{"id":4235,"date":"2021-10-12T21:39:50","date_gmt":"2021-10-12T20:39:50","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4235"},"modified":"2021-10-12T21:39:50","modified_gmt":"2021-10-12T20:39:50","slug":"the-sequential-organ-failure-assessment-sofa-and-revised-ventilator-triage-guidance-since-we-are-still-implementing-outdated-and-more-inequitable-frameworks-now-will-we-learn-any-lessons-longer-te","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2021\/10\/12\/the-sequential-organ-failure-assessment-sofa-and-revised-ventilator-triage-guidance-since-we-are-still-implementing-outdated-and-more-inequitable-frameworks-now-will-we-learn-any-lessons-longer-te\/","title":{"rendered":"The Sequential Organ Failure Assessment (SOFA) and revised ventilator triage guidance: since we are still implementing outdated and more inequitable frameworks now, will we learn any lessons longer term?"},"content":{"rendered":"

By Harald Schmidt<\/a>,\u00a0Dorothy E Roberts<\/a>,\u00a0\u00a0Amaka D Eneanya<\/a><\/p>\n

Ventilator triage guidance can\u00a0reduce<\/a>,\u00a0maintain<\/a>, or\u00a0exacerbate<\/a>\u00a0existing social, racial and ethnic health inequities, raising non-trivial\u00a0legal issues<\/a>. Over the last 18 months, there has been an intense reckoning with the fact that traditional rationing frameworks focused on maximizing overall benefits tend to\u00a0worsen<\/a>\u00a0Covid-19\u2019s disparate impact on disadvantaged communities of color. Yet, as\u00a0ICUs filled up again recently,<\/a>\u00a0officials implemented outdated, and more inequitable, triage guidelines. This must change. Moreover, there seems to be no effective process for ensuring that earlier versions of influential model frameworks are updated, nor ways of ensuring\u00a0transparency<\/a>\u00a0about the type of Crisis Standards of Care (CSC) rules that are adopted. This, too, must change.<\/p>\n

On September 9, 2021, Idaho\u00a0activated<\/a>\u00a0CSC rules in response to rapidly rising Covid-19 hospitalizations in some areas, emphasizing that ventilator rationing should be based on \u201cobjective criteria<\/a>\u201d. The state\u2019s\u00a0Patient Care Strategies for Scarce Resource Situations<\/a>\u00a0describe the process.<\/p>\n

To save the most lives, patients should be ranked on the Sequential Organ Failure Assessment (SOFA) score, a measure to predict the likelihood that a patient survives the ICU.\u00a0 The worse the prognosis, the higher the point score. In addition, to save life years, patients \u201cwith major comorbidities with substantial impact on near-term survival\u201d receive further points, doubled for those with severe comorbidities expected to die \u201cin the near-term\u201d.\u00a0 The policy also includes adjustments for patients with disabilities, and five types of hierarchical tie-breakers for patients with equal scores.\u00a0 Patients with the lowest overall scores are categorized as High Priority, and all remaining as either Intermediate, or Lowest Priority (to be \u201creassess[ed] as needed<\/a>\u201d).<\/p>\n

To the extent that the process identifies mostly specific and empirically measurable outcomes, it might be viewed as being based on objective criteria.<\/p>\n

But these criteria are far from objective in several ways.<\/p>\n

First, assessing \u201cnear-term survival\u201d differs from, for example, reading oxygen levels:\u00a0subjective<\/a>\u00a0judgements will typically play a role.<\/p>\n

Second, in another important sense of objectivity\u2014that of being value-neutral or impartial\u2014the adjective does not apply, as prioritizing saving the most lives and life years are value judgements by themselves.<\/p>\n

Third, independently, the empirical measures used to achieve these goals risk exacerbating existing racial inequities.<\/p>\n

One\u00a0main<\/a>\u00a0reason is the reliance on\u00a0 SOFA, already deemed\u00a0unfit<\/a>\u00a0for purpose<\/a>\u00a0by key experts on scientific grounds.\u00a0In addition, SOFA is inequitable.<\/p>\n

As we outline in our response<\/a>,\u00a0drawing on data of more than 100,000 patients,\u00a0Deepshikha Ashana and colleagues<\/a>\u00a0found that a version of Idaho\u2019s approach leads to more than 80% of Black patients being included in lower priority categories, and more than 9% being erroneously excluded from receiving the highest prioritization.\u00a0\u00a0William Miller and colleagues<\/a>\u00a0likewise found that SOFA overestimated Black patients\u2019 mortality, and misclassified more than 15% from the highest to the intermediate priority. A study by\u00a0Sivasubramanium Bhavani, Yuan Luo, and colleagues<\/a>,\u00a0published concurrent to our response being copy-edited,\u00a0simulated ventilation needs of a diverse group of Covid-19 patients in Chicago. Black patients presented with higher average SOFA scores than white patients (9.2 vs. 7.5) and SOFA-only based triage assigned Black patients substantially fewer ventilators than white ones (44% vs 54%).\u00a0\u00a0Shireen Roy and colleagues<\/a>\u00a0likewise found: \u201cBlack COVID patients would have been denied care despite having similar clinical outcomes to white patients.\u201d<\/p>\n

