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Battisti D, Mannelli C. Who decides who goes first? Taking democracy seriously in micro-allocative healthcare decisions. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2025; 28:327-337. [PMID: 40089616 PMCID: PMC12103312 DOI: 10.1007/s11019-025-10263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/27/2025] [Indexed: 03/17/2025]
Abstract
The structural scarcity of healthcare resources has deeply challenged their fair distribution, prompting the need for allocation criteria. Long under the spotlight of the bioethical debate with an extraordinary peak during the recent COVID-19 pandemic, micro-allocation of healthcare has been extensively discussed in the literature with regard to issues of substantive and formal justice. This paper addresses a relatively underdiscussed question within the field of formal justice: who should define micro-allocation criteria in healthcare? To explore this issue, we first establish formal requirements that must be met for allocation criteria to be considered fair and legitimate. Then, we introduce three possible answers to the research question: the attending physician, the team of physicians, and the team of experts. We discuss and then reject all of them, arguing that the task of defining allocation criteria should be assigned to a political representative, supported by a cross-disciplinary team of experts. This proposal is based on the need to take democracy seriously as a tool for making substantive allocative decisions in light of the inevitable disagreement on such matters within a community. To support this claim, we present two key arguments-the democracy argument and the consistency argument. We also pre-emptively respond to two significant critiques: the too-specificity of the decision critique and the catastrophic outcomes critique. In conclusion, we argue that our proposal offers the fairest and most legitimate decision-making process for healthcare micro-allocation.
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Affiliation(s)
- Davide Battisti
- Department of Law, University of Bergamo, Via Gianbattista Moroni, 255, 24127, Bergamo, BG, Italy.
| | - Chiara Mannelli
- Istituto Superiore di Sanità, Bioethics Unit, Via Giano Della Bella, 34, 00162, Rome, Italy
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Hermsen M, Lyons PG, Persad G, Bewley AF, Mao C, Chhikara K, Mayampurath A, Churpek M, Peek ME, Luo Y, Parker WF. Age and Saving Lives in Crisis Standards of Care: A Multicenter Cohort Study of Triage Score Prognostic Accuracy. Crit Care Explor 2025; 7:e1256. [PMID: 40358051 PMCID: PMC12074069 DOI: 10.1097/cce.0000000000001256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2025] Open
Abstract
IMPORTANCE Current protocols to triage life support use scores that are biased and inaccurate. OBJECTIVES To determine if adding age to triage protocols used in disaster scenarios improves the identification of critically ill patients likely to survive. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study from March 1, 2020, to March 1, 2022, at 22 hospitals in three networks, divided into derivation (12 hospitals) and validation cohorts (ten hospitals). Participants were critically ill adults (90% COVID-19 positive) who would have needed life support during an overwhelming case surge. Life support was defined as vasoactive medications for shock, invasive or noninvasive mechanical ventilation, or oxygen therapy with Pao2/Fio2 less than 200. MAIN OUTCOMES AND MEASURES The primary outcome was death in the intensive care unit. We fit logistic regression models using a modified Sequential Organ Failure Assessment (SOFA) score with and without age in the derivation cohort and assessed predictive performance in the validation cohort using area under the receiver operating characteristic curves (AUCs) and compared observed and predicted mortality. RESULTS The final analysis contained 7,660 patients with 16,711 life-support episodes. In the validation cohort, the AUC for age plus SOFA was significantly higher than the AUC for SOFA alone (0.66 vs. 0.54; p < 0.001). SOFA score substantially overpredicted mortality (13% predicted vs. 5% observed) for younger patients (< 40 yr) and underestimated mortality (14% predicted vs. 31% observed) for older patients (> 80 yr). In contrast, age plus SOFA had good calibration overall and across age groups. The addition of age improved but did not eliminate differences between observed and predicted mortality across racial-ethnic groups. CONCLUSIONS AND RELEVANCE Age-inclusive triage better identifies ICU survivors than SOFA alone and is more equitable. Incorporating age into prioritization algorithms could save more lives in a crisis scenario.
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Affiliation(s)
- Michael Hermsen
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Patrick G. Lyons
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Govind Persad
- University of Denver Sturm College of Law, Denver, CO
| | - Alice F. Bewley
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Chengsheng Mao
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kaveri Chhikara
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Anoop Mayampurath
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Matthew Churpek
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Monica E. Peek
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Yuan Luo
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William F. Parker
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
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Rong R, Gu Z, Lai H, Nelson TL, Keller T, Walker C, Jin KW, Chen C, Navar AM, Velasco F, Peterson ED, Xiao G, Yang DM, Xie Y. A deep learning model for clinical outcome prediction using longitudinal inpatient electronic health records. JAMIA Open 2025; 8:ooaf026. [PMID: 40213364 PMCID: PMC11984207 DOI: 10.1093/jamiaopen/ooaf026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Revised: 03/07/2025] [Accepted: 03/20/2025] [Indexed: 04/16/2025] Open
Abstract
Objectives Recent advances in deep learning show significant potential in analyzing continuous monitoring electronic health records (EHR) data for clinical outcome prediction. We aim to develop a Transformer-based, Encounter-level Clinical Outcome (TECO) model to predict mortality in the intensive care unit (ICU) using inpatient EHR data. Materials and Methods The TECO model was developed using multiple baseline and time-dependent clinical variables from 2579 hospitalized COVID-19 patients to predict ICU mortality and was validated externally in an acute respiratory distress syndrome cohort (n = 2799) and a sepsis cohort (n = 6622) from the Medical Information Mart for Intensive Care IV (MIMIC-IV). Model performance was evaluated based on the area under the receiver operating characteristic (AUC) and compared with Epic Deterioration Index (EDI), random forest (RF), and extreme gradient boosting (XGBoost). Results In the COVID-19 development dataset, TECO achieved higher AUC (0.89-0.97) across various time intervals compared to EDI (0.86-0.95), RF (0.87-0.96), and XGBoost (0.88-0.96). In the 2 MIMIC testing datasets (EDI not available), TECO yielded higher AUC (0.65-0.77) than RF (0.59-0.75) and XGBoost (0.59-0.74). In addition, TECO was able to identify clinically interpretable features that were correlated with the outcome. Discussion The TECO model outperformed proprietary metrics and conventional machine learning models in predicting ICU mortality among patients with COVID-19, widespread inflammation, respiratory illness, and other organ failures. Conclusion The TECO model demonstrates a strong capability for predicting ICU mortality using continuous monitoring data. While further validation is needed, TECO has the potential to serve as a powerful early warning tool across various diseases in inpatient settings.
