Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19

Elisabeth D Riviello,Daniel P Walsh,Tenzin Dechen,David N Sontag,Noa Talmor,Michael Rosenblatt,Jennifer P Stevens,Margaret M Hayes,Nicole H Moraco,Rose L Molina,Ashley L O’Donoghue,Michael N Cocchi,Anne Mosenthal

doi:10.1001/jamanetworkopen.2022.1744

Abstract

Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Race, ethnicity, Social Vulnerability Index. The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Highlights

In this study, a crisis standards of care (CSOC) priority score resulted in lower prioritization of Black patients to receive scarce resources
Key Points Question Is a crisis standards of care scoring system designed to allocate scarce resources in the COVID-19 pandemic associated with inequities in resource allocation by race?. In this cohort study of 498 adults admitted to the intensive care unit and preemptively scored during a COVID-19 surge, nearly twice the proportion of Black patients were scored in the lowest priority group compared with all other patients, a significant difference. Meaning These findings suggest that a scoring system designed to maximize lives and life-years saved in the setting of resource scarcity during the COVID-19 pandemic may result in racial inequities in prioritization
CSOC Score Performance We evaluated the discrimination of the priority score to estimate the likelihood of in-hospital mortality using the area under the receiver operating characteristic curve (AUROC), and the calibration using Hosmer-Lemeshow test of difference

Summary

Introduction

During the COVID-19 pandemic, regional surges in the number of critically ill patients led to concerns that available critical care resources, including ventilators as well as staffed intensive care unit (ICU) beds, could be inadequate to meet patient needs. In response, crisis standards of care (CSOC) plans for allocation of resources were developed. Initial ethical frameworks for CSOC plans focused primarily on prioritizing the greatest number of lives saved and life-years saved. Policies to operationalize these frameworks most often included the Sequential Organ Failure Assessment (SOFA) score for estimating the likelihood of acute mortality and assessment of life expectancy or comorbidities for longer-term mortality prediction.2,6,7Advocacy groups and ethicists, citing the known impact of structural racism on health outcomes before and during the COVID-19 pandemic, subsequently highlighted the need to include equity as a primary goal of CSOC triage scores. Scoring systems could exacerbate racial inequities in several ways. Initial ethical frameworks for CSOC plans focused primarily on prioritizing the greatest number of lives saved and life-years saved.. Initial ethical frameworks for CSOC plans focused primarily on prioritizing the greatest number of lives saved and life-years saved.3-5 Policies to operationalize these frameworks most often included the Sequential Organ Failure Assessment (SOFA) score for estimating the likelihood of acute mortality and assessment of life expectancy or comorbidities for longer-term mortality prediction.. Advocacy groups and ethicists, citing the known impact of structural racism on health outcomes before and during the COVID-19 pandemic, subsequently highlighted the need to include equity as a primary goal of CSOC triage scores.. Because poor health status is an outcome of structural racism, allocating resources first to patients who are less sick could increase already-present disparities; this is a potential problem even if scoring systems perfectly estimate the likelihood of mortality. Bedside clinicians participate in scoring, and explicit or implicit biases could play a role in perpetuating disparities. Scores could have differential discrimination or calibration characteristics in different racial groups, which could result in worsening inequities. because poor health status is an outcome of structural racism, allocating resources first to patients who are less sick could increase already-present disparities; this is a potential problem even if scoring systems perfectly estimate the likelihood of mortality.

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