When there isn’t enough health care to go around, how should Oregon decide who gets it?
Would flipping a coin be better than what Oregon does now?
A state committee for the Oregon Health Authority is looking at how medical providers should make triage decisions. It meets again this week.
The concern is the current tools Oregon has for making triage decisions were not developed with much input from the community, there may discrimination, the tools are at risk for bias and there is just not much experience or research to lean on.
For instance, during the peaks of the pandemic there were sometimes hard choices that needed to be made in the country about who gets access to ventilators. So if the pandemic fell disproportionately on disadvantaged groups, did the decisions about who gets a ventilator exacerbate that problem?
The state could take various approaches for triage:
It could choose survivability — what saves the most lives.
It could aim to reduce or eliminate health inequities.
It could try to reduce the risk for essential workers.
It could do it randomly, flip a coin.
Or it could do some mix of the above.
The approach most often used in the country is survivability. That is typically based on what is called a sequential organ failure assessment, SOFA. It looks at various indicators of health and body function. For instance, one part of that assessment is the Glasgow Coma Score. It’s a way of looking at levels of consciousness and brain function. Patients doing poorly on that and other tests would be more likely to be denied resources based on the assumption they would be less likely to survive.
But there have been equity concerns about how that is used. People with disabilities may do more poorly on scores like the Glasgow Coma Score. And sequential organ failure assessment has also raised other concerns. One study looked at 2,982 patients admitted with COVID-19 in the Yale New Haven Health System. Non-Hispanic Black patients had greater odds of having higher SOFA scores than Non-Hispanic White patients. So they would be more likely to be denied resources.
Oregon’s existing triage guidelines try to recognize the limitations of the various approaches. It uses a modified organ failure assessment. It makes adjustments for people with chronic diseases and disabilities. There’s a pause built in to try to look for biases. And if multiple individuals get the same score for prioritization, coins could be flipped.
The committee, the Resource Allocation Advisory Committee, is not going to make a final decision this week on what approach Oregon should use. And it is going to allow public comment.
What causes you concern about Oregon’s triage approach? What should Oregon’s policy be? The email for the committee is OHAResourceallocation@dhsoha.state.or.us.