Process-wise, it is also concerning that the Idaho framework does not reflect that the authors of the model guidance that the state adopted published a substantially revised version in December 2020 in the\u00a0academic literature<\/a>, and in June 2021 on the\u00a0guideline website<\/a>. These versions drop SOFA, and include changes such as integrating disadvantage indices to mitigate inequitable outcomes (first proposed for ventilator rationing\u00a0in April 2020<\/a>)<\/u>.<\/p>\n

Unfortunately, the Idaho case is not unique. For example, outdated rules based on the same model guidance are also found in\u00a0Montana\u2019s<\/a>\u00a0recently activated CSC framework, and in\u00a0New Jersey\u2019s<\/a>, as emerged when we had to address a surprising, erroneous and confusing commentary seeking to undermine our\u00a0constructive proposal<\/a>\u00a0to avoid inequitable outcomes from using the SOFA score (see here\u00a0<\/a>and note that\u00a0Alaska\u2019s\u00a0<\/a>\u00a0recently\u00a0activated<\/a>,\u00a0as well as<\/a>\u00a0implemented<\/a>,\u00a0CSC draw explicitly on SOFA).<\/p>\n

It is critical that users of model guidance frameworks review more inequitable outdated versions, not least as the SOFA score not only disadvantage racial\/ethnic groups, but also\u00a0people with disabilities<\/a>.<\/p>\n

More broadly, it is critical to ensure\u00a0transparency<\/a>\u00a0about the types of triage frameworks adopted across the country, and to create incentives for hospitals to establish, share and update frameworks. We make constructive suggestions toward this end in our response<\/a>, and hope that these will also be of use to ongoing and future efforts to assess CSR standards for equity, as also urged recently in the final\u00a0recommendations<\/a>\u00a0of the White House Health Equity Task Force.<\/p>\n

Paper title: <\/strong>Sequential organ failure assessment, ventilator rationing and evolving triage guidance: new evidence underlines the need to recognise and revise, unjust allocation frameworks<\/span><\/a><\/p>\n

Author(s): <\/strong>Harald Schmidt<\/a>,\u00a0<\/span>Dorothy E Roberts<\/a>,\u00a0\u00a0<\/span>Amaka D Eneanya<\/a>\u00a0<\/span><\/p>\n

Affiliations: <\/strong><\/p>\n

HS: Medical Ethics and Health Policy,\u00a0University of Pennsylvania Perelman School of Medicine,\u00a0Philadelphia,\u00a0Pennsylvania,\u00a0USA<\/p>\n

DER: Penn Law, Departments of Africana Studies and Sociology,\u00a0School of Arts and Sciences, University of Pennsylvania,\u00a0Philadelphia,\u00a0PA,\u00a0USA<\/p>\n

ADE: Renal-Electrolyte and Hypertension Division,\u00a0Perelman School of Medicine, University of Pennsylvania,\u00a0Philadelphia,\u00a0PA,\u00a0USA<\/p>\n

Competing interests: <\/strong>None<\/span><\/p>\n

Social media accounts of post author(s): <\/strong><\/p>\n

@harald_tweets<\/a><\/p>\n

@DorothyERoberts<\/a><\/p>\n

@AmakaEMD<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

By Harald Schmidt,\u00a0Dorothy E Roberts,\u00a0\u00a0Amaka D Eneanya Ventilator triage guidance can\u00a0reduce,\u00a0maintain, or\u00a0exacerbate\u00a0existing social, racial and ethnic health inequities, raising non-trivial\u00a0legal issues. Over the last 18 months, there has been an intense reckoning with the fact that traditional rationing frameworks focused on maximizing overall benefits tend to\u00a0worsen\u00a0Covid-19\u2019s disparate impact on disadvantaged communities of color. Yet, as\u00a0ICUs […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":353,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,2143],"tags":[],"class_list":["post-4235","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-distributive-justice"],"yoast_head":"\nThe Sequential Organ Failure Assessment (SOFA) and revised ventilator triage guidance: since we are still implementing outdated and more inequitable frameworks now, will we learn any lessons longer term? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2021\/10\/12\/the-sequential-organ-failure-assessment-sofa-and-revised-ventilator-triage-guidance-since-we-are-still-implementing-outdated-and-more-inequitable-frameworks-now-will-we-learn-any-lessons-longer-te\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The Sequential Organ Failure Assessment (SOFA) and revised ventilator triage guidance: since we are still implementing outdated and more inequitable frameworks now, will we learn any lessons longer term? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Harald Schmidt,\u00a0Dorothy E Roberts,\u00a0\u00a0Amaka D Eneanya Ventilator triage guidance can\u00a0reduce,\u00a0maintain, or\u00a0exacerbate\u00a0existing social, racial and ethnic health inequities, raising non-trivial\u00a0legal issues. 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