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Affiliation(s)
- Ruichen Rong
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Zifan Gu
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Hongyin Lai
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Tanna L Nelson
- Texas Health Resources, Arlington, TX 76011, United States
| | - Tony Keller
- Texas Health Resources, Arlington, TX 76011, United States
| | - Clark Walker
- Texas Health Resources, Arlington, TX 76011, United States
| | - Kevin W Jin
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Program in Computational Biology and Biomedical Informatics, Yale University, New Haven, CT 06511, United States
- Department of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT 06511, United States
| | - Catherine Chen
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Ann Marie Navar
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | | | - Eric D Peterson
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Guanghua Xiao
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Donghan M Yang
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Yang Xie
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
- Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
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Savulescu J. Collective Reflective Equilibrium, Algorithmic Bioethics and Complex Ethics. Camb Q Healthc Ethics 2025:1-16. [PMID: 39895279 DOI: 10.1017/s0963180124000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
Abstract
John Harris has made many seminal contributions to bioethics. Two of these are in the ethics of resource allocation. Firstly, he proposed the "fair innings argument" which was the first sufficientarian approach to distributive justice. Resources should be provided to ensure people have a fair innings-when Harris first wrote this, around 70 years of life, but perhaps now 80. Secondly, Harris famously advanced the egalitarian position in response to utilitarian approaches to allocation (such as maximizing Quality Adjusted Life Years [QALYs]) that what people want is the greatest chance of the longest, best quality life for themselves, and justice requires treating these claims equally. Harris thus proposed both sufficientarian and egalitarian approaches. This chapter compares these approaches with utilitarian and contractualist approaches and provides a methodology for deciding among these (Collective Reflective Equilibrium). This methodology is applied to the allocation of ventilators in the pandemic (as an example) and an ethical algorithm for their deployment created. This paper describes the concept of algorithmic bioethics as a way of addressing pluralism of values and context specificity of moral judgment and policy, and addressing complex ethics.
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Affiliation(s)
- Julian Savulescu
- Chen Su Lan Centennial Professor in Medical Ethics, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Uehiro Chair in Practical Ethics, Uehiro Oxford Institute, University of Oxford, Oxford, UK
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5
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Rong R, Gu Z, Lai H, Nelson TL, Keller T, Walker C, Jin KW, Chen C, Navar AM, Velasco F, Peterson ED, Xiao G, Yang DM, Xie Y. A deep learning model for clinical outcome prediction using longitudinal inpatient electronic health records. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2025:2025.01.21.25320916. [PMID: 39974062 PMCID: PMC11838940 DOI: 10.1101/2025.01.21.25320916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Abstract
Objective Recent advances in deep learning show significant potential in analyzing continuous monitoring electronic health records (EHR) data for clinical outcome prediction. We aim to develop a Transformer-based, Encounter-level Clinical Outcome (TECO) model to predict mortality in the intensive care unit (ICU) using inpatient EHR data. Materials and Methods TECO was developed using multiple baseline and time-dependent clinical variables from 2579 hospitalized COVID-19 patients to predict ICU mortality, and was validated externally in an ARDS cohort (n=2799) and a sepsis cohort (n=6622) from the Medical Information Mart for Intensive Care (MIMIC)-IV. Model performance was evaluated based on area under the receiver operating characteristic (AUC) and compared with Epic Deterioration Index (EDI), random forest (RF), and extreme gradient boosting (XGBoost). Results In the COVID-19 development dataset, TECO achieved higher AUC (0.89-0.97) across various time intervals compared to EDI (0.86-0.95), RF (0.87-0.96), and XGBoost (0.88-0.96). In the two MIMIC testing datasets (EDI not available), TECO yielded higher AUC (0.65-0.76) than RF (0.57-0.73) and XGBoost (0.57-0.73). In addition, TECO was able to identify clinically interpretable features that were correlated with the outcome. Discussion TECO outperformed proprietary metrics and conventional machine learning models in predicting ICU mortality among COVID-19 and non-COVID-19 patients. Conclusions TECO demonstrates a strong capability for predicting ICU mortality using continuous monitoring data. While further validation is needed, TECO has the potential to serve as a powerful early warning tool across various diseases in inpatient settings.
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Affiliation(s)
- Ruichen Rong
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Zifan Gu
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Hongyin Lai
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | | | | | | | - Kevin W. Jin
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Catherine Chen
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ann Marie Navar
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | | | - Eric D. Peterson
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Guanghua Xiao
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
- Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Donghan M. Yang
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Yang Xie
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
- Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
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Accogli A, Vergano M. Managing the Labyrinth of Complex Ethical Issues in Anesthesia Practice: The Anesthesiologist's Ariadne's Thread. Anesthesiol Clin 2024; 42:357-366. [PMID: 39054012 DOI: 10.1016/j.anclin.2023.12.006] [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: 07/27/2024]
Abstract
Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician.
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Affiliation(s)
- Agnese Accogli
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, Turin, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy.
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Fatani M, Shamayleh A, Alshraideh H. Assessing the Disruption Impact on Healthcare Delivery. J Prim Care Community Health 2024; 15:21501319241260351. [PMID: 38907592 PMCID: PMC11193933 DOI: 10.1177/21501319241260351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/04/2024] [Accepted: 05/21/2024] [Indexed: 06/24/2024] Open
Abstract
Health emergency outbreaks such as the COVID-19 pandemic make it challenging for healthcare systems to ration medical resources and patient care. Such disastrous events have been increasing over the past years and are becoming inevitable, necessitating the need for healthcare to be well-prepared and resilient to unpredictable rises in demand. Quantitative and qualitative based decision support systems increase the effectiveness of planning, alleviating uncertainties associated with the crisis. This study aims to understand how the COVID-19 pandemic has affected the performance of healthcare systems in different areas and to address the associated disruption. A cross-sectional online survey was conducted in the Kingdom of Saudi Arabia and the United Arab Emirates among healthcare workers who worked during the pandemic. The pandemic-related disruption and its psychometric properties were assessed using Structural Equations Modeling (SEM) with 5 latent factors: Staff Mental Health, Communication Level, Planning and Readiness, Healthcare Supply Chain, and Telehealth. Responses from highly qualified participants with many years of experience in hospital settings were collected and analyzed. Results show that the model satisfactorily fits the data with a CLI of 0.91 and TLI of 0.88. The model indicates that enhancing supply chain management, planning, telehealth usage, and communication level across the healthcare system can mitigate the disruption. However, the lack of mental health management for healthcare workers can significantly disrupt the quality of delivered care. Staff mental health and healthcare supply chain, respectively, are the highest contributors to varying degrees of disruption in healthcare delivery. This study provides a direction for more research focusing on determinants of healthcare efficiency. It also provides decision-makers insights into the main factors leading to disruptions in healthcare systems, allowing them to shape their outbreak response and better prepare for future health emergencies.
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Affiliation(s)
- Maymunah Fatani
- Biomedical Engineering Graduate Program, American University of Sharjah, Sharjah UAE
- Engineering Systems Management, American University of Sharjah, Sharjah UAE
- Department of Industrial Engineering, American University of Sharjah, Sharjah UAE
| | - Abdulrahim Shamayleh
- Biomedical Engineering Graduate Program, American University of Sharjah, Sharjah UAE
- Engineering Systems Management, American University of Sharjah, Sharjah UAE
- Department of Industrial Engineering, American University of Sharjah, Sharjah UAE
| | - Hussam Alshraideh
- Biomedical Engineering Graduate Program, American University of Sharjah, Sharjah UAE
- Engineering Systems Management, American University of Sharjah, Sharjah UAE
- Department of Industrial Engineering, American University of Sharjah, Sharjah UAE
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8
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Kyu Oh T, Song IA. Extracorporeal Membrane Oxygenation Support and Critically Ill COVID-19 Patient Outcomes: A Population-Based Cohort Study. ASAIO J 2024; 70:68-74. [PMID: 37788479 DOI: 10.1097/mat.0000000000002065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
We selected critically ill patients with coronavirus disease 2019 (COVID-19) who were receiving extracorporeal membrane oxygenation (ECMO) support and had been transferred to experienced centers. Thus, we aimed to evaluate factors that were associated with receiving ECMO support and factors that were associated with patient mortality. Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients admitted to an intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of COVID-19 were included. They were divided into two groups: ECMO group (n = 455) and non-ECMO group (n = 12,648). Receiving ECMO support was less associated with old age [odds ratio (OR), 0.95; 95% confidence interval (CI), 0.94-0.96; p < 0.001], underlying severe disabilities (OR, 0.49; 95% CI, 0.29-0.83; p = 0.008), and booster vaccination status (second: OR, 0.61; 95% CI, 0.39-0.94; p = 0.024; third: OR, 0.40; 95% CI, 0.25-0.65; p < 0.001). In addition, after adjusting for various variables, low mortality in patients with ECMO support was associated with having previously received a second booster vaccination (OR, 0.33; 95% CI, 0.14-0.77; p = 0.010). Vaccination and booster therapy may lower the need for ECMO support and lower mortality among critically ill patients with COVID-19 with ECMO support.
