Rationing Scarce Healthcare Capacity: A Study of the Ventilator Allocation Guidelines During the COVID-19 Pandemic
研究评估了美国各州呼吸机分配指南，利用机器学习预测患者存活概率和使用时长，提出了一种改进的优先排序方案（ISP-LU），能增加存活人数并减少等待死亡风险，同时限制种族差异。
In the United States, even though national guidelines for allocating scarce healthcare resources are lacking, 26 states have specific ventilator allocation guidelines to be invoked in case of a shortage. While several states developed their guidelines in response to the recent COVID‐19 pandemic, New York State developed these guidelines in 2015 as “pandemic influenza is a foreseeable threat, one that we cannot ignore.” The primary objective of this study is to assess the existing procedures and priority rules in place for allocating/rationing scarce ventilator capacity and propose alternative (and improved) priority schemes. We first build machine learning models using inpatient records of COVID‐19 patients admitted to New York‐Presbyterian/Columbia University Irving Medical Center and an affiliated community health center to predict survival probabilities as well as ventilator length‐of‐use. Then, we use the resulting point estimators and their uncertainties as inputs for a multiclass priority queueing model with abandonments to assess three priority schemes: (i) SOFA‐P (Sequential Organ Failure Assessment based prioritization), which most closely mimics the existing practice by prioritizing patients with sufficiently low SOFA scores; (ii) ISP (incremental survival probability), which assigns priority based on patient‐level survival predictions; and (iii) ISP‐LU (incremental survival probability per length‐of‐use), which takes into account survival predictions and resource use duration. Our findings highlight that our proposed priority scheme, ISP‐LU, achieves a demonstrable improvement over the other two alternatives. Specifically, the expected number of survivals increases and death risk while waiting for ventilator use decreases. We also show that ISP‐LU is a robust priority scheme whose implementation yields a Pareto‐improvement over both SOFA‐P and ISP in terms of maximizing saved lives after mechanical ventilation while limiting racial disparity in access to the priority queue.