Racial Equity in Crisis Standards of Care—Reassuring Data or Reason for Concern? | Critical Care Medicine | JAMA Network Open | JAMA Network
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Health Policy
March 19, 2021

Racial Equity in Crisis Standards of Care—Reassuring Data or Reason for Concern?

Author Affiliations
  • 1Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
  • 2Boston University School of Medicine, Boston, Massachusetts
  • 3Department of Emergency Medicine, Massachusetts General Hospital, Boston
  • 4Department of Emergency Medicine, University of California, San Francisco
JAMA Netw Open. 2021;4(3):e214527. doi:10.1001/jamanetworkopen.2021.4527

The coronavirus disease 2019 (COVID-19) pandemic has led to more than 956 000 hospitalizations in the United States as of February 5, 2021,1 bringing hospital systems close to exhausting available critical care resources during surges in infection rates. In an attempt to ensure the fair allocation of scarce resources, hospital systems have developed crisis standards of care (CSC) guidelines. Health equity experts have raised concerns that indiscriminate implementation of these guidelines will exacerbate racial and ability-based inequities that have plagued our current health care system. In their study, Gershengorn et al2 sought to determine whether the application of proposed CSC guidelines during a surge of COVID-19 cases at 2 urban hospitals in Miami, Florida, would be associated with an unanticipated increase in resource allocation disparities across race and ethnicity. Reviewing 5613 patient-days of data from 1127 patients who required or were at risk of requiring mechanical ventilation during admission at their hospitals, they found no association of race or ethnicity with the priority scores that guided their CSC resource allocation policy.

Although these findings suggest that CSC guidelines may not exacerbate the existing racial inequities in our health care system, it is critical to consider them in the broader context of 2 ongoing pandemics: COVID-19 and US racism. These mutualistic pandemics have thrown into stark relief the separate and unequal systems through which US residents access health care. Throughout this past year, Black, Latinx, Indigenous, and other individuals from racial and ethnic minority groups have experienced disproportionate effects of the COVID-19 pandemic.3 Underresourced racial and ethnic minority communities typically rely on health care facilities, especially safety-net hospitals, that have been hit the hardest by surges in COVID-19. Ill-equipped to handle these surges, many of these safety-net hospitals have had to cancel income-generating elective surgical procedures because their inpatient beds are filled with COVID-19 admissions. Safety-net hospitals thus become reliant on a tenuous stream of government funding and may be more likely to enact CSC than better-resourced facilities. Additionally, the resource constraints at safety-net hospitals in diverse communities may lead to compromised care even before CSC enactment.4

Although the new presidential administration has placed greater national focus on public health measures, the course of the pandemic remains troubling. If pandemic surges exhaust local resources such that CSC must be enacted, our system will have already failed. We must ensure that the cost of those failures does not disproportionately fall on racial and ethnic minority groups and other marginalized communities.5 To prevent CSC from compounding harm at the end stage of a public health and medical system failure, resource allocation criteria must be developed, revised, and implemented through an identity-conscious lens. Failure to explicitly consider the particular risks faced by racial and ethnic minority groups, individuals with disabilities, and other marginalized populations may lead to unintended harms. For example, it is critical that CSC guidelines explicitly outline accommodations to preclude discrimination on the basis of disability. Most CSC guidelines incorporate the Sequential Organ Failure Assessment (SOFA) score,6 which includes the Glasgow Coma Scale (GCS) as an assessment of neurologic function. However, many people with disabilities—although they may be at their functional baseline—are unable to perform the tasks required to attain a high GCS score. CSC guidelines must ensure that people with disabilities are not penalized with a lower GCS score, particularly if their disabilities preclude them from speaking clearly or following motor commands. Empirically examining this type of discrimination may be more challenging than measuring racial bias, in part due to highly variable and incomplete documentation of baseline ability status in electronic medical records.

Similarly, critical care and health equity experts have raised concerns about racial bias inherent in the seemingly colorblind SOFA score. Given the unjustly high prevalence of chronic kidney disease among Black US residents, it may be reasonable to limit the number of points added to SOFA scores for certain components, such as kidney function, as has been done in the Massachusetts CSC guidelines. Ongoing exploration of racial differences in SOFA scoring may further inform the development and modification of CSC guidelines. Although the inclusion of comorbid conditions was not associated with racialized differences in priority score in the study by Gershengorn et al,2 the inequitable distribution of life-limiting health conditions—an individual-level manifestation of structural racism—nevertheless makes their inclusion in CSC guidelines problematic. Moreover, robust data demonstrating that clinicians can accurately estimate 5-year mortality within disease-specific or specialty-specific contexts is lacking.

Lastly, the core criteria (SOFA scores and life-limiting comorbidities) in the CSC framework used by Gershengorn et al2 and other institutions across the country6,7 seem to have limited discriminatory value. With more than 70% of patients stratified into the highest priority group, their utility in critical care triage is suspect. Secondary tie-breaker criteria may be needed to improve the ability of CSC guidelines to more broadly and effectively guide the allocation of resources. Additions to screening tools, especially less objective criteria, may introduce bias, necessitating further evaluation in new cohorts to establish their validity. During such validation, we recommend considering the potential for downstream harm to communities of color and at-risk populations—with input from the communities most likely to be affected by these unintended consequences. It is therefore essential that these second-tier criteria be examined as thoroughly as the SOFA and comorbidity criteria.

As COVID-19 cases continue to rise throughout much of the country and amid concerns of evolving and more virulent strains, it is clear that we have not yet turned the corner of this pandemic. If we are forced to activate CSC guidelines for critical care resource allocation, we must ensure that they equitably serve our most marginalized and at-risk populations. Further prospective and validation studies are needed before CSC can be deemed free of racial and other biases.

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Article Information

Published: March 19, 2021. doi:10.1001/jamanetworkopen.2021.4527

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

Corresponding Author: Emily C. Cleveland Manchanda, MD, MPH, Department of Emergency Medicine, Boston Medical Center, 800 Harrison Ave, BCD Bldg, First Floor, Boston, MA 02118 (emily.cleveland@bmc.org).

Conflict of Interest Disclosures: Dr Rodriguez reported having served on the Biden/Harris coronavirus disease 2019 advisory board. No other disclosures reported.

Additional Contributions: We are grateful to the many researchers, ethicists, clinicians, and advocates who have dedicated their energy to ensuring that crisis standards of care equitably safeguard our health system’s resources.

References
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Cleveland Manchanda  EC, Sanky  C, Appel  JM.  Crisis standards of care in the USA: a systematic review and implications for equity amidst COVID-19.   J Racial Ethn Health Disparities. Published online August 13, 2020. doi:10.1007/s40615-020-00840-5Google Scholar
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