Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States
Julia L. Jezmir, Maheetha Bharadwaj, Alexander Chaitoff, Bradford Diephuis, Conor Crowley, Sandeep P. Kishore, Eric Goralnick, Louis T. Merriam, Aimee Milliken, Chanu Rhee, Nicholas Sadovnikoff, Sejal B. Shah, Shruti Gupta, David E. Leaf, William B. Feldman, Edy Y. Kim, Carl P. Walther, Samaya J. Anumudu, Justin Arunthamakun, Kathleen F. Kopecky, Gregory P. Milligan, Peter A. McCullough, Thuy-Duyen Nguyen, Shahzad Shaefi, Megan L. Krajewski, Sidharth Shankar, Ameeka Pannu, Juan D. Valencia, Sushrut S. Waikar, Zoé A. Kibbelaar, Ambarish M. Athavale, Peter C. Hart, Shristi Upadhyay, Ishaan Vohra, Oyintayo Ajiboye, Adam Green, Jean-Sébastien Rachoin, Christa Schorr, Lisa Shea, Daniel Edmonston, Christopher L. Mosher, Alexandre M. Shehata, Zaza Cohen, Valerie Allusson, Gabriela Bambrick‐Santoyo, Noor ul aain Bhatti, Bijal Mehta, Aquino Williams, Samantha K. Brenner, Patricia Walters, Ronaldo C. Go, Keith Rose, Miguel A. Hernán, Amy M. Zhou, Ethan C. Kim, Rebecca Lisk, Lili Chan, Kusum S. Mathews, Steven G. Coca, Deena R. Altman, Aparna Saha, Howard Soh, Huei Hsun Wen, Sonali Bose, Emily Leven, Jing G. Wang, Gohar Mosoyan, Girish N. Nadkarni, Pattharawin Pattharanitima, Allon N. Friedman, John Guirguis, Rajat Kapoor, Christopher Meshberger, Katherine Kelly, Chirag R. Parikh, Brian T. Garibaldi, Celia P. Corona‐Villalobos, Yumeng Wen, Steven Menez, Rubab F. Malik, Elena Cervantes, Samir C. Gautam, Mary C. Mallappallil, Jie Ouyang, Sabu John, Ernie Yap, Yohannes Adama Melaku, Ibrahim Mohamed, Siddartha Bajracharya, Isha Puri, Mariah Thaxton, Jyotsna Bhattacharya, John E. Wagner, Leon Boudourakis, H. Bryant Nguyen, Afshin Ahoubim, Leslie F. Thomas, Dheeraj Reddy Sirganagari, Pramod Guru, Kianoush Kashani
Abstract
Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.