Rationing and triage of scarce, lifesaving therapy in the context of the COVID-19 pandemic: a cross-sectional, social media-driven, scenario-based online query of societal attitudes
This article has been Reviewed by the following groups
Discuss this preprint
Start a discussion What are Sciety discussions?Listed in
- Evaluated articles (ScreenIT)
Abstract
The recent coronavirus disease 2019 (COVID-19) pandemic made us aware that medical resources are limited. When demand for essential resources surpasses availability, difficult triaging decisions are necessary. While algorithms exist, almost nothing is known on societal attitudes regarding triage criteria.
Methods:
A cross-sectional survey was conducted via social media channels to query a broad sample of society. Participants were asked to make triage decisions in case-based vignettes, exploring a variety of factors. They also were asked to assess how sure they were about their decisions, and how such decisions should be reached.
Results:
The survey was completed in full by 1626 participants in April 2020. Median age was 39 years (range, 12–80 y), 984 (61%) were female. Patient prognosis, responsibility toward others, the absence of behavior-induced comorbidities, and younger age were rated the most important triage criteria, while participants found that insurance status, social status, and nationality should not play a substantial role. Ethics-committees and point systems were regarded potentially helpful for triage decision-making, while decisions based on order of presentation (first-come first-serve) or on a legal basis were viewed critically. Participants were least sure about their decision when dealing with age or behavior-induced comorbidities. Overall, women were surer about their decisions than men, participants of Christian faith were also more secure about their decision than atheists-agnostics.
Conclusions:
This study uses social media to generate insight into public opinion and attitudes regarding triage criteria and modalities. These findings may be helpful for the development of future medical triage algorithms.
Article activity feed
-
-
-
SciScore for 10.1101/2020.07.28.20163360: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement After the imaginary case-vignettes, the participants were asked about their opinion on the modalities that should be employed to make triage decisions (a. drawing lots [randomization], b. chronologic distribution ["first come, first serve"], c. legal criteria [laws that specify how a physician should decide in a particular circumstance], d. ethics committees [on-site counselling of the physicians by an interdisciplinary team], e. decision committees [the decision is made by an independent team remote from the treatment location], f. a point-system similar to what is used for organ transplantation. Randomization not detected. Blinding not detected. Power Analysis not … SciScore for 10.1101/2020.07.28.20163360: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement After the imaginary case-vignettes, the participants were asked about their opinion on the modalities that should be employed to make triage decisions (a. drawing lots [randomization], b. chronologic distribution ["first come, first serve"], c. legal criteria [laws that specify how a physician should decide in a particular circumstance], d. ethics committees [on-site counselling of the physicians by an interdisciplinary team], e. decision committees [the decision is made by an independent team remote from the treatment location], f. a point-system similar to what is used for organ transplantation. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable %] 397 [24%] mean age (years, [95%CI]) female gender (n, [%]) 40 [39-40] 38 [34-43] 46 [44-49] 40 [ Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
However, it also has several limitations. The most obvious one is the fact that an online survey based on recruitment through social media does not necessarily confer a representative sample of society in general. In addition, those working in healthcare seemed overrepresented. We cannot make any statements regarding recall, since the denominator of how many people actually were reached is lacking. What we have shown, however, is that a large group of people can be recruited through an online survey in a very short time, and that the interest was high enough so that almost half of those that clicked the link also completed the survey in whole. We interpret this finding as a general interest in the subject of triage, and a willingness to participate in the public discourse around the factors that should play a role. In the future, more precise and representative measurements may be obtained by using more elaborate distribution channels, focus groups, and more detailed demographic information. Also, one may question whether the general public should be included in the discussion about triage criteria or not. While some may argue that categorical principles interpreted by experts in the relevant fields should receive priority, we strongly believe that it is appropriate and necessary in a democratic society to develop such criteria in a societal discourse and to facilitate participatory processes. In this regard, this study is also a small pilot test case for the implementation of such participation. Since a large part of this public exchange currently takes place on social media, we found it reasonable to evaluate whether these new technologies can be harnessed to foster a culture of participation and inclusion, even when the subject matter are complex ethical decisions. This study also shows that something as abstract as moral attitudes involved in medical triage can be quantified in an empirical study. We suggest that the findings of this study are used as a backdrop for a broader public debriefing on triage criteria after the COVID-19 pandemic subsides. This should include a push to establish morally acceptable triage criteria and algorithms for future disasters and pandemics. CONCLUSION This study generated a snapshot of the attitudes of a sample of German-speaking participants regarding criteria and modalities for the allocation of life-saving, limited resources during the height of the COVID-19 pandemic. According to the participants, prognosis, responsibility towards others, the absence of behavior-associated co-morbidities, along with younger age should be criteria for allocation of scarce ventilators. Insurance status, social status, as well as nationality and asylum status should not play a relevant role. Ethics-committees and a point system similar to what is used for organ transplantation were deemed potentially helpful in triage decision making. The findings and results of this study may be useful in creating future surveys addressed at a broader public. Similar but refined methods may be useful to expand future triage-algorithms by a dimension of societal consensus. FIGURE LEGENDS Participants' decisions on the case scenarios. The paired characteristics of the imaginary patients A versus B comprise 1. young/old, 2. public/private insurance, 3. with or without fateful co-morbidities, 4. with or without behavior-associated co-morbidities, 5. working or not working/working in healthcare, 6. local nationality/asylum seeker, 7. high/low social status, 8. unfavorable/favorable prognosis, 9. consent given/lacking, 10. single household/mother of 4 children. Figure 1: Opinions of the participants regarding the weighting of the respective triage criteria (a) and triage modalities (b). Participants regarded triage by prognosis as the most appropriate criterion, followed by behavior-associated co-morbidities and responsibility for others, as well as age (a). Most participants determined ethics committees and a pointsystem similar to that used in organ transplantation to be the triage modalities (b). (ns: non-significant, *: p<0·05). Figure 2: Contributors Oliver J. Muensterer: Conception of the study; study design; creation of the online survey; data collection and processing; creating figures and tables; drafting and editing of the manuscript. Emilio A. Gianicolo: Data processing; statistical analysis; editing tables; review and editing of manuscript. Norbert W. Paul: Mentoring and overseeing the master thesis; conception of the study; study design; co-drafting, review and editing of the manuscript. Funding The work of NWP regarding concepts of rationing was partly funded through the DFG-grant “Graduiertenkolleg 2015/2”, Research Training Group “Life Sciences – Life Writing”. Other work is based on intramural funding. Competing interests None declared. Patient consent for publication Not required. According to state law, institutional review board approval was waived because no patient data was included in the study. Participation in the online study was voluntary and anonymous. No identifiable information was collected or stored.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
About SciScore
SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore is not a substitute for expert review. SciScore checks for the presence and correctness of RRIDs (research resource identifiers) in the manuscript, and detects sentences that appear to be missing RRIDs. SciScore also checks to make sure that rigor criteria are addressed by authors. It does this by detecting sentences that discuss criteria such as blinding or power analysis. SciScore does not guarantee that the rigor criteria that it detects are appropriate for the particular study. Instead it assists authors, editors, and reviewers by drawing attention to sections of the manuscript that contain or should contain various rigor criteria and key resources. For details on the results shown here, including references cited, please follow this link.
-
SciScore for 10.1101/2020.07.28.20163360: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement Consent: The fictitious patient pairs differed in one principal characteristic [1. age, 2. insurance status, 3. fateful, non-behavior-associated co-morbidities (such as other preexisting conditions), 4. behavior-associated co-morbidities (resulting from behavior, such as smoking or drinking alcohol), 5. working in a healthcare profession, 6. asylum status/nationality, 7. social status, 8. prognosis/chance of therapeutic success, 9. explicit consent for the intensive therapy, 10. responsibility for others].
IRB: After the imaginary case-vignettes, the participants were asked about their opinion on the modalities that should be employed to make triage decisions …SciScore for 10.1101/2020.07.28.20163360: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement Consent: The fictitious patient pairs differed in one principal characteristic [1. age, 2. insurance status, 3. fateful, non-behavior-associated co-morbidities (such as other preexisting conditions), 4. behavior-associated co-morbidities (resulting from behavior, such as smoking or drinking alcohol), 5. working in a healthcare profession, 6. asylum status/nationality, 7. social status, 8. prognosis/chance of therapeutic success, 9. explicit consent for the intensive therapy, 10. responsibility for others].
IRB: After the imaginary case-vignettes, the participants were asked about their opinion on the modalities that should be employed to make triage decisions (a. drawing lots [randomization], b. chronologic distribution [“first come, first serve”], c. legal criteria [laws that specify how a physician should decide in a particular circumstance], d. ethics committees [on-site counselling of the physicians by an interdisciplinary team], e. decision committees [the decision is made by an independent team remote from the treatment location], f. a point-system similar to what is used for organ transplantation.Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:However, it also has several limitations. The most obvious one is the fact that an online survey based on recruitment through social media does not necessarily confer a representative sample of society in general. In addition, those working in healthcare seemed overrepresented. We cannot make any statements regarding recall, since the denominator of how many people actually were reached is lacking. What we have shown, however, is that a large group of people can be recruited through an online survey in a very short time, and that the interest was high enough so that almost half of those that clicked the link also completed the survey in whole. We interpret this finding as a general interest in the subject of triage, and a willingness to participate in the public discourse around the factors that should play a role. In the future, more precise and representative measurements may be obtained by using more elaborate distribution channels, focus groups, and more detailed demographic information. Also, one may question whether the general public should be included in the discussion about triage criteria or not. While some may argue that categorical principles interpreted by experts in the relevant fields should receive priority, we strongly believe that it is appropriate and necessary in a democratic society to develop such criteria in a societal discourse and to facilitate participatory processes. In this regard, this study is also a small pilot test case for the implementation o...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
-
