Twice as many Black COVID patients deemed lowest priority in ICU triage system

A crisis-standards-of-care (CSOC) scoring system used to triage COVID-19 intensive care unit (ICU) patients assigned twice the proportion of Black patients as other patients to the lowest-priority group, finds a modeling study published yesterday in JAMA Network Open.

During the pandemic, health systems developed CSOC scoring systems to prioritize the allocation of scarce resources such as ventilators. While the Massachusetts Department of Health published and then revised guidelines for COVID-related resource rationing, and Beth Israel preemptively scored patients to prepare for shortages, resources remained adequate, and allocation didn't occur. This study is an analysis of that data.

A team led by Beth Israel Deaconess Medical Center researchers analyzed the link between the CSOC scoring system with estimated excess deaths by race, ethnicity, and residence in a socially vulnerable area among 498 adults admitted to an ICU at one of six Boston hospitals amid a COVID-19 surge from Apr 13 to May 22, 2020. Median participant age was 67 years, 38.4% were women, 15.9% were Black, and 45.7% had COVID-19.

The researchers scored participants by severity of infection using the Sequential Organ Failure Assessment score and severity of chronic illness using underlying illnesses, life expectancy, and the US Centers for Disease Control and Prevention Social Vulnerability Index (SVI).

Higher proportion of excess deaths

Relative to other participants, Black patients were more likely to be assigned to the lowest-priority group (15.2% vs 8.1%). An exploratory simulation using the score for allocation of ventilators (with only high-priority patients receiving ventilators) showed 43.9% excess deaths among Black participants, compared with 28.6% among all other patients.

When the model allocated ventilators to both the intermediate- and high-priority groups, excess deaths were 4.9% among Black participants, compared with 3.0% among all others. A model using a random lottery resulted in more estimated excess deaths overall without improving racial equity. 

Relative to their White peers, Black patients had a higher prevalence of COVID-19 (31.5% vs 72.2%). Hispanic and non-Hispanic patients had similar rates of infection (41.8% vs 43.9%). Patients living in socially vulnerable areas were more likely than others to test positive for COVID-19 (62.2% vs 39.4%).

Overall, 49.5% of patients received mechanical ventilation for a median of 10 days. Median hospital length of stay was 13 days, while it was 6 days in the ICU. Of all patients, 23.9% died in the hospital, and 45.3% were released to home without hospice care.

Compared with their White counterparts, Black patients had longer median length of mechanical ventilation (8 vs 15 days) and longer ICU (5 vs 8) and hospital (10 vs 13) stays. The likelihood of death or release home was not statistically significant between Black and White patients (death, 26.6% vs 20.8%; release home, 24.1% vs 36.2%).

When separated into COVID-19 and non–COVID-19 groups, the only statistically significant difference in outcomes between Black and White patients was the median ICU length of stay in the uninfected group (7 vs 4 days).

Ongoing CSOC outcomes assessments needed

The study authors noted that CSOC scoring systems could deepen racial disparities through physician bias, differential discrimination or calibration characteristics among racial groups, and allocation of scarce resources to less-ill patients (because poor health is an outcome of structural racism).

"Had this scoring system been actually used, it could have led to resources being disproportionately allocated away from Black patients due to a higher proportion of Black patients falling in the lowest priority group based on severity of illness scoring," the researchers wrote. "Ongoing assessment of outcomes with different CSOC policies in real-world settings should drive the development and modification of CSOC policies to dismantle structural racism and maximize equitable outcomes for patients."

In a related commentary, Hayley Gershengorn, MD, of the University of Miami Miller School of Medicine, said that the paradigm of CSOC policies must not be abandoned, lest there be unweighted lottery, first-come-first-served resource allocation, or rationing favoring those with greater means (eg, money, connections).

"We must do all we can to enhance the likelihood that CSOC policies will not exacerbate disparities," she wrote. "To accomplish this, all policy stakeholders (eg, clinicians, patients, ethicists, caregivers, administrators) must be represented on committees tasked with developing CSOC policies."

She added that CSOC policies need to be feasible, useful, and acceptable to all stakeholders. "Our relevant professional organizations must band together to lead creation of a single guidance document (with the possibility for amendments appropriate to local communities) to which local governments can turn to regulate policy; in no way can any of us trust an outcome that we know would have been different had we been admitted to a hospital down the street," she wrote.

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