In a study reported in JAMA Oncology, Hantel et al found that among U.S. states with crisis standards-of-care guidelines, 55% deprioritized some patients with cancer in resource allocation and 26% included cancer-related categorical exclusions.

As stated by the investigators, “State crisis standards-of-care guidelines in the U.S. allocate scarce health-care resources among patients. Anecdotal reports suggest that guidelines may disproportionately allocate resources away from patients with cancer, but no comprehensive evaluation has been performed.”

Study Details

The cross-sectional population-based analysis examined state-endorsed crisis standards-of-care guidelines published before May 20, 2020, that included health-care resource allocation recommendations.

Key Findings

Overall, 31 states had health-care resource allocation guidelines that met inclusion criteria; of these, 17 were published or updated since the first U.S. case of COVID-19.

Among the 31 states, 3 had an oncologist or a palliative care specialist listed on the guideline task force, 18 did not, and 10 did not list authors.

Crisis standards-of-care guidelines were more likely to be publicly available in states with available hospital bed capacity predicted to exceed 100% at 6 months (χ2 = 3.82, P = .05) and in those that contained a National Cancer Institute–designated comprehensive cancer center (χ2 = 6.21, P = .01).

The primary goals of resource allocation were to maximize the number of lives saved in 31 states (100%) and maximize the number of life-years saved in 22 states (71%). The most frequent primary methods of prioritization were the Sequential Organ Failure Assessment score (27 states, 87%) and deprioritizing persons with worse long-term prognoses (22 states, 71%).

Guidelines in 26 states (84%) recommended use of a triage team or officer to separate allocation decisions from front-line clinicians; 13 (42%) permitted at least one type of appeal for allocation decisions.

Guidelines from 24 states (77%) deprioritized or categorically excluded at least some patients with comorbid conditions, which included cancer in 19 states (61%). A total of 17 states (55%) had provisions that deprioritized at least some patients with cancer for resource allocation, and 8 (26%) categorically excluded at least some patients with cancer from allocation.

States with a comprehensive cancer center were significantly less likely to have cancer-related categorical exclusions on multivariate analysis (odds ratio = 0.06, 95% confidence interval = 0.004–0.87).

Both the presence of an in-state comprehensive cancer center and presence of an oncologist or palliative care specialist on the state crisis standards-of-care task force were associated with inclusion of palliative care provisions.

The investigators concluded: “Among states with crisis standards-of-care guidelines, most deprioritized some patients with cancer during resource allocation, and one-fourth categorically excluded them. The presence of an in-state comprehensive cancer center was associated with guideline availability, palliative care provisions, and lower odds of cancer-related exclusions. These data suggest that equitable state-level crisis standards-of-care considerations for patients with cancer benefit from the input of oncology stakeholders.”

Gregory A. Abel, MD, MPH, of the Division of Population Sciences, Dana-Farber Cancer Institute, is the corresponding author for the JAMA Oncology article.

Disclosure: The study was supported by grants from the National Cancer Institute. For full disclosures of the study authors, visit jamanetwork.com.