Health Care Workers
This study by Yang et al. assesses whether health care workers (HCWs) are at risk of worse outcomes associated with COVID-19 (mechanical ventilation or death) compared to patients who are not HCWs. The target of the study was to gain additional information on the potential role of infectious dose to which a person is exposed in explaining differences in clinical outcomes. HCWs have experienced a higher risk of COVID-19 infection than the general population and may also be exposed to higher infectious doses due to their repeated and prolonged interactions with patients with severe infection in the health care setting. The study used data from 122 HCWs hospitalized with laboratory-confirmed COVID-19 and used propensity matching to compare them to 366 other persons hospitalized with COVID-19 who are similar in terms of demographic characteristics, comorbidities, presenting symptoms, medications, and treatments. HCWs tend to be younger, have fewer comorbidities, and are less likely to be smokers compared to the general population, so propensity matching allows a more “apples to apples” comparison. The study found that HCWs did not experience worse outcomes than the matched non-HCW patients; in fact, the HCWs had modestly better outcomes. The authors note that factors such as more meticulous PPE use may explain this result. They also note, however, that other burdens associated with the current pandemic, including physical, psychological, social, and practical burdens, are also disproportionately affecting the HCW population and require attention.
This perspective article by White and Lo argues that ICU triage protocols should simultaneously promote population health outcomes and mitigate health inequities. This is in response to concerns that existing ICU triage protocols for allocation of scarce resources (typically designed to save the most lives or the most life-years) may compound existing inequities that fall disproportionately on poor, Black, Latinx, and Indigenous communities, including the burdens of COVID-19. To balance the goal of saving the most lives while also distributing health benefits equitably, the authors recommend 3 strategies for ICU triage:
- introducing a correction factor into triage scores to reduce the impact of baseline structural inequities
- giving heightened priority to individuals in essential, high-risk occupations
- rejecting use of longer-term life expectancy and categorical exclusions among allocation criteria.
The article also sets out a number of strategies to promote justice in ICU triage, including modifications to existing guidelines, procedural justice considerations, and state-level policy considerations. Of note, the authors also participated in production of a model scarce resource allocation plan in the early stages of the pandemic (the “University of Pittsburgh Model”’, as well as a related JAMA viewpoint). That model was highly influential in shaping state and facility allocation frameworks nationally, but it also received criticism from some disability advocates and others for its inclusion of SOFA score and 1-5 year life expectancy among relevant factors, which could disadvantage persons with disabilities or chronic conditions.