Resource Allocation and Crisis Standards of Care

1. This article by Fox et al. details the experience of 4 health systems collaborating to set statewide allocation criteria for remdesivir use in COVID-19 patients in Utah.
   • Remdesivir received an emergency use authorization (EUA) in May 2020 for use in patients with suspected or confirmed severe COVID-19; however, use criteria under the EUA were broad, and states and hospitals were largely left to develop their own allocation strategies for the scarce resource in the absence of any national directives. Coordination among hospitals, health systems, and state authorities promotes fairness and effectiveness in allocation criteria by reducing the likelihood that care will vary due to issues of distribution, geography, luck, or similar differences unrelated to relevant clinical or ethical criteria.
   • The article describes the process used by the 4 largest health systems in Utah to coordinate a uniform approach in the state for allocating the drug to patients. The systems were represented by infectious disease specialists, chief medical officers, and pharmacists and met multiple times online and via email over a 9-day period to develop allocation criteria. They also agreed to use the framework to develop criteria for future therapeutics such as monoclonal antibodies. This work took place within the broader context of statewide crisis standards of care (CSC) planning, which including development of prioritization methods generally and a focus on “load leveling” to distribute the burdens of care and resources across the state so that hospitals would not be forced to limit care or resources unless or until resources were depleted statewide.

2. This article by Elson et al. highlights the experience of Maryland in responding to the COVID-19 pandemic with a focus on the role of the Maryland Healthcare Ethics Committee Network. Maryland lacks a state-endorsed plan for allocation of scarce resources under CSC, even though a plan was published in 2017 that included information from public forums across the state. The article highlights 8 specific lessons learned from the state’s response and gaps in preparedness that should inform future implementation of plans for allocating scarce resources:
   • Deliberative democracy provided a strong foundation for the allocation framework.
   • Community consensus is informative, not normative.
   • Hearing community voices has inherent value.
   • Lack of transparency and political leadership gaps generate a fragmented response.
   • Pandemic politics requires diplomacy and persistence.
   • Strong leadership is needed to avoid implementation of scarce resource allocation plans and to plan for allocation when necessary.
   • An effective pandemic response requires coordination and information-sharing beyond the acute care hospital.
   • The ability to correct course is crucial (specifically noting reconsideration of no-visitor policies).

3. This article by Wunsch et al. compares criteria under two different ventilator allocation triage guidelines that both rely on Sequential Organ Failure Assessment (SOFA) scores and comorbidities. The study applied both approaches retrospectively to over 40,000 critically ill adult patients at over 200 hospitals who received mechanical ventilation in 2014-2015, eliminating the influence of the COVID-19 pandemic.
   • The first approach was the New York State Ventilator Allocation plan developed in 2015, and the second was a set of two criteria from an allocation framework developed in 2020 (by White & Lo) that prioritizes both lives and life-years saved (but excluding two other criteria of that plan that prioritize essential workers and younger patients). Under the New York State criteria, 8.9% of patients would have been in the lowest priority category, while under the other approach 4.3% were in the lowest tier. Only 1.6% were in the lowest category under both, indicating little agreement between the two sets of criteria.
   • Based on this lack of agreement, application of these different criteria during circumstances of actual resource scarcity would produce meaningfully different results in terms of which patients are would be likely to have ventilation withheld or withdrawn. Despite limitations of the study identified by the authors, these results are highly illuminating regarding the importance of choice of allocation criteria and how these choices may impact care decisions during public health crises when resources are scarce.