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Zhang C. Equitable resource allocation in health emergencies: addressing racial disparities and ethical dilemmas. JOURNAL OF MEDICAL ETHICS 2024:jme-2024-109947. [PMID: 38816070 DOI: 10.1136/jme-2024-109947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/11/2024] [Indexed: 06/01/2024]
Abstract
This paper explores resource allocation complexities during health emergencies, focusing on pervasive racial disparities, notably affecting black communities. It aims to investigate alternatives to the Most Lives Saved approach, particularly its potential to exacerbate disparities. To analyse resource allocation strategies, the essay reviews the Dual-Principled System proposed by Bruce and Tallman (B+T) in 2021. B+T's proposal critiques previous methods like the Area Deprivation Index and First Come First Serve while seeking to balance equity and utility by adjusting triage scores based on diseases displaying racial disparities. However, the study identifies inherent challenges in subjectivity, complexity and fairness, necessitating a careful examination and potential innovative solutions. The examination of the Dual-Principled System uncovers challenges, leading to the identification of three main issues and potential solutions. Furthermore, to address subjectivity concerns, it is necessary to adopt objective disease selection criteria through data analysis. Moreover, proposed solutions for complexity include real-time data updates, adaptability and regional considerations. Fairness concerns can be mitigated through educational campaigns and a lottery system integrated with triage score adjustments. The study emphasises nuanced resource allocation with objective disease selection, adaptable strategies and educational initiatives, including a lottery system, aligning with fairness, equity and practicality. As healthcare evolves, resource allocation must align with justice, fostering inclusivity and responsiveness for all.
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Horvat CM, King AJ, Huang DT. Designing and Implementing "Living and Breathing" Clinical Trials: An Overview and Lessons Learned from the COVID-19 Pandemic. Crit Care Clin 2023; 39:717-732. [PMID: 37704336 PMCID: PMC9935272 DOI: 10.1016/j.ccc.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The practice of medicine is characterized by uncertainty, and the findings of randomized clinical trials (RCTs) are meant to help curb that uncertainty. Traditional RCTs, however, have many limitations. To overcome some of these limitations, new trial paradigms rooted in the origins of evidence-based medicine are beginning to disrupt the traditional mold. These new designs recognize uncertainty permeates medical decision making and aim to capitalize on modern health system infrastructure to integrate investigation as a component of care delivery. This article provides an overview of "living, breathing" trials, including current state, anticipated developments, and areas of controversy.
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Affiliation(s)
- Christopher M Horvat
- UPMC Children's Hospital of Pittsburgh, Faculty Pavilion, 4401 Penn Avenue, Suite 0200, Pittsburgh, PA 15224, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, 603A, Pittsburgh, PA 15261, USA.
| | - Andrew J King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, 603A, Pittsburgh, PA 15261, USA
| | - David T Huang
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, 603A, Pittsburgh, PA 15261, USA
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Abstract
This Viewpoint discusses the unfairness of current CAR T-cell therapy allocation practices and offers alternative methods to more fairly allocate therapy.
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Affiliation(s)
- Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - William F Parker
- Division of the Biological Sciences, University of Chicago, Chicago, Illinois
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Mekontso Dessap A, Richard JCM, Baker T, Godard A, Carteaux G. Technical Innovation in Critical Care in a World of Constraints: Lessons from the COVID-19 Pandemic. Am J Respir Crit Care Med 2023; 207:1126-1133. [PMID: 36716353 PMCID: PMC10161748 DOI: 10.1164/rccm.202211-2174cp] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.
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Affiliation(s)
- Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
| | - Jean-Christophe Marie Richard
- Vent’Lab, Medical ICU, Angers University Hospital, University of Angers, Angers, France
- Med2Lab, Air Liquide Medical Systems, Antony, France
| | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Global Public Health, Karolinska Institute, Stockholm, Sweden
- Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Aurélie Godard
- Médecins Sans Frontières – Centre Opérationel Paris, Paris, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
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Soltanisehat L, Barker K, González AD. Multiregional, multi-industry impacts of fairness on pandemic policies. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2023. [PMID: 37185973 DOI: 10.1111/risa.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/17/2023] [Accepted: 03/16/2023] [Indexed: 05/17/2023]
Abstract
The health and economic crisis caused by the COVID-19 pandemic highlights the necessity for a deeper understanding and investigation of state- and industry-level mitigation policies. While different control strategies in the early stages, such as lockdowns and school and business closures, have helped decrease the number of infections, these strategies have had an adverse economic impact on businesses and some controversial impacts on social justice. Therefore, optimal timing and scale of closure and reopening strategies are required to prevent both different waves of the pandemic and the negative socioeconomic impact of control strategies. This article proposes a novel multiobjective mixed-integer linear programming formulation, which results in the optimal timing of closure and reopening of states and industries in each. The three objectives being pursued include: (i) the epidemiological impact of the pandemic in terms of the percentage of the infected population; (ii) the social vulnerability index of the pandemic policy based on the vulnerability of communities to getting infected, and for losing their job; and (iii) the economic impact of the pandemic based on the inoperability of industries in each state. The proposed model is implemented on a dataset that includes 50 states, the District of Columbia, and 19 industries in the United States. The Pareto-optimal solutions suggest that for any control decision (state and industry closure or reopening), the economic impact and the epidemiological impact change in the opposite direction.
