US State Government Crisis Standards of Care Guidelines

Abstract

IMPORTANCE State crisis standards of care (CSC) guidelines in the US allocate scarce health care resources among patients. Anecdotal reports suggest that guidelines may disproportionately allocate resources away from patients with cancer, but no comprehensive evaluation has been performed. OBJECTIVE To examine the implications of US state CSC guidelines for patients with cancer, including allocation methods, cancer-related categorical exclusions and deprioritizations, and provisions for blood products and palliative care.DESIGN, SETTING, AND PARTICIPANTS This cross-sectional population-based analysis examined state-endorsed CSC guidelines published before May 20, 2020, that included health care resource allocation recommendations. MAIN OUTCOMES AND MEASURESGuideline publication before or within 120 days after the first documented US case of coronavirus disease 2019 (COVID-19), inclusion of cancer-related categorical exclusions and/or deprioritizations, provisions for blood products and/or palliative care, and associations between these outcomes and state-based cancer demographics.RESULTS Thirty-one states had health care resource allocation guidelines that met inclusion criteria, of which 17 had been published or updated since the first US case of COVID-19. States whose available hospital bed capacity was predicted to exceed 100% at 6 months (χ 2 = 3.82; P = .05) or that had a National Cancer Institute-designated Comprehensive Cancer Center (CCC; χ 2 = 6.21; P = .01) were more likely to have publicly available guidelines. The most frequent primary methods of prioritization were the Sequential Organ Failure Assessment score (27 states [87%]) and deprioritizing persons with worse long-term prognoses (22 states [71%]). Seventeen states' (55%) allocation methods included cancer-related deprioritizations, and 8 states (26%) included cancer-related categorical exclusions. The presence of an in-state CCC was associated with lower likelihood of cancer-related categorical exclusions (multivariable odds ratio, 0.06 [95% CI, 0.004-0.87]). Guidelines with disability rights statements were associated with specific provisions to allocate blood products (multivariable odds ratio, 7.44 [95% CI,. Both the presence of an in-state CCC and having an oncologist and/or palliative care specialist on the state CSC task force were associated with the inclusion of palliative care provisions.CONCLUSIONS AND RELEVANCE Among states with CSC guidelines, most deprioritized some patients with cancer during resource allocation, and one-fourth categorically excluded them. The presence of an in-state CCC was associated with guideline availability, palliative care provisions, and lower odds of cancer-related exclusions. These data suggest that equitable state-level CSC considerations for patients with cancer benefit from the input of oncology stakeholders.

Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States

“…During the COVID-19 pandemic, more than 30 US states developed crisis standards of care (CSC) guidelines. [2][3][4] These guidelines are designed to help hospitals allocate resources, such as ventilators, if they became scarce. 5 Unlike the ''all-come, allserved'' promise of hospital resources during non-crisis situations, CSC guidelines aim to maximize the population-wide benefit.…”

“…6,7 State guidelines generally describe ethical principles and outline triage algorithms for resource allocation. 2,3 To maximize the population-wide benefit, these algorithms aim to identify patients most likely to survive if offered scarce resources. Nearly 90% of states with CSC triage algorithms adapted Sequential Organ Failure Assessment (SOFA) or Modified SOFA (MSOFA) scores to predict short-term prognosis (i.e., survival to hospital discharge) in an effort to maximize the number of lives saved.…”

“…Nearly 90% of states with CSC triage algorithms adapted Sequential Organ Failure Assessment (SOFA) or Modified SOFA (MSOFA) scores to predict short-term prognosis (i.e., survival to hospital discharge) in an effort to maximize the number of lives saved. 2,3,[8][9][10][11] States vary in their use SOFA/MSOFA scores-for example, by grouping scores in different ranges to assign priority points or by modifying scoring calculations. 2,3 Approximately 70% of states also incorporate measures of comorbidities in priority scoring, which may affect both shortand long-term prognosis.…”

“…2,3,[8][9][10][11] States vary in their use SOFA/MSOFA scores-for example, by grouping scores in different ranges to assign priority points or by modifying scoring calculations. 2,3 Approximately 70% of states also incorporate measures of comorbidities in priority scoring, which may affect both shortand long-term prognosis. 2,3 Additionally, some states use a multicomponent model that incorporates factors such as estimated survival or duration of benefit or need in addition to SOFA scores.…”

“…2,3 Approximately 70% of states also incorporate measures of comorbidities in priority scoring, which may affect both shortand long-term prognosis. 2,3 Additionally, some states use a multicomponent model that incorporates factors such as estimated survival or duration of benefit or need in addition to SOFA scores. 2 Although ethicists have debated triage approaches, CSC algorithms have had limited empirical testing in the COVID-19 pandemic.…”