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Affiliation(s)
- Tak Kyu Oh
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - In-Ae Song
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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Kara MA. Is It Possible to Allocate Life? Triage, Ageism, and Narrative Identity. New Bioeth 2023; 29:322-339. [PMID: 37791914 DOI: 10.1080/20502877.2023.2261735] [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: 10/05/2023]
Abstract
Triage protocols can exclude older patients for the sake of effectiveness and this may be defended as the older have already had their fair share of life, which can mean fair amounts or complete lives. Nevertheless, if life is considered as a narrative, mentioning amounts might be nonsensical. Narratives have a quality of unity; so, life events are fragments whose meanings are dependent on the meaning of the whole. Thus, time units do not represent a reliable measure of the content of life. In addition, people's experience is different from the external flow of time, making its significance relative. Moreover, to compare the completeness of lives qualitatively, it is necessary to have a common cultural understanding, which is improbable to agree on in a modern society. Therefore, basic assumptions of the accounts that refer to fair shares of lives are mistaken, and these accounts do not support age-based rationing.
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Affiliation(s)
- Mahmut Alpertunga Kara
- History of Medicine and Ethics Department, Faculty of Medicine, Istanbul Medeniyet University Medicine, Istanbul, Türkiye
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Battisti D, Camporesi S. A proposal for formal fairness requirements in triage emergency departments: publicity, accessibility, relevance, standardisability and accountability. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109188. [PMID: 37620136 DOI: 10.1136/jme-2023-109188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
This paper puts forward a wish list of requirements for formal fairness in the specific context of triage in emergency departments (EDs) and maps the empirical and conceptual research questions that need to be addressed in this context in the near future. The pandemic has brought to the fore the necessity for public debate about how to allocate resources fairly in a situation of great shortage. However, issues of fairness arise also outside of pandemics: decisions about how to allocate resources are structurally unavoidable in healthcare systems, as value judgements underlie every allocative decision, although they are not always easily identifiable. In this paper, we set out to bridge this gap in the context of EDs. In the first part, we propose five formal requirements specifically applied for ED triage to be considered fair and legitimate: publicity, accessibility, relevance, standardisability and accountability. In the second part of the paper, we map the conceptual and empirical ethics questions that will need to be investigated to assess whether healthcare systems guarantee a formally just ED triage. In conclusion, we argue that there is a vast research landscape in need of an in-depth conceptual and empirical investigation in the context of ED triage in ordinary times. Addressing both types of questions in this context is vital for promoting a fair and legitimate ED triage and for fostering reflection on formal fairness allocative issues beyond triage.
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Affiliation(s)
| | - Silvia Camporesi
- Department of Political Science, University of Vienna, Vienna, Austria
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Nielsen L, Albertsen A. Pandemic justice: fairness, social inequality and COVID-19 healthcare priority-setting. JOURNAL OF MEDICAL ETHICS 2023; 49:283-287. [PMID: 36600629 DOI: 10.1136/jme-2022-108384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Abstract
A comprehensive understanding of the ethics of the COVID-19 pandemic priorities must be sensitive to the influence of social inequality. We distinguish between ex-ante and ex-post relevance of social inequality for COVID-19 disadvantage. Ex-ante relevance refers to the distribution of risks of exposure. Ex-post relevance refers to the effect of inequality on how patients respond to infection. In the case of COVID-19, both ex-ante and ex-post effects suggest a distribution which is sensitive to the prevalence social inequality. On this basis, we provide a generic fairness argument for the claim that welfare states ought to favour a healthcare priority scheme that gives particular weight to protecting the socially disadvantaged.
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Affiliation(s)
- Lasse Nielsen
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
- Centre for the Experimental-Philosophical Study of Discrimination, Aarhus University, Aarhus, Denmark
| | - Andreas Albertsen
- Centre for the Experimental-Philosophical Study of Discrimination, Aarhus University, Aarhus, Denmark
- Department of Political Science, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
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12
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Albertsen A. Covid-19 and age discrimination: benefit maximization, fairness, and justified age-based rationing. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:3-11. [PMID: 36242727 PMCID: PMC9568913 DOI: 10.1007/s11019-022-10118-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old.
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Affiliation(s)
- Andreas Albertsen
- Department of Political Science, Aarhus University and the Centre for the Experimental-Philosophical Study of Discrimination, CEPDISC, Aarhus University, Aarhus, Denmark.
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Fifolt M, McCormick LC, Wilson ME, Erwin PC. Exploring the Preliminary Steps of One County Health Department to Manage the COVID-19 Pandemic. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:667-673. [PMID: 35703308 PMCID: PMC9555586 DOI: 10.1097/phh.0000000000001538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This case study describes how one county health department in Alabama used the best available evidence to address the needs of its citizens during the first 6 months of the COVID-19 pandemic. The authors explore issues of scope of authority by government officials, individual freedom versus population health, and challenges of health communication during a disease outbreak. Despite the availability of vaccines, boosters, and access to vaccines by children as young as 5 years, COVID-19 cases are on the rise across the United States more than 2 years after the official news broke out of Wuhan, China. Health officials have expressed concerns that backlash against governmental public health during the pandemic will limit public health authorities from responding to the traditional challenges that were present pre-COVID-19 and will remain in a post-COVID-19 world.
