How have US clinicians planned for and responded to resource limitation during the coronavirus disease 2019 pandemic?
This qualitative study included interviews with 61 clinicians across the United States. While institutions planned for an explicit and systematic approach to resource allocation in crisis settings, this approach did not address many challenges encountered by frontline clinicians, leaving them to struggle with what constituted acceptable standards of care and to make difficult allocation decisions.
The findings of this study suggest that expanding the scope of institutional planning to address a broader spectrum of resource limitation may help to support clinicians, promote equity, and optimize care during the pandemic.
Little is known about how US clinicians have responded to resource limitation during the coronavirus disease 2019 (COVID-19) pandemic.
To describe the perspectives and experiences of clinicians involved in institutional planning for resource limitation and/or patient care during the pandemic.
Design, Setting, and Participants
This qualitative study used inductive thematic analysis of semistructured interviews conducted in April and May 2020 with a national group of clinicians (eg, intensivists, nephrologists, nurses) involved in institutional planning and/or clinical care during the COVID-19 pandemic across the United States.
Main Outcomes and Measures
Emergent themes describing clinicians’ experience providing care in settings of resource limitation.
The 61 participants (mean [SD] age, 46  years; 38 [63%] women) included in this study were practicing in 15 US states and were more heavily sampled from areas with the highest rates of COVID-19 infection at the time of interviews (ie, Seattle, New York City, New Orleans). Most participants were White individuals (39 [65%]), were attending physicians (45 [75%]), and were practicing in large academic centers (≥300 beds, 51 [85%]; academic centers, 46 [77%]). Three overlapping and interrelated themes emerged from qualitative analysis, as follows: (1) planning for crisis capacity, (2) adapting to resource limitation, and (3) multiple unprecedented barriers to care delivery. Clinician leaders worked within their institutions to plan a systematic approach for fair allocation of limited resources in crisis settings so that frontline clinicians would not have to make rationing decisions at the bedside. However, even before a declaration of crisis capacity, clinicians encountered varied and sometimes unanticipated forms of resource limitation that could compromise care, require that they make difficult allocation decisions, and contribute to moral distress. Furthermore, unprecedented challenges to caring for patients during the pandemic, including the need to limit in-person interactions, the rapid pace of change, and the dearth of scientific evidence, added to the challenges of caring for patients and communicating with families.
Conclusions and Relevance
The findings of this qualitative study highlighted the complexity of providing high-quality care for patients during the COVID-19 pandemic. Expanding the scope of institutional planning to address resource limitation challenges that can arise long before declarations of crisis capacity may help to support frontline clinicians, promote equity, and optimize care as the pandemic evolves.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: October 3, 2020.
Published: November 6, 2020. doi:10.1001/jamanetworkopen.2020.27315
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Butler CR et al. JAMA Network Open.
Corresponding Author: Catherine R. Butler, MD, MA, Division of Nephrology, Department of Medicine, University of Washington, 1959 NE Pacific St, Campus Box 356521, Seattle, WA 98195 (email@example.com).
Author Contributions: Drs Butler and O’Hare had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Butler, Wong, O’Hare.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Butler, Wong.
Critical revision of the manuscript for important intellectual content: Butler, Wightman, O’Hare.
Statistical analysis: Butler.
Obtained funding: Wong.
Administrative, technical, or material support: Butler, Wong, O’Hare.
Supervision: All authors.
Conflict of Interest Disclosures: Dr O’Hare reported receiving grants from US Department of Veterans Affairs Health Services Research and Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and the US Centers for Disease Control and Prevention; participating in an operation project with the US Department of Veterans Affairs National Center for Ethics in Health Care; and receiving personal fees from UpToDate, the Coalition for the Supportive Care of Kidney Patients, Hammersmith Hospital, the University of Alabama, Birmingham, the University of Pennsylvania, the New York Society of Nephrology, the University of California, San Francisco, Fresenius Medical Care, Dialysis Clinic, Inc, the Devenir Foundation, the Japanese Society of Dialysis Therapy, Chugai Pharmaceuticals, and the American Society of Nephrology outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by the National Institute of Health National Institute of Diabetes and Digestive and Kidney Diseases (grant No. 5T32DK007467-33 to Dr Butler and grant No. 1K23DK107799-01A1 to Dr Wong), a COVID-19 Research Award from the University of Washington Institute of Translational Health Sciences (to Dr. Butler), and the Division of Nephrology, University of Washington (faculty funds to Dr O’Hare).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or National Institute of Diabetes and Digestive and Kidney Diseases.
Additional Contributions: We are truly grateful for the generosity of clinician participants who volunteered their time during a period of unprecedented demands on their energy. We would also like to thank Mark Tonelli, MD (Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington), for his help facilitating recruitment and thoughtful input on an early draft of the manuscript and Ross Burnside for his help with transcription. They were not compensated for their time.
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