Inequitable Resource Allocation Amidst a Pandemic—A Crisis Within a Crisis

Hayley B. Gershengorn
2022 JAMA Network Open  
The COVID-19 pandemic has made us reconsider our approach to many aspects of health care. Two issues frequently discussed are the impact of systemic racism on access and outcomes as well as the need to establish practical and valid crisis standards of care (CSOC) policies to assist in resource allocation when demand exceeds supply. At their intersection is the possibility for inequitable triage, a humanmade crisis we cannot accept. Elsewhere in JAMA Network Open, Riviello and colleagues 1
more » ... igate the differential impact of the Massachusetts Department of Public Health's CSOC guidelines regarding resource allocation for patients of varying races and ethnicities. They used data from 498 critically ill adults in 6 greater Boston hospitals during the spring 2020 COVID-19 surge for whom, in preparation for possible triage, nurses had prospectively assigned priority scores based on estimates of short-term mortality (using Sequential Organ Failure Assessment [SOFA] score) and longer-term mortality (initially from comorbidity burden and later using attending physicians' estimates of expected 1-and 5-year survival). Using this schema, they found that Black patients were more likely to be in the lowest priority group than White patients (15.2% vs 8.1%; P = .046 for lowest vs middle and high priority groups combined); however, when considering the distribution across all priority groups (low vs middle vs high, all separately) or individual priority score components (SOFA, comorbidities, or lifeexpectancy estimates), they found no difference between Black and White individuals. In a simulation using the CSOC guidelines where only the highest priority patients received ventilators, they found that 18 of 41 Black patients (43.9%) who received a ventilator would have been denied one vs only 58 of 203 patients identifying as other races (28.6%; P = .05). No difference in priority was found for Hispanic and non-Hispanic patients. These findings add to a growing yet inconsistent evidence base pertaining to CSOC equity. Two studies 2,3 evaluated the differential accuracy of SOFA scores across racial and ethnic groups, a score many CSOC policies rely on to estimate short-term mortality. In 1 study, 2 mortality discrimination by
doi:10.1001/jamanetworkopen.2022.1751 pmid:35289866 fatcat:eavnvb2ucrdyzjaunsi35znfxa