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

Abstract

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.

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols

“…This finding is in prima facie tension with previously reported simulations of triage protocols with COVID-19 positive cohorts,(8) pre-pandemic cohorts,(9,10) and with the lived experience of actual COVID mortality in intensive care units. (5,20) Age-adjusted rates of survival remained significantly lower for White patients, and thus it is unlikely that the observed racial disparities are solely explained by the different age distributions amongst White non-Hispanic, Hispanic and Black non-Hispanic patients in our sample. Rather, we suspect that hospital-level population bias may explain this difference.…”

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

“…Schmidt et al 2022 echo these points, noting that the SOFA score's creatinine measure simultaneously measures kidney function and social disadvantage and that, when this measure is included, the SOFA score generally advantages White patients while disadvantaging Black patients. 15 It should be clear to Dr D that creating a more equitable triage protocol is an urgent task required to reduce health care and health disparities among Black and other historically marginalized groups.…”

“…This could be done, for example, by removing the creatinine component from the SOFA score, as the Black population has elevated creatinine levels. 4,7,8,15 Sederstrom and Wiggleton-Little propose that SOFA scores be amended to allocate points back to Black Americans to alleviate some of the burden of blackness for patients in triage. 14 Moreover, the approach assigns additional points to patients who currently reside in areas of resource deprivation.…”

Centring race, deprivation, and disease severity in healthcare priority setting

“…Schmidt et al defend their work against these criticisms 11. They point out that White and Lo’s description of the guidelines refers to a more recent, corrected version that has not yet been updated in the public domain.…”

“…They point out that White and Lo’s description of the guidelines refers to a more recent, corrected version that has not yet been updated in the public domain. They also direct readers towards two recent studies reporting racially unjust outcomes when using the SOFA heuristic,12 13 which suggest that, if ventilator access came under pressure due a new strain of COVID-19, or a future pandemic, the current policy ‘would lead to the deaths of large numbers of black patients by inappropriately denying them ICU care despite good prognoses’ 11…”