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Affiliation(s)
- Leili Soltanisehat
- School of Finance and Operations, University of Tulsa, Tulsa, Oklahoma, USA
| | - Kash Barker
- School of Industrial and Systems Engineering, University of Oklahoma, Norman, Oklahoma, USA
| | - Andrés D González
- School of Industrial and Systems Engineering, University of Oklahoma, Norman, Oklahoma, USA
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The Use of ECMO for COVID-19: Lessons Learned. Clin Chest Med 2022; 44:335-346. [PMID: 37085223 PMCID: PMC9705197 DOI: 10.1016/j.ccm.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has seen an increase in global cases of severe acute respiratory distress syndrome (ARDS), with a concomitant increased demand for extracorporeal membrane oxygenation (ECMO). Outcomes of patients with severe ARDS due to COVID-19 infection receiving ECMO support are evolving. The need for surge capacity, practical and ethical limitations on implementing ECMO, and the prolonged duration of ECMO support in patients with COVID-19-related ARDS has revealed limitations in organization and resource utilization. Coordination of efforts at multiple levels, from research to implementation, resulted in numerous innovations in the delivery of ECMO.
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Parker WF, Persad G, Peek ME. Errors in Converting Principles to Protocols: Where the Bioethics of U.S. Covid-19 Vaccine Allocation Went Wrong. Hastings Cent Rep 2022; 52:8-14. [PMID: 36226880 PMCID: PMC9827540 DOI: 10.1002/hast.1416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
For much of 2021, allocating the scarce supply of Covid-19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the ACIP violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy-five years of age as the only criterion to identify individuals at high risk of death from Covid-19 during phase 1b, failing to recommend place-based vaccine distribution, and implicitly endorsing first-come, first-served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade-offs between principles may have prevented these mistakes and saved lives.
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McCreary EK, Kip KE, Bariola JR, Schmidhofer M, Minnier T, Mayak K, Albin D, Daley J, Linstrum K, Hernandez E, Sackrowitz R, Hughes K, Horvat C, Snyder GM, McVerry BJ, Yealy DM, Huang DT, Angus DC, Marroquin OC. A learning health system approach to the COVID-19 pandemic: System-wide changes in clinical practice and 30-day mortality among hospitalized patients. Learn Health Syst 2022; 6:e10304. [PMID: 35860323 PMCID: PMC9284933 DOI: 10.1002/lrh2.10304] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Rapid, continuous implementation of credible scientific findings and regulatory approvals is often slow in large, diverse health systems. The coronavirus disease 2019 (COVID-19) pandemic created a new threat to this common "slow to learn and adapt" model in healthcare. We describe how the University of Pittsburgh Medical Center (UPMC) committed to a rapid learning health system (LHS) model to respond to the COVID-19 pandemic. Methods A treatment cohort study was conducted among 11 429 hospitalized patients (pediatric/adult) from 22 hospitals (PA, NY) with a primary diagnosis of COVID-19 infection (March 19, 2020 - June 6, 2021). Sociodemographic and clinical data were captured from UPMC electronic medical record (EMR) systems. Patients were grouped into four time-defined patient "waves" based on nadir of daily hospital admissions, with wave 3 (September 20, 2020 - March 10, 2021) split at its zenith due to high volume with steep acceleration and deceleration. Outcomes included changes in clinical practice (eg, use of corticosteroids, antivirals, and other therapies) in relation to timing of internal system analyses, scientific publications, and regulatory approvals, along with 30-day rate of mortality over time. Results The mean (SD) daily number of admissions across hospitals was 26 (29) with a maximum 7-day moving average of 107 patients. System-wide implementation of the use of dexamethasone, remdesivir, and tocilizumab occurred within days of release of corresponding seminal publications and regulatory actions. After adjustment for differences in patient clinical profiles over time, each month of hospital admission was associated with an estimated 5% lower odds of 30-day mortality (adjusted odds ratio [OR] = 0.95, 95% confidence interval: 0.93-0.97, P < .001). Conclusions In our large LHS, near real-time changes in clinical management of COVID-19 patients happened promptly as scientific publications and regulatory approvals occurred throughout the pandemic. Alongside these changes, patients with COVID-19 experienced lower adjusted 30-day mortality following hospital admission over time.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Kevin E. Kip
- Health Services DivisionClinical Analytics, UPMCPittsburghPennsylvaniaUSA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Mark Schmidhofer
- Division of Cardiology, Dept of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Tami Minnier
- Health Services DivisionUPMC Wolff Center and Quality Offices, UPMCPittsburghPennsylvaniaUSA
| | - Katelyn Mayak
- Media Relations DepartmentUPMC Communications, UPMCPittsburghPennsylvaniaUSA
| | - Debbie Albin
- UPMC EnterprisesUPMC Supply Chain Management/HC Pharmacy, UPMCPittsburghPennsylvaniaUSA