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Affiliation(s)
- Matthew Fifolt
- Department of Health Policy and Organization (Drs Fifolt and Erwin), Department of Environmental Health Sciences (Dr McCormick), School of Public Health (Drs Fifolt, McCormick, and Erwin), and Jefferson County Department of Health (Dr Wilson), University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa C. McCormick
- Department of Health Policy and Organization (Drs Fifolt and Erwin), Department of Environmental Health Sciences (Dr McCormick), School of Public Health (Drs Fifolt, McCormick, and Erwin), and Jefferson County Department of Health (Dr Wilson), University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark E. Wilson
- Department of Health Policy and Organization (Drs Fifolt and Erwin), Department of Environmental Health Sciences (Dr McCormick), School of Public Health (Drs Fifolt, McCormick, and Erwin), and Jefferson County Department of Health (Dr Wilson), University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul C. Erwin
- Department of Health Policy and Organization (Drs Fifolt and Erwin), Department of Environmental Health Sciences (Dr McCormick), School of Public Health (Drs Fifolt, McCormick, and Erwin), and Jefferson County Department of Health (Dr Wilson), University of Alabama at Birmingham, Birmingham, Alabama
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14
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Tomov L, Miteva D, Sekulovski M, Batselova H, Velikova T. Pandemic control - do's and don'ts from a control theory perspective. World J Methodol 2022; 12:392-401. [PMID: 36186747 PMCID: PMC9516542 DOI: 10.5662/wjm.v12.i5.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/06/2022] [Accepted: 08/10/2022] [Indexed: 02/08/2023] Open
Abstract
Managing a pandemic is a difficult task. Pandemics are part of the dynamics of nonlinear systems with multiple different interactive features that co-adapt to each other (such as humans, animals, and pathogens). The target of controlling such a nonlinear system is best achieved using the control system theory developed in engineering and applied in systems biology. But is this theory and its principles actually used in controlling the current coronavirus disease-19 pandemic? We review the evidence for applying principles in different aspects of pandemic control related to different goals such as disease eradication, disease containment, and short- or long-term economic loss minimization. Successful policies implement multiple measures in concordance with control theory to achieve a robust response. In contrast, unsuccessful policies have numerous failures in different measures or focus only on a single measure (only testing, vaccines, etc.). Successful approaches rely on predictions instead of reactions to compensate for the costs of time delay, on knowledge-based analysis instead of trial-and-error, to control complex nonlinear systems, and on risk assessment instead of waiting for more evidence. Iran is an example of the effects of delayed response due to waiting for evidence to arrive instead of a proper risk analytical approach. New Zealand, Australia, and China are examples of appropriate application of basic control theoretic principles and focusing on long-term adaptive strategies, updating measures with the evolution of the pandemic.
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Affiliation(s)
- Latchezar Tomov
- Department of Informatics, New Bulgarian University, Sofia 1618, Bulgaria
| | - Dimitrina Miteva
- Department of Genetics, Sofia University "St. Kliment Ohridski", Sofia 1164, Bulgaria
| | - Metodija Sekulovski
- Department of Anesthesiology and Intensive care, University Hospital Lozenetz, Sofia 1407, Bulgaria
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Hristiana Batselova
- Department of Epidemiology and Disaster Medicine, Medical University, Plovdiv, University Hospital "St George", Plovdiv 6000, Bulgaria
| | - Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
- Department of Clinical Immunology, University Hospital Lozenetz, Sofia 1407, Bulgaria
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15
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Dieteren CM, van Hulsen MAJ, Rohde KIM, van Exel J. How should ICU beds be allocated during a crisis? Evidence from the COVID-19 pandemic. PLoS One 2022; 17:e0270996. [PMID: 35947541 PMCID: PMC9365136 DOI: 10.1371/journal.pone.0270996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 06/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background The first wave of the COVID-19 pandemic overwhelmed healthcare systems in many countries, and the rapid spread of the virus and the acute course of the disease resulted in a shortage of intensive care unit (ICU) beds. We studied preferences of the public in the Netherlands regarding the allocation of ICU beds during a health crisis. Methods We distributed a cross-sectional online survey at the end of March 2020 to a representative sample of the adult population in the Netherlands. We collected preferences regarding the allocation of ICU beds, both in terms of who should be involved in the decision-making and which rationing criteria should be considered. We conducted Probit regression analyses to investigate associations between these preferences and several characteristics and opinions of the respondents. Results A total of 1,019 respondents returned a completed survey. The majority favored having physicians (55%) and/or expert committees (51%) play a role in the allocation of ICU beds and approximately one-fifth did not favor any of the proposed decision-makers. Respondents preferred to assign higher priority to vulnerable patients and patients who have the best prospect of full recovery. They also preferred that personal characteristics, including age, play no role. Conclusion “Our findings show that current guidelines for allocating ICU beds that include age as an independent criterion may not be consistent with societal preferences. Age may only play a role indirectly, in relation to the vulnerability of patients and their prospect of full recovery. Allocation of ICU beds during a health crisis requires a multivalue ethical framework.”
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Affiliation(s)
- Charlotte M. Dieteren
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, The Netherlands
- * E-mail:
| | - Merel A. J. van Hulsen
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Research Institute of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kirsten I. M. Rohde
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Research Institute of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, The Netherlands
- Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
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16
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O'Sullivan L, Aldasoro E, O'Brien Á, Nolan M, McGovern C, Carroll Á. Ethical values and principles to guide the fair allocation of resources in response to a pandemic: a rapid systematic review. BMC Med Ethics 2022; 23:70. [PMID: 35799187 PMCID: PMC9261249 DOI: 10.1186/s12910-022-00806-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/17/2022] [Indexed: 11/21/2022] Open
Abstract
Background The coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic. Methods A rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically. Results A total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty. Conclusions Allocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00806-8.
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Affiliation(s)
- Lydia O'Sullivan
- School of Medicine, University College Dublin, Dublin 4, Ireland. .,Health Research Board-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland.
| | - Edelweiss Aldasoro
- International Foundation for Integrated Care, Annexe Offices, Linton Road, Oxford, OX2 6UD, England
| | | | - Maeve Nolan
- National Rehabilitation Hospital, Dun Laoghaire, Dublin, A96 E2H2, Ireland
| | - Cliona McGovern
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Áine Carroll
- School of Medicine, University College Dublin, Dublin 4, Ireland.,International Foundation for Integrated Care and the National Rehabilitation Hospital, Dun Laoghaire, Dublin, Ireland
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17
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Kessler SE, Aunger R. The evolution of the human healthcare system and implications for understanding our responses to COVID-19. Evol Med Public Health 2022; 10:87-107. [PMID: 35284079 PMCID: PMC8908543 DOI: 10.1093/emph/eoac004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/14/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has revealed an urgent need for a comprehensive, multidisciplinary understanding of how healthcare systems respond successfully to infectious pathogens-and how they fail. This study contributes a novel perspective that focuses on the selective pressures that shape healthcare systems over evolutionary time. We use a comparative approach to trace the evolution of care-giving and disease control behaviours across species and then map their integration into the contemporary human healthcare system. Self-care and pro-health environmental modification are ubiquitous across animals, while derived behaviours like care for kin, for strangers, and group-level organizational responses have evolved via different selection pressures. We then apply this framework to our behavioural responses to COVID-19 and demonstrate that three types of conflicts are occurring: (1) conflicting selection pressures on individuals, (2) evolutionary mismatches between the context in which our healthcare behaviours evolved and our globalized world of today and (3) evolutionary displacements in which older forms of care are currently dispensed through more derived forms. We discuss the significance of understanding how healthcare systems evolve and change for thinking about the role of healthcare systems in society during and after the time of COVID-19-and for us as a species as we continue to face selection from infectious diseases.
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Affiliation(s)
- Sharon E Kessler
- Department of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK
| | - Robert Aunger
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
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18
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Wilkinson DJC. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:48-63. [PMID: 33289443 PMCID: PMC8567739 DOI: 10.1080/15265161.2020.1851809] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
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19
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Sathya A, Rubenfeld GD, Fowler R. What Can Simulations Tell Us About Triage Protocols in a Real Pandemic? Chest 2021; 160:398-399. [PMID: 34366023 PMCID: PMC8339400 DOI: 10.1016/j.chest.2021.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Abhinay Sathya
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Gordon D Rubenfeld
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rob Fowler
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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20
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Brayda-Bruno M, Giorgino R, Gallazzi E, Morelli I, Manfroni F, Briguglio M, Accetta R, Mangiavini L, Peretti GM. How SARS-CoV-2 Pandemic Changed Traumatology and Hospital Setting: An Analysis of 498 Fractured Patients. J Clin Med 2021; 10:jcm10122585. [PMID: 34208115 PMCID: PMC8230877 DOI: 10.3390/jcm10122585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/11/2022] Open
Abstract
Background: SARS-CoV-2 pandemic is one of the biggest challenges for many health systems in the world, making lots of them overwhelmed by the enormous pressure to manage patients. We reported our Institutional Experience, with specific aims to describe the distribution and type of treated injuries, and the organizational setup of our hospital. Methods: Data of fractured patients admitted for surgical treatment in the time frames 9 March 2020–4 May 2020 and 1 March 2019–31 May 2019 were collected and compared. Furthermore, surgery duration and some parameters of effectiveness in health management were compared. Results: A total of 498 patients were included. Mean age significantly lower age in 2019 and femoral fractures were significantly more frequent 2020. Mean surgery time was significantly longer in 2020. Mortality rate difference between the two years was found to be statistically significant. Time interval between diagnosis and surgery and between diagnosis and discharge/decease was significantly lower in 2020. In 2020, no patient admitted with a negative swab turned positive in any of the following tests for SARS-CoV-2. Conclusions: The COVID-19 pandemic has modified the epidemiology of hospitalized patients for traumatic reasons, leading to an increased admission of older patients with femoral fractures. Nevertheless, our institutional experience showed that an efficient change in the hospital organization, with an improvement of several parameters of effectiveness in health management, led to a null infection rate between patients.
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Affiliation(s)
- Marco Brayda-Bruno
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
| | - Riccardo Giorgino
- Residency Program in Orthopedics and Traumatology, University of Milan, 20122 Milan, Italy
- Correspondence:
| | - Enrico Gallazzi
- Ortopedia e Traumatologia 3, ASST Centro Specialistico Ortopedico Traumatologico G. Pini–CTO, 20122 Milan, Italy;
| | - Ilaria Morelli
- U.O.C. Ortopedia e Traumatologia Nuovo Ospedale di Legnano ASST Ovest Milanese, 20025 Legnano, Italy;
| | - Francesca Manfroni
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
| | - Matteo Briguglio
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
| | - Riccardo Accetta
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
| | - Laura Mangiavini
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
| | - Giuseppe Maria Peretti
- IRCCS Orthopedic Institute Galeazzi, 20144 Milan, Italy; (M.B.-B.); (F.M.); (M.B.); (R.A.); (L.M.); (G.M.P.)
