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Assessment of Disparities Associated With a Crisis Standards of Care Resource Allocation Algorithm for Patients in 2 US Hospitals During the COVID-19 Pandemic

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To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is there an association of race and/or ethnicity with priority scores based on both short-term and longer-term estimated mortality used for resource allocation under crisis standards of care?

Findings  In this retrospective cohort study of 1127 patients with 5613 patient-days in 2 US hospitals, there was no significant association of race or ethnicity with priority score.

Meaning  In this study, the use of a crisis standards of care resource allocation policy based on both short-term and longer-term estimated mortality did not appear to discriminate against hospitalized patients based on self-identified race or ethnicity.


Importance  Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity.

Objective  To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution’s resource allocation policy.

Design, Setting, and Participants  This cohort study included adults (aged ≥18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida.

Exposures  Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic).

Main Outcomes and Measures  The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome.

Results  The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13).

Conclusions and Relevance  In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning the resource allocation policy. Despite this finding, any policy to guide altered standards of care during a crisis should be monitored to ensure equitable distribution of resources.

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Article Information

Accepted for Publication: February 7, 2021.

Published: March 19, 2021. doi:10.1001/jamanetworkopen.2021.4149

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Gershengorn HB et al. JAMA Network Open.

Corresponding Author: Hayley B. Gershengorn, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Rosenstiel Medical Science Building, Room 7043B, Miami, FL 33136 (hbg20@med.miami.edu).

Author Contributions: Dr Gershengorn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gershengorn, Holt, Mora, West, Goodman, Kett, Brosco.

Acquisition, analysis, or interpretation of data: Gershengorn, Holt, Rezk, Delgado, Shah, Arora, Colucci, Mora, Iyengar, Lopez, Martinez, West, Kett, Brosco.

Drafting of the manuscript: Gershengorn, Holt, Delgado, Mora, Iyengar, Goodman.

Critical revision of the manuscript for important intellectual content: Gershengorn, Holt, Rezk, Shah, Arora, Colucci, Lopez, Martinez, West, Goodman, Kett, Brosco.

Statistical analysis: Gershengorn, Rezk, Iyengar.

Administrative, technical, or material support: Holt, Rezk, Delgado, Shah, Mora, Lopez, Kett, Brosco.

Supervision: Lopez, Kett.

Communicating crisis standards of care to institutional leadership: Goodman.

Conflict of Interest Disclosures: Dr Gershengorn reported receiving personal fees from Gilead outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Gershengorn received funding from the University of Miami Hospital through the UHealth-DART research group.

Role of the Funder/Sponsor: The funder 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.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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