| | - Jessica Daley
- UPMC EnterprisesUPMC Supply Chain Management/HC Pharmacy, UPMCPittsburghPennsylvaniaUSA
| | - Kelsey Linstrum
- UPMC Health SystemUPMC Office of Healthcare InnovationPittsburghPennsylvaniaUSA
| | - Erik Hernandez
- Department of PharmacyUPMC Pinnacle, UPMCPittsburghPennsylvaniaUSA
| | - Rachel Sackrowitz
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Kailey Hughes
- Division of Infectious Diseases, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Christopher Horvat
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Critical Care MedicineUPMC Children’s Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Bryan J. McVerry
- Department of Medicine, Division of PulmonaryAllergy, and Critical Care MedicinePittsburghPennsylvaniaUSA
| | - Donald M. Yealy
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - David T. Huang
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Derek C. Angus
- UPMC Health SystemUPMC Office of Healthcare InnovationPittsburghPennsylvaniaUSA
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Oscar C. Marroquin
- Health Services DivisionClinical Analytics, UPMCPittsburghPennsylvaniaUSA
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9
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Adoption and Deadoption of Medications to Treat Hospitalized Patients With COVID-19. Crit Care Explor 2022; 4:e0727. [PMID: 35923589 PMCID: PMC9333499 DOI: 10.1097/cce.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES: The COVID-19 pandemic was characterized by rapidly evolving evidence regarding the efficacy of different therapies, as well as rapidly evolving health policies in response to that evidence. Data on adoption and deadoption are essential as we learn from this pandemic and prepare for future public health emergencies. DESIGN: We conducted an observational cohort study in which we determined patterns in the use of multiple medications to treat COVID-19: remdesivir, hydroxychloroquine, IV corticosteroids, tocilizumab, heparin-based anticoagulants, and ivermectin. We analyzed changes both overall and within subgroups of critically ill versus Noncritically ill patients. SETTING: Data from Optum’s deidentified Claims-Clinical Dataset, which contains multicenter electronic health record data from U.S. hospitals. PATIENTS: Adults hospitalized with COVID-19 from January 2020 to June 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 141,533 eligible patients, 34,515 (24.4%) required admission to an ICU, 14,754 (10.4%) required mechanical ventilation, and 18,998 (13.4%) died during their hospitalization. Averaged over the entire time period, corticosteroid use was most common (47.0%), followed by remdesivir (33.2%), anticoagulants (19.3%), hydroxychloroquine (7.3%), and tocilizumab (3.4%). Usage patterns varied substantially across treatments. For example, hydroxychloroquine use peaked in March 2020 and leveled off to near zero by June 2020, whereas the use of remdesivir, corticosteroids, and tocilizumab all increased following press releases announcing positive results of large international trials. Ivermectin use increased slightly over the study period but was extremely rare overall (0.4%). CONCLUSIONS: During the COVID-19 pandemic, medication treatment patterns evolved reliably in response to emerging evidence and changes in policy. These findings may inform efforts to promote optimal adoption and deadoption of treatments for acute care conditions.
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Brodie D, Abrams D, MacLaren G, Brown CE, Evans L, Barbaro RP, Calfee CS, Hough CL, Fowles JA, Karagiannidis C, Slutsky AS, Combes A. Extracorporeal Membrane Oxygenation during Respiratory Pandemics: Past, Present, and Future. Am J Respir Crit Care Med 2022; 205:1382-1390. [PMID: 35213298 PMCID: PMC9875895 DOI: 10.1164/rccm.202111-2661cp] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The role of extracorporeal membrane oxygenation (ECMO) in the management of severe acute respiratory failure, including acute respiratory distress syndrome, has become better defined in recent years in light of emerging high-quality evidence and technological advances. Use of ECMO has consequently increased throughout many parts of the world. The coronavirus disease (COVID-19) pandemic, however, has highlighted deficiencies in organizational capacity, research capability, knowledge sharing, and resource use. Although governments, medical societies, hospital systems, and clinicians were collectively unprepared for the scope of this pandemic, the use of ECMO, a highly resource-intensive and specialized form of life support, presented specific logistical and ethical challenges. As the pandemic has evolved, there has been greater collaboration in the use of ECMO across centers and regions, together with more robust data reporting through international registries and observational studies. Nevertheless, centralization of ECMO capacity is lacking in many regions of the world, and equitable use of ECMO resources remains uneven. There are no widely available mechanisms to conduct large-scale, rigorous clinical trials in real time. In this critical care review, we outline lessons learned during COVID-19 and prior respiratory pandemics in which ECMO was used, and we describe how we might apply these lessons going forward, both during the ongoing COVID-19 pandemic and in the future.