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
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21
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Shander A, Mesrobian J, Weiss J, Javidroozi M. Deploying Healthcare Providers during COVID-19 Pandemic. Disaster Med Public Health Prep 2021; 16:1-13. [PMID: 33866981 PMCID: PMC8209429 DOI: 10.1017/dmp.2021.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/19/2021] [Accepted: 04/05/2021] [Indexed: 12/22/2022]
Abstract
As the COVID-19 pandemic runs its course around the globe, a mismatch of resources and needs arises: In some areas, healthcare systems are faced with increased number of COVID-19 patients potentially exceeding their capacity, while in other areas, healthcare systems are faced with procedural cancellations and drop in demands. TeamHealth (Knoxville, TN), a multidisciplinary healthcare organization was able to roll out a systemic approach to redeploy its clinicians practicing in the fields of emergency medicine, hospital medicine and anesthesiology from areas of less need (faced with reduced or no work) to areas outside of their normal practice facing immediate need.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, TeamHealth, Knoxville, TN, USA
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - Jay Mesrobian
- Department of Anesthesiology, TeamHealth, Knoxville, TN, USA
| | - Jeffrey Weiss
- Department of Anesthesiology, TeamHealth, Knoxville, TN, USA
| | - Mazyar Javidroozi
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
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22
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Who Should Get COVID-19 Vaccine First? A Survey to Evaluate Hospital Workers' Opinion. Vaccines (Basel) 2021; 9:vaccines9030189. [PMID: 33668695 PMCID: PMC7996211 DOI: 10.3390/vaccines9030189] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/07/2023] Open
Abstract
Prospective planning of COVID-19 vaccines allocation will be essential to maximize public health and societal benefits while preserving equity. Decisions about how to allocate limited supplies of vaccines need to be clear about the criteria used in setting priorities, with a specific commitment to transparency and communication. The aim of our study was to think through these competing demands, focusing on the opinion of healthcare workers (HCWs). The primary endpoint of the study was to assess the opinion of all the HCWs in a University based Italian Hospital about the fairest priority order to COVID 19 vaccines and to understand on which criteria the prioritization preferences of HCWs are implicitly based. The secondary endpoints were to assess whether HCWs approach differs from national guidelines and to assess the attitude of HCWs towards mandatory vaccination. An online survey accounting with multiple choice single answer questions and ranking questions was administered to all the HCWs of the University Hospital P. Giaccone of Palermo (Italy) and completed by a total of 465 participants. Almost all respondents confirmed the need for prioritization in COVID-19 vaccination for HCWs (n = 444; 95.5%), essential services and law enforcement (both n = 428; 92%). Clinically vulnerable individuals, HCWs and population over 65 years have been considered the first three groups to be involved in getting vaccination, being indicated as first position group by 26.5%, 32.5% and 21.9% of respondents, respectively. A large majority of respondents (85%) asked for a consistent, transparent and detailed order of priority at a national level. After adjusting for potential confounding due to sex and age, physicians have been found to be statistically significantly associated with the choice of mandatory vaccination (odds ratio (OR): 10.2; 95% confidence interval (CI) = 2.7-39.1) or with other strategies different from voluntary (OR = 7.2; 95% CI = 1.9-27.3). The broad consensus expressed by respondents towards mandatory vaccination for HCWs is extremely relevant at a time when vaccination hesitation is one of the biggest obstacles to achieving herd immunity. Data show a mismatch in the position attributed to long-term care residents compared to the position of absolute priority assigned by most of national distribution plans, impelling us to reflect on the issue of maximizing benefit from limited healthcare resources. Our findings clearly indicate a preference for COVID-19 frontline health professionals as the first tier of recipients, since they better meet all the criteria (higher risk, immediate system stability). As the guidelines are likely to directly affect a considerable number of citizens, our results call for policy interventions to inform people on the ethical rationale behind vaccine distribution decisions, to avoid resentment and feelings of unfairness.
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23
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Farsalinos K, Poulas K, Kouretas D, Vantarakis A, Leotsinidis M, Kouvelas D, Docea AO, Kostoff R, Gerotziafas GT, Antoniou MN, Polosa R, Barbouni A, Yiakoumaki V, Giannouchos TV, Bagos PG, Lazopoulos G, Izotov BN, Tutelyan VA, Aschner M, Hartung T, Wallace HM, Carvalho F, Domingo JL, Tsatsakis A. Improved strategies to counter the COVID-19 pandemic: Lockdowns vs. primary and community healthcare. Toxicol Rep 2020; 8:1-9. [PMID: 33294384 PMCID: PMC7713637 DOI: 10.1016/j.toxrep.2020.12.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 02/08/2023] Open
Abstract
COVID-19 pandemic mitigation strategies are mainly based on social distancing measures and healthcare system reinforcement. However, many countries in Europe and elsewhere implemented strict, horizontal lockdowns because of extensive viral spread in the community which challenges the capacity of the healthcare systems. However, strict lockdowns have various untintended adverse social, economic and health effects, which have yet to be fully elucidated, and have not been considered in models examining the effects of various mitigation measures. Unlike commonly suggested, the dilemma is not about health vs wealth because the economic devastation of long-lasting lockdowns will definitely have adverse health effects in the population. Furthermore, they cannot provide a lasting solution in pandemic containment, potentially resulting in a vicious cycle of consecutive lockdowns with in-between breaks. Hospital preparedness has been the main strategy used by governments. However, a major characteristic of the COVID-19 pandemic is the rapid viral transmission in populations with no immunity. Thus, even the best hospital system could not cope with the demand. Primary, community and home care are the only viable strategies that could achieve the goal of pandemic mitigation. We present the case example of Greece, a country which followed a strategy focused on hospital preparedness but failed to reinforce primary and community care. This, along with strategic mistakes in epidemiological surveillance, resulted in Greece implementing a second strict, horizontal lockdown and having one of the highest COVID-19 death rates in Europe during the second wave. We provide recommendations for measures that will reinstate primary and community care at the forefront in managing the current public health crisis by protecting hospitals from unnecessary admissions, providing primary and secondary prevention services in relation to COVID-19 and maintaining population health through treatment of non-COVID-19 conditions. This, together with more selective social distancing measures (instead of horizontal lockdowns), represents the only viable and realistic long-term strategy for COVID-19 pandemic mitigation.
