How US States Would Allocate Ventilators in a Shortage Varies Widely

By Linda Carroll

June 22, 2020

(Reuters Health) - With the COVID-19 pandemic far from over, the specter of ventilator shortages has highlighted the issue of how the life-saving machines should be divvied up. A new U.S. study has found wide variation in state guidelines tackling the question of who should get priority if ventilators need to be rationed.

As of May 10, based on an internet search, 26 states had publicly posted ventilator guidelines and 14 had pediatric guidelines, researchers reported in JAMA Network Open.

Many of the guidelines ranked the health of the patient most important, some prioritized pregnant women, some prioritized healthcare workers and other workers vital to the public health response. Many grappled with the possibility of taking one patient off a ventilator so it could be used for a patient the guidelines had deemed to be of higher priority.

"The variety really shocked me," said lead author Dr. Gina Piscitello, a palliative care physician at Rush Medical College in Chicago.

"We all have the same goal with the pandemic; if there is a ventilator shortage we would want equitable access," Dr. Piscitello said. "But with so much variety in protocol there would have been disparities in allocation throughout the United States."

Despite some troubling issues with existing guidelines, such as certain patients eligible for ventilators in some states but not in others, Dr. Piscitello would like to see all states come up with something. "Those state departments of health that have no guidelines should make them," she said.

Most states, 15, used the Sequential Organ Failure Assessment Score in their initial ranking of adult patients, and assessment of limited life expectancy from underlying conditions or comorbidities was included in the initial evaluation of patients in six states. Exclusion criteria were included in the guidelines covering adults in 11 states, while 10 of the 14 state pediatric guidelines listed exclusion criteria.

Dr. Jeremy Beitler hopes the new study will spark further discussion.

"I think the study has the potential to reignite conversation on where we want to go with this problem," said Dr. Beitler, director of clinical research for the Center for Acute Respiratory Failure at NewYork Presbyterian Hospital and Columbia University.

Based on his experience in New York City, Dr. Beitler believes there needs to be coordination across the states when it comes to ventilators. Access to ventilators in New York wasn't just limited by the state's supply, but also by each health system. "In New York City, hospitals weren't sharing ventilators outside of their networks," Dr. Beitler said. "Everything was siloed."

While hospitals in New York were just days away from having to ration ventilators, there was never a national shortage, Dr. Beitler said. "We have to view ventilators as a national resource," he added. "There could be a role for the federal government to facilitate that."

The new study may also spark conversations regarding the fairness of using health scores as a determining factor, Dr. Beitler said. Patients with chronic conditions such as hypertension, heart disease and diabetes often are the same ones who have been disadvantaged over the years by structural racism, he noted.

The study brings up some thorny issues, said Dr. Albert Wu, an internist and a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

"It's something that we rarely think about as Americans," Dr. Wu said. "We don't like to think about limiting or allocating resources. We have a little bit of an aversion to that. Rationing is a dirty word."

"But the fact is we ration all the time," Dr. Wu said. "But many of the mechanisms are not so visible. Some of that rationing is based on access or even privilege. This paper, aided by the COVID-19 crisis, pulls back the curtain a little and makes some of those factors more visible."

Still, Dr. Wu said, "it doesn't seem right that the guidelines in some states provide greater access for some groups and potentially discrimination against others. So it would be important to develop national guidelines so that everyone has the same chance at survival. There's been talk about nationalizing some of these scare resources. That might be the fairest thing to do."

SOURCE: https://bit.ly/30VcccB JAMA Network Open, online June 19, 2020.

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