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Affiliation(s)
- Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York;,Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Darryl Abrams
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York;,Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic, and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Crystal E. Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Ryan P. Barbaro
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Jo-anne Fowles
- Intensive Care, Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada;,Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, and,Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Sorbonne University, INSERM, UMRS1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; and,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique – Hôpitaux de Paris Sorbonne Hôpital Pitié-Salpêtrière, Paris, France
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Awasthi R, Guliani KK, Khan SA, Vashishtha A, Gill MS, Bhatt A, Nagori A, Gupta A, Kumaraguru P, Sethi T. VacSIM: Learning effective strategies for COVID-19 vaccine distribution using reinforcement learning. INTELLIGENCE-BASED MEDICINE 2022; 6:100060. [PMID: 35610985 PMCID: PMC9119863 DOI: 10.1016/j.ibmed.2022.100060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 12/18/2021] [Accepted: 03/29/2022] [Indexed: 12/18/2022]
Abstract
A COVID-19 vaccine is our best bet for mitigating the ongoing onslaught of the pandemic. However, vaccine is also expected to be a limited resource. An optimal allocation strategy, especially in countries with access inequities and temporal separation of hot-spots, might be an effective way of halting the disease spread. We approach this problem by proposing a novel pipeline VacSIM that dovetails Deep Reinforcement Learning models into a Contextual Bandits approach for optimizing the distribution of COVID-19 vaccine. Whereas the Reinforcement Learning models suggest better actions and rewards, Contextual Bandits allow online modifications that may need to be implemented on a day-to-day basis in the real world scenario. We evaluate this framework against a naive allocation approach of distributing vaccine proportional to the incidence of COVID-19 cases in five different States across India (Assam, Delhi, Jharkhand, Maharashtra and Nagaland) and demonstrate up to 9039 potential infections prevented and a significant increase in the efficacy of limiting the spread over a period of 45 days through the VacSIM approach. Our models and the platform are extensible to all states of India and potentially across the globe. We also propose novel evaluation strategies including standard compartmental model-based projections and a causality-preserving evaluation of our model. Since all models carry assumptions that may need to be tested in various contexts, we open source our model VacSIM and contribute a new reinforcement learning environment compatible with OpenAI gym to make it extensible for real-world applications across the globe. 2
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Affiliation(s)
- Raghav Awasthi
- Indraprastha Institute of Information Technology Delhi, India
| | | | - Saif Ahmad Khan
- Indraprastha Institute of Information Technology Delhi, India
| | | | | | - Arshita Bhatt
- Bhagwan Parshuram Institute of Technology, New Delhi, India
| | - Aditya Nagori
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Aniket Gupta
- Indraprastha Institute of Information Technology Delhi, India
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12
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Badalov E, Blackler L, Scharf AE, Matsoukas K, Chawla S, Voigt LP, Kuflik A. COVID-19 double jeopardy: the overwhelming impact of the social determinants of health. Int J Equity Health 2022; 21:76. [PMID: 35610645 PMCID: PMC9129892 DOI: 10.1186/s12939-022-01629-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/03/2022] [Indexed: 12/18/2022] Open
Abstract
Background The COVID-19 pandemic has strained healthcare systems by creating a tragic imbalance between needs and resources. Governments and healthcare organizations have adapted to this pronounced scarcity by applying allocation guidelines to facilitate life-or-death decision-making, reduce bias, and save as many lives as possible. However, we argue that in societies beset by longstanding inequities, these approaches fall short as mortality patterns for historically discriminated against communities have been disturbingly higher than in the general population. Methods We review attack and fatality rates; survey allocation protocols designed to deal with the extreme scarcity characteristic of the earliest phases of the pandemic; and highlight the larger ethical perspectives (Utilitarianism, non-Utilitarian Rawlsian justice) that might justify such allocation practices. Results The COVID-19 pandemic has dramatically amplified the dire effects of disparities with respect to the social determinants of health. Patients in historically marginalized groups not only have significantly poorer health prospects but also lower prospects of accessing high quality medical care and benefitting from it even when available. Thus, mortality among minority groups has ranged from 1.9 to 2.4 times greater than the rest of the population. Standard allocation schemas, that prioritize those most likely to benefit, perpetuate and may even exacerbate preexisting systemic injustices. Conclusions To be better prepared for the inevitable next pandemic, we must urgently begin the monumental project of addressing and reforming the structural inequities in US society that account for the strikingly disparate mortality rates we have witnessed over the course of the current pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-022-01629-0.
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Affiliation(s)
- Elizabeth Badalov
- City University of New York (CUNY) Hunter College, New York, NY, USA
| | - Liz Blackler
- Ethics Committee Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amy E Scharf
- Ethics Committee Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Konstantina Matsoukas
- Ethics Committee Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Medical Library Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sanjay Chawla
- Ethics Committee Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Anesthesiology, Pain and Critical Care Medicine Memorial Sloan Kettering Center, New York, NY, USA.,Department of Medicine Memorial Sloan Kettering Center, New York, NY, USA.,Department of Anesthesiology Weill Cornel Medical Center, New York, NY, USA
| | - Louis P Voigt
- Ethics Committee Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Anesthesiology, Pain and Critical Care Medicine Memorial Sloan Kettering Center, New York, NY, USA. .,Department of Medicine Memorial Sloan Kettering Center, New York, NY, USA. .,Department of Anesthesiology Weill Cornel Medical Center, New York, NY, USA. .,Department of Medicine Weill Cornell Medical Center, New York, NY, USA.
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13
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Riviello ED, Dechen T, O’Donoghue AL, Cocchi MN, Hayes MM, Molina RL, Moraco NH, Mosenthal A, Rosenblatt M, Talmor N, Walsh DP, Sontag DN, Stevens JP. Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19. JAMA Netw Open 2022; 5:e221744. [PMID: 35289860 PMCID: PMC8924715 DOI: 10.1001/jamanetworkopen.2022.1744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. OBJECTIVE To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. EXPOSURES Race, ethnicity, Social Vulnerability Index. MAIN OUTCOMES AND MEASURES The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. RESULTS Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. CONCLUSIONS AND RELEVANCE In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.
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Affiliation(s)
- Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley L. O’Donoghue
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael N. Cocchi
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rose L. Molina
- Harvard Medical School, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicole H. Moraco
- Division of General Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Anne Mosenthal
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Michael Rosenblatt
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Noa Talmor
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel P. Walsh
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Critical Care, Beth Israel Deaconess Hospital–Plymouth, Plymouth, Massachusetts
| | - David N. Sontag
- Harvard Medical School, Boston, Massachusetts
- Office of the General Counsel, Beth Israel Lahey Health, Cambridge, Massachusetts
- Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P. Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Fumagalli R. We Should Not Use Randomization Procedures to Allocate Scarce Life-Saving Resources. Public Health Ethics 2021; 15:87-103. [PMID: 35702644 PMCID: PMC9188376 DOI: 10.1093/phe/phab025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures (RAND) to allocate scarce life-saving resources (SLSR). In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims to these resources rather than use RAND to allocate such resources.
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Affiliation(s)
- Roberto Fumagalli
- King’s College London, UK, London School of Economics, UK and University of Pennsylvania, USA
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15
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Ingraham NE, Purcell LN, Karam BS, Dudley RA, Usher MG, Warlick CA, Allen ML, Melton GB, Charles A, Tignanelli CJ. Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language. J Gen Intern Med 2021; 36:3462-3470. [PMID: 34003427 PMCID: PMC8130213 DOI: 10.1007/s11606-021-06790-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19. OBJECTIVE Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19. DESIGN Retrospective cohort study SETTING: Health records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020 PATIENTS: Polymerase chain reaction-positive COVID-19 patients EXPOSURES: Area Deprivation Index (ADI) and primary language MAIN MEASURES: The primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression. RESULTS A total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. CONCLUSIONS Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.
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Affiliation(s)
- Nicholas E. Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Laura N. Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
| | - Basil S. Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. Adams Dudley
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Michael G. Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN USA
| | | | - Michele L. Allen
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN USA
| | - Genevieve B. Melton
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
- School of Public Health, University of North Carolina, Chapel Hill, NC USA
| | - Christopher J. Tignanelli
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN USA
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16
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Brown SD, Hardy SM, Bruno MA. Rationing and Disparities in Health Care: Implications for Radiology Clinical Practice Guidelines. J Am Coll Radiol 2021; 19:84-89. [PMID: 34687667 DOI: 10.1016/j.jacr.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/26/2022]
Abstract
We examine the relationship between the rationing of health care resources and disparities in health care delivery and the specific implications for radiologic resource allocation frameworks such as the ACR Appropriateness Criteria. We explore what rationing is in this context and how it is manifested in radiology. We review how rationing has taken many forms and how rationing has influenced the development of disparities in access and outcomes within health care and specifically within the context of radiology. We describe how the relationship between rationing and health care delivery disparities manifested during the coronavirus disease 2019 pandemic and the corrective measures that were proposed to established rationing frameworks to facilitate more equitable pandemic-related resource distribution. We offer suggestions regarding how such solutions might be brought into radiologic resource allocation schemes to help mitigate disparities in radiologic care in the future.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts; and Center for Bioethics, Harvard Medical School, Boston, Massachusetts.
| | - Seth M Hardy
- Department of Radiology, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael A Bruno
- Vice-Chair, Quality and Chief, Emergency Radiology, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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17
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Kiptanui Z, Ghosh S, Ali S, Desai K, Harris I. Transparency, health equity, and strategies in state-based protocols for remdesivir allocation and use. PLoS One 2021; 16:e0257648. [PMID: 34662359 PMCID: PMC8523064 DOI: 10.1371/journal.pone.0257648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background The Emergency Use Authorization (EUA) of remdesivir for coronavirus disease 2019 raised questions on transparency of applied strategy, and how to equitably allocate and prioritize eligible patients given limited supply of the medication. The absence of federal oversight highlighted the critical role by states in health policymaking during a pandemic. Objective To identify public state-based protocols for remdesivir allocation and clinical guidance for prioritizing remdesivir use and assess approaches and inclusion of language promoting equitable access or mitigating health disparities. Methods We identified remdesivir allocation strategies and clinical use guidelines for all 50 states in the U.S. and the District of Columbia accessible on state health department websites or via internet searches. Public protocols dated between May 1, 2020 and September 30, 2020 were included in the study. We reviewed strategies for allocation and clinical use, including whether protocols contained explicit language on equitable access to remdesivir or mitigating health disparities. Results A total of 38 states had a remdesivir allocation strategy, with 33 states (87%) making these public. States used diverse allocation strategies, and only 10 (30%) of the 33 states included language on equitable allocation. A total of 30 states had remdesivir clinical use guidelines, where all were publicly accessible. All guidelines referenced recommendations by federal agencies but varied in their presentation format. Of the 30 states, 12 (40%) had guidelines that included language on equitable use. Neither an allocation strategy or clinical use guideline were identified (public or non-public) for 10 states and the District of Columbia during the study period. Conclusions The experience with the remdesivir EUA presents an opportunity for federal and state governments to develop transparent protocols promoting fair and equal access to treatments for future pandemics.
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Affiliation(s)
- Zippora Kiptanui
- Index Analytics LLC, Catonsville, MD, United States of America
- * E-mail:
| | - Sanchari Ghosh
- IMPAQ International LLC, Columbia, Maryland, United States of America
| | - Sabeen Ali
- IMPAQ International LLC, Columbia, Maryland, United States of America
| | - Karishma Desai
- IMPAQ International LLC, Columbia, Maryland, United States of America
| | - Ilene Harris
- IMPAQ International LLC, Columbia, Maryland, United States of America
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18
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Voit K, Timmermann C, Steger F. Medication of Hydroxychloroquine, Remdesivir and Convalescent Plasma during the COVID-19 Pandemic in Germany-An Ethical Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115685. [PMID: 34073254 PMCID: PMC8197849 DOI: 10.3390/ijerph18115685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/20/2022]
Abstract
This paper aims to analyze the ethical challenges in experimental drug use during the early stage of the COVID-19 pandemic, using Germany as a case study. In Germany uniform ethical guidelines were available early on nationwide, which was considered as desirable by other states to reduce uncertainties and convey a message of unity. The purpose of this ethical analysis is to assist the preparation of future guidelines on the use of medicines during public health emergencies. The use of hydroxychloroquine, remdesivir and COVID-19 convalescent plasma in clinical settings was analyzed from the perspective of the ethical principles of beneficence, non-maleficence, justice and autonomy. We observed that drug safety and drug distribution during the pandemic affects all four ethical principles. We therefore recommend to establish ethical guidelines (i) to discuss experimental treatment options with patients from all population groups who are in urgent need, (ii) to facilitate the recording of patient reactions to drugs in off-label use, (iii) to expand inclusion criteria for clinical studies to avoid missing potentially negative effects on excluded groups, and (iv) to maintain sufficient access to repurposed drugs for patients with prior conditions.
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19
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Sultan H, Mansour R, Shamieh O, Al-Tabba' A, Al-Hussaini M. DNR and COVID-19: The Ethical Dilemma and Suggested Solutions. Front Public Health 2021; 9:560405. [PMID: 34055703 PMCID: PMC8149588 DOI: 10.3389/fpubh.2021.560405] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 03/19/2021] [Indexed: 12/21/2022] Open
Abstract
Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.
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Affiliation(s)
- Hala Sultan
- School of Medicine, University of Jordan, Amman, Jordan
| | - Razan Mansour
- Outcomes and Implementation Research Unit, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, United States
| | - Omar Shamieh
- Department of Palliative Care, King Hussein Cancer Center, Amman, Jordan
| | | | - Maysa Al-Hussaini
- Human Research Protection Program, King Hussein Cancer Center, Amman, Jordan
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20
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Verma AA, Pai M, Saha S, Bean S, Fralick M, Gibson JL, Greenberg RA, Kwan JL, Lapointe-Shaw L, Tang T, Morris AM, Razak F. Managing drug shortages during a pandemic: tocilizumab and COVID-19. CMAJ 2021; 193:E771-E776. [PMID: 33952621 PMCID: PMC8177913 DOI: 10.1503/cmaj.210531] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Amol A Verma
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont.
| | - Menaka Pai
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Sally Bean
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Michael Fralick
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Jennifer L Gibson
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Rebecca A Greenberg
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Janice L Kwan
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Terence Tang
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Andrew M Morris
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Fahad Razak
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
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21
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 242] [Impact Index Per Article: 80.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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22
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Supady A, Curtis JR, Abrams D, Lorusso R, Bein T, Boldt J, Brown CE, Duerschmied D, Metaxa V, Brodie D. Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks. THE LANCET. RESPIRATORY MEDICINE 2021; 9:430-434. [PMID: 33450202 PMCID: PMC7837018 DOI: 10.1016/s2213-2600(20)30580-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/22/2022]
Abstract
The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.
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Affiliation(s)
- Alexander Supady
- Interdisciplinary Medical Intensive Care, Department of Medicine III, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Heidelberg Institute of Global Health, University of Heidelberg, Germany.
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Darryl Abrams
- Columbia University College of Physicians & Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Thomas Bein
- Department of Anesthesia and Operative Intensive Care, University Hospital Regensburg, Germany
| | - Joachim Boldt
- Department of Medical Ethics and the History of Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Crystal E Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Daniel Duerschmied
- Interdisciplinary Medical Intensive Care, Department of Medicine III, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Daniel Brodie
- Columbia University College of Physicians & Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA
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23
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Riley W, Love K, McCullough J. Public Policy Impact of the COVID-19 Pandemic on Blood Supply in the United States. Am J Public Health 2021; 111:860-866. [PMID: 33734852 PMCID: PMC8034029 DOI: 10.2105/ajph.2021.306157] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic has precipitated an acute blood shortage for medical transfusions, exacerbating an already tenuous blood supply system in the United States, contributing to the public health crisis, and raising deeper questions regarding emergency preparedness planning for ensuring blood availability. However, these issues around blood availability during the pandemic are related primarily to the decline in supply caused by reduced donations during the pandemic rather than increased demand for transfusion of patients with COVID-19.The challenges to ensure a safe blood supply during the pandemic will continue until a vaccine is developed, effective treatments are available, or the virus goes away. If this virus or a similar virus were capable of transmission through blood, it would have a catastrophic impact on the health care system, causing a future public health emergency that would jeopardize the national blood supply.In this article, we identify the impact of the COVID-19 pandemic on blood supply adequacy, discuss the public health implications, propose recovery strategies, and present recommendations for preparing for the next disruption in blood supply driven by a public health emergency.
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Affiliation(s)
- William Riley
- All authors are with the College of Health Solutions, Arizona State University, Phoenix. Jeffrey McCullough is also with the University of Minnesota, Minneapolis
| | - Kailey Love
- All authors are with the College of Health Solutions, Arizona State University, Phoenix. Jeffrey McCullough is also with the University of Minnesota, Minneapolis
| | - Jeffrey McCullough
- All authors are with the College of Health Solutions, Arizona State University, Phoenix. Jeffrey McCullough is also with the University of Minnesota, Minneapolis
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24
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Abstract
The allocation of vaccines and therapeutics for Covid‐19 obviously raises ethical questions, and physicians and ethicists have begun to address them. Writers have identified various criteria that should guide allocation decisions, but the criteria often conflict and need to be balanced against one another. This article proposes a model for thinking about how different considerations that are relevant to the distribution of vaccines and scarce treatments for Covid‐19 could be integrated into an allocation procedure. The model employs the construct of a weighted lottery, which is a construct that has been employed in other contexts that involve the distribution of scarce resources. The article highlights the advantages of applying a weighted lottery to the Covid‐19 context and offers an illustration for how it might work in practice. The primary aim of the article is to articulate the structural features of a weighted lottery for this context and to bring out its advantages over other methods for allocating Covid‐19 medications.
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25
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Powell K, Meyers C. Guidance for Medical Ethicists to Enhance Social Cooperation to Mitigate the Pandemic. HEC Forum 2021; 33:73-90. [PMID: 33587216 PMCID: PMC7882860 DOI: 10.1007/s10730-021-09445-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 11/12/2022]
Abstract
The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric’s ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society’s willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.
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Affiliation(s)
| | - Christopher Meyers
- California State University, Bakersfield, Kegley Institute of Ethics, Bakersfield, CA, USA
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26
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Mun F, Hale CM, Hennrikus EF. A survey of US hospitals' criteria for the allocation of remdesivir to treat COVID-19. Am J Health Syst Pharm 2021; 78:235-241. [PMID: 33289021 PMCID: PMC7799270 DOI: 10.1093/ajhp/zxaa391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To determine how hospitals across the United States determined allocation criteria for remdesivir, approved in May 2020 for treatment of coronavirus disease 2019 (COVID-19) through an emergency use authorization, while maintaining fair and ethical distribution when patient needs exceeded supply. Methods A electronic survey inquiring as to how institutions determined remdesivir allocation was developed. On June 17, 2020, an invitation with a link to the survey was posted on the Vizient Pharmacy Network Community pages and via email to the American College of Clinical Pharmacy’s Infectious Disease Practice and Research Network listserver. Results 66 institutions representing 28 states responded to the survey. The results showed that 98% of surveyed institutions used a multidisciplinary team to develop remdesivir allocation criteria. A majority of those teams included clinical pharmacists (indicated by 97% of respondents), adult infectious diseases physicians (94%), and/or adult intensivists (69%). Many teams included adult hospitalists (49.2%) and/or ethicists (35.4%). Of the surveyed institutions, 59% indicated that all patients with COVID-19 were evaluated for treatment, and 50% delegated initial patient identification for potential remdesivir use to treating physicians. Prioritization of remdesivir allocation was often determined on a “first come, first served” basis (47% of respondents), according to a patient’s respiratory status (28.8%) and/or clinical course (24.2%), and/or by random lottery (22.7%). Laboratory parameters (10.6%), comorbidities (4.5%), and essential worker status (4.5%) were rarely included in allocation criteria; no respondents reported consideration of socioeconomic disadvantage or use of a validated scoring system. Conclusion The COVID-19 pandemic has exposed the inconsistencies of US medical centers’ methods for allocating a limited pharmacotherapy resource that required rapid, fair, ethical and equitable distribution. The medical community, with citizen participation, needs to develop systems to continuously reevaluate criteria for treatment allocation as additional guidance and data emerge.
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Affiliation(s)
- Frederick Mun
- Pennsylvania State University College of Medicine, Hershey, PA
| | - Cory M Hale
- Department of Pharmacy, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, PA
| | - Eileen F Hennrikus
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, PA
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27
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Vong G. Promoting the sustainability of healthcare resources with existing ethical principles: scarce COVID-19 medications, vaccines and principled parsimony. JOURNAL OF MEDICAL ETHICS 2021; 47:104-105. [PMID: 33431647 DOI: 10.1136/medethics-2020-107132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA 30322-1007, USA
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28
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Bruce L, Tallman R. Promoting racial equity in COVID-19 resource allocation. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106794. [PMID: 33514637 PMCID: PMC7852067 DOI: 10.1136/medethics-2020-106794] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 06/12/2023]
Abstract
Due to COVID-19's strain on health systems across the globe, triage protocols determine how to allocate scarce medical resources with the worthy goal of maximising the number of lives saved. However, due to racial biases and long-standing health inequities, the common method of ranking patients based on impersonal numeric representations of their morbidity is associated with disproportionately pronounced racial disparities. In response, policymakers have issued statements of solidarity. However, translating support into responsive COVID-19 policy is rife with complexity. Triage does not easily lend itself to race-based exceptions. Reordering triage queues based on an individual patient's racial affiliation has been considered but may be divisive and difficult to implement. And while COVID-19 hospital policies may be presented as rigidly focused on saving the most lives, many make exceptions for those deemed worthy by policymakers such as front-line healthcare workers, older physicians, pregnant women and patients with disabilities. These exceptions demonstrate creativity and ingenuity-hallmarks of policymakers' abilities to flexibly respond to urgent societal concerns-which should also be extended to patients of colour. This paper dismantles common arguments against the confrontation of racial inequity within COVID-19 triage protocols, highlights concerns related to existing proposals and proposes a new paradigm to increase equity when allocating scarce COVID-19 resources.
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Affiliation(s)
- Lori Bruce
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut, USA
- Bioethics Program (joint program with Clarkson University), Mount Sinai School of Medicine, Schenectady, New York, USA
- Sherwin B Nuland Summer Institute in Bioethics, Yale University, New Haven, Connecticut, USA
| | - Ruth Tallman
- Sherwin B Nuland Summer Institute in Bioethics, Yale University, New Haven, Connecticut, USA
- Art, Art History, Humanities, Music, Philosophy, Political Science, and Religion, Hillsborough Community College-Dale Mabry Campus, Tampa, Florida, USA
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29
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Vincent JL, Wendon J, Martin GS, Juffermans NP, Creteur J, Cecconi M. COVID-19: What we've done well and what we could or should have done better-the 4 Ps. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:40. [PMID: 33509218 PMCID: PMC7841973 DOI: 10.1186/s13054-021-03467-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/13/2021] [Indexed: 12/15/2022]
Abstract
The current coronavirus pandemic has impacted heavily on ICUs worldwide. Although many hospitals and healthcare systems had plans in place to manage multiple casualties as a result of major natural disasters or accidents, there was insufficient preparation for the sudden, massive influx of severely ill patients with COVID-19. As a result, systems and staff were placed under immense pressure as everyone tried to optimize patient management. As the pandemic continues, we must apply what we have learned about our response, both good and bad, to improve organization and thus patient care in the future.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Julia Wendon
- Department of Critical Care, Kings College Hospital Foundation Trust, London, UK
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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30
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Peek ME, Simons RA, Parker WF, Ansell DA, Rogers SO, Edmonds BT. COVID-19 Among African Americans: An Action Plan for Mitigating Disparities. Am J Public Health 2020; 111:286-292. [PMID: 33351662 DOI: 10.2105/ajph.2020.305990] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities.However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation.Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois' mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.
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Affiliation(s)
- Monica E Peek
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Russell A Simons
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - William F Parker
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - David A Ansell
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Selwyn O Rogers
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Brownsyne Tucker Edmonds
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
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31
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Roope LSJ, Buckell J, Becker F, Candio P, Violato M, Sindelar JL, Barnett A, Duch R, Clarke PM. How Should a Safe and Effective COVID-19 Vaccine be Allocated? Health Economists Need to be Ready to Take the Baton. PHARMACOECONOMICS - OPEN 2020; 4:557-561. [PMID: 32880878 PMCID: PMC7471481 DOI: 10.1007/s41669-020-00228-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Laurence S J Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Buckell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Frauke Becker
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paolo Candio
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mara Violato
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jody L Sindelar
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Raymond Duch
- Nuffield College, University of Oxford, Oxford, UK
| | - Philip M Clarke
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.
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32
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Martin DE, Parsons JA, Caskey FJ, Harris DCH, Jha V. Ethics of kidney care in the era of COVID-19. Kidney Int 2020; 98:1424-1433. [PMID: 33038425 PMCID: PMC7539938 DOI: 10.1016/j.kint.2020.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 02/08/2023]
Abstract
The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.
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Affiliation(s)
| | - Jordan A Parsons
- Bristol Medical School, University of Bristol, Bristol, UK; Instituts für Geschichte und Ethik der Medizin, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
| | - David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
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Rescue Treatment With High-Dose Gaseous Nitric Oxide in Spontaneously Breathing Patients With Severe Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0277. [PMID: 33225304 DOI: 10.1097/cce.0000000000000277] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Treatment options are limited for patients with respiratory failure due to coronavirus disease 2019. Conventional oxygen therapy and awake proning are options, but the use of high-flow nasal cannula and continuous positive airway pressure are controversial. There is an urgent need for effective rescue therapies. Our aim is to evaluate the role of inhaled nitric oxide 160 ppm as a possible rescue therapy in nonintubated coronavirus disease 2019 patients. Design Retrospective evaluation of coronavirus disease 2019 patients in respiratory distress receiving nitric oxide gas as rescue therapy. Setting Massachusetts General Hospital, between March 18, 2020, and May 20, 2020, during the local coronavirus disease 2019 surge. Patients Coronavirus disease 2019 patients at high risk for acute hypoxemic respiratory failure with worsening symptoms despite use of supplemental oxygen and/or awake proning. Interventions Patients received nitric oxide at concentrations of 160 ppm for 30 minutes twice per day via a face mask until resolution of symptoms, discharge, intubation, or the transition to comfort measures only. Measurements and Main Results Between March 18, 2020, and May 20, 2020, five patients received nitric oxide inhalation as a rescue therapy for coronavirus disease 2019 at Massachusetts General Hospital. All received at least one dosage. The three patients that received multiple treatments (ranging from five to nine) survived and were discharged home. Maximum methemoglobin concentration after 30 minutes of breathing nitric oxide was 2.0% (1.7-2.3%). Nitrogen dioxide was below 2 ppm. No changes in mean arterial pressure or heart rate were observed during or after nitric oxide treatment. Oxygenation and the respiratory rate remained stable during and after nitric oxide treatments. For two patients, inflammatory marker data were available and demonstrate a reduction or a cessation of escalation after nitric oxide treatment. Conclusions Nitric oxide at 160 ppm may be an effective adjuvant rescue therapy for patients with coronavirus disease 2019.
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Zimmerman RK, South-Paul JE, Poland GA. Rationing of Civilian Coronavirus Disease 2019 Vaccines While Supplies Are Limited. J Infect Dis 2020; 222:1776-1779. [PMID: 32894861 PMCID: PMC7499655 DOI: 10.1093/infdis/jiaa569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/02/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Behavioral and Community Health Sciences, Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jeannette E South-Paul
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gregory A Poland
- Mayo Vaccine Research Group, Mayo Clinic, Rochester, Minnesota, USA
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, UPMC Health System and The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, UPMC Health System and The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Associate Editor, JAMA
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Affiliation(s)
- Ameet Sarpatwari
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna Kaltenboeck
- Drug Pricing Lab, Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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