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Affiliation(s)
- Konstantinos Farsalinos
- Laboratory of Molecular Biology and Immunology, Department of Pharmacy, University of Patras, Panepistimiopolis, 26500, Greece
- School of Public Health, University of West Attica, L Alexandras 196A, Athens, 11521, Greece
| | - Konstantinos Poulas
- Laboratory of Molecular Biology and Immunology, Department of Pharmacy, University of Patras, Panepistimiopolis, 26500, Greece
| | - Dimitrios Kouretas
- Department of Biochemistry and Biotechnology, University of Thessaly, Larisa, 41500, Greece
| | | | - Michalis Leotsinidis
- Lab. of Public Health, Medical School, University of Patras, University Campus, 26504, Greece
| | - Dimitrios Kouvelas
- Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349, Craiova, Romania
| | - Ronald Kostoff
- School of Public Policy, Georgia Institute of Technology, Gainesville, VA, 20155, USA
| | - Grigorios T. Gerotziafas
- Sorbonne Université, INSERM, UMR_S 938, Group de recherche « Cancer-Hemostasis-Angiogenesis », Centre de recherche Saint-Antoine, CRSA, Centre de Thrombose, Tenon-Saint Antoine, University Hospitals, Assistance publique Hôpitaux de Paris, France
| | - Michael N. Antoniou
- Gene Expression and Therapy Group, King's College London, Department of Medical and Molecular Genetics, School of Basic & Medical Biosciences, 8th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - Riccardo Polosa
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia, 97 95131, Catania, Italy
- Centro Prevenzione Cura Tabagismo, Center of Excellence for the Acceleration of Harm Reduction, University of Catania, 95123, Catania, Italy
| | - Anastastia Barbouni
- School of Public Health, University of West Attica, L Alexandras 196A, Athens, 11521, Greece
| | - Vassiliki Yiakoumaki
- Department of History, Archaeology and Social Anthropology, University of Thessaly, 38221, Volos, Greece
| | - Theodoros V. Giannouchos
- Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Pantelis G. Bagos
- Department of Computer Science and Biomedical Informatics, University of Thessaly, Lamia, 35100, Greece
| | - George Lazopoulos
- Department of Cardiac Surgery, University Hospital of Heraklion, Crete, Greece
| | - Boris N. Izotov
- Department of Analytical Toxicology, Pharmaceutical Chemistry and Pharmacognosy, Sechenov University, 119991, Moscow, Russia
| | - Victor A. Tutelyan
- Federal Research Centre of Nutrition, Biotechnology and Food Safety, Moscow, Russian Federation
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Eisntein College of Medicine, 1300 Morris Park Avenue Bronx, NY, 10461, USA
| | - Thomas Hartung
- Center for Alternatives to Animal Testing, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
- Department of Pharmacology and Toxicology, University of Konstanz, 78464, Konstanz, Germany
| | - Heather M. Wallace
- Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Félix Carvalho
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313, Porto, Portugal
| | - Jose L. Domingo
- Laboratory of Toxicology and Environmental Health, School of Medicine, IISPV, Universitat Rovira i Virgili, Reus, Catalonia, Spain
| | - Aristides Tsatsakis
- Department of Analytical Toxicology, Pharmaceutical Chemistry and Pharmacognosy, Sechenov University, 119991, Moscow, Russia
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003, Heraklion, Greece
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Laurie GT. Enacting Bioethics. Asian Bioeth Rev 2020; 12:253-255. [PMID: 32837559 PMCID: PMC7389153 DOI: 10.1007/s41649-020-00141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Graeme T. Laurie
- Edinburgh Law School, The University of Edinburgh, Edinburgh, UK
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de Castro-Hamoy L, de Castro LD. Age Matters but it should not be Used to Discriminate Against the Elderly in Allocating Scarce Resources in the Context of COVID-19. Asian Bioeth Rev 2020; 12:331-340. [PMID: 32837555 PMCID: PMC7298697 DOI: 10.1007/s41649-020-00130-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023] Open
Abstract
A patient's age serves as a very useful guide to physicians in deciding what disease manifestations to anticipate, what treatment to offer for certain conditions, and how to prepare for possible emergencies. In the context of the COVID-19 pandemic, determining treatment options on the basis of a patient's chronological age can easily give rise to unjustified discrimination. This is of particular significance in situations where the allocation of scarce critical care resources could have a direct impact on who will live and who will die. This paper examines the fairness of recommendations contained in resource allocation guidelines in the Philippines that have implications for the way elderly patients could be treated or excluded from some forms of critical care treatment in the context of the ongoing Corona virus emergency.
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Affiliation(s)
- Leniza de Castro-Hamoy
- National Institutes of Health, University of the Philippines Manila, Manila, Philippines.,Department of Pediatrics, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Leonardo D de Castro
- Department of Philosophy, University of the Philippines Diliman, Quezon City, Philippines
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