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Potential Impact of State Government Crisis Standards-of-Care Guidelines on Resource Allocation for Patients With Cancer


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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 POINTS

  • 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.
  • 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.

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.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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