failure Assessment (SOFA) scores to triage patients during the COVID-19 pandemic and how inequitable outcomes in triage protocols could be reduced. It also considers the nature and scope of clinician governor responses to members of federally protected classes who are disadvantaged by use of the SOFA score and argues that clinician leaders of the Centers for Disease Control and Prevention, specifically, should provide federal guidance that motivates clear legal accountability.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. CaseDr D is an infectious disease specialist, an epidemiologist, and the medical director of a state department of health. Following a flu season that was socially and fiscally devastating, Dr D administers budget for essential personnel, surge planning, tertiary triage strategy, and critical care inventory (eg, ventilators, dialysis machines, medications, personal protective equipment). Dr D assembles a central committee of regional triage officers from around the state, which forges consensus about communication plans that activate the triage strategy across the state in response to an emergency (ie, epidemic, multi-locale mass casualty events, natural disaster) and how to train teams to implement protocols efficiently and equitably.State epidemiological data reveal that low-income communities and communities of color were inequitably burdened (in terms of higher morbidity, more complications, higher mortality) by the most recent flu outbreak. Age-adjusted flu hospitalizations were highest among Black persons, second highest among American Indian and Alaska Native persons, and third highest among Latinx persons.

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Equitably Allocating Resources during Crises: Racial Differences in Mortality Prediction Models

Cited by 76 publications

References 45 publications

Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19

Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19

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

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

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