How new clinical roles in primary care impact on equitable distribution of workforce: a retrospective study.

BACKGROUND: There are inequalities in the geographical distribution of the primary care workforce in England. Primary care networks (PCNs), and the associated Additional Roles Reimbursement Scheme (ARRS) funding, have stimulated employment of new healthcare roles. However, it is not clear whether this will impact inequalities. AIM: To examine whether the ARRS impacted inequality in the distribution of the primary care workforce. DESIGN AND SETTING: A retrospective before-and-after study of English PCNs in 2019 and 2022. METHOD: The study combined workforce, population, and deprivation data at network level for March 2019 and March 2022. The change was estimated between 2019 and 2022 in the slope index of inequality (SII) across deprivation of full-time equivalent (FTE) GPs (total doctors, qualified GPs, and doctors-in-training), nurses, direct patient care, administrative, ARRS and non- ARRS, and total staff per 10 000 patients. RESULTS: A total of 1255 networks were included. Nurses and qualified GPs decreased in number while all other staff roles increased, with ARRS staff having the greatest increase. There was a pro- rich change in the SII for administrative staff (-0.482, 95% confidence interval [CI] = -0.841 to -0.122, P<0.01) and a pro- poor change for doctors-in-training (0.161, 95% CI = 0.049 to 0.274, P<0.01). Changes in distribution of all other staff types were not statistically significant. CONCLUSION: Between 2019 and 2022 the distribution of administrative staff became less pro-poor, and doctors-in-training became pro-poor. The changes in inequality in all other staff groups were mixed. The introduction of PCNs has not substantially changed the longstanding inequalities in the geographical distribution of the primary care workforce.

335º Reunião Ordinária do Conselho Nacional de Saúde - 20 out. 2022

Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19.

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

The role of childrens' vaccination for COVID-19-Pareto-optimal allocations of vaccines.

COVID-19 vaccines have been approved for children of age five and older in many countries. However, there is an ongoing debate as to whether children should be vaccinated and at what priority. In this work, we use mathematical modeling and optimization to study how vaccine allocations to different age groups effect epidemic outcomes. In particular, we consider the effect of extending vaccination campaigns to include the vaccination of children. When vaccine availability is limited, we consider Pareto-optimal allocations with respect to competing measures of the number of infections and mortality and systematically study the trade-offs among them. In the scenarios considered, when some weight is given to the number of infections, we find that it is optimal to allocate vaccines to adolescents in the age group 10-19, even when they are assumed to be less susceptible than adults. We further find that age group 0-9 is included in the optimal allocation for sufficiently high values of the basic reproduction number.

Optimal vaccine allocation for COVID-19 in the Netherlands: A data-driven prioritization.

For the control of COVID-19, vaccination programmes provide a long-term solution. The amount of available vaccines is often limited, and thus it is crucial to determine the allocation strategy. While mathematical modelling approaches have been used to find an optimal distribution of vaccines, there is an excessively large number of possible allocation schemes to be simulated. Here, we propose an algorithm to find a near-optimal allocation scheme given an intervention objective such as minimization of new infections, hospitalizations, or deaths, where multiple vaccines are available. The proposed principle for allocating vaccines is to target subgroups with the largest reduction in the outcome of interest. We use an approximation method to reconstruct the age-specific transmission intensity (the next generation matrix), and express the expected impact of vaccinating each subgroup in terms of the observed incidence of infection and force of infection. The proposed approach is firstly evaluated with a simulated epidemic and then applied to the epidemiological data on COVID-19 in the Netherlands. Our results reveal how the optimal allocation depends on the objective of infection control. In the case of COVID-19, if we wish to minimize deaths, the optimal allocation strategy is not efficient for minimizing other outcomes, such as infections. In simulated epidemics, an allocation strategy optimized for an outcome outperforms other strategies such as the allocation from young to old, from old to young, and at random. Our simulations clarify that the current policy in the Netherlands (i.e., allocation from old to young) was concordant with the allocation scheme that minimizes deaths. The proