Crisis standard of care guidelines may not exacerbate racial inequities

There are two simultaneously occurring pandemics in the U.S.: Racism and COVID-19. "These mutualistic pandemics have thrown into stark focus the separate and unequal systems through which people access health care," explained corresponding author Emily Cleveland Manchanda, MD, assistant professor of emergency medicine at Boston University School of Medicine.

Cleveland Manchanda and colleagues authored a JAMA Network Open commentary explaining that it is imperative that crisis standards of care (CSC), guidelines designed to ensure the fair allocation of scarce hospital resources across racial and ethnic groups, do not exacerbate racial inequities further. Their commentary is in response to a study also published in JAMA Network Open that found no racial disparities in simulated patient prioritization for resource allocation using CSC guidelines at two Miami hospitals.

Throughout this past year Black, Latinx, Indigenous and other people of color (BIPOC) have suffered grossly disproportionate effects of the COVID-19 pandemic. According to Cleveland Manchanda, under-resourced communities of color typically rely on health care facilities, especially safety-net hospitals that have been hit the hardest by surges in COVID-19. Ill-equipped to handle these surges, many of these safety-net hospitals have had to cancel income-generating elective surgical procedures because their inpatient beds are filled with COVID-19 admissions.

Safety-net hospitals thus become reliant on a tenuous stream of government funding and may be more likely to enact CSC than better-resourced facilities. Additionally, the resource constraints at safety-net hospitals in diverse communities may lead to compromised care even before CSC enactment."

Cleveland Manchanda, Director for Equity Initiatives in the Emergency Medicine Department at Boston Medical Center

Cleveland Manchanda stresses that to prevent CSC from compounding harm during a public health crisis, resource allocation criteria must be developed, revised and implemented through an identity-conscious lens. "Failure to explicitly consider the particular risks faced by BIPOC, disabled and other marginalized populations may lead to unintended harms."

Cleveland Manchanda believes that if we are forced to activate CSC guidelines for critical care resource allocation, we must ensure that they equitably serve our most marginalized and at-risk patients populations. "Further prospective and validation studies are needed before CSC can be deemed free of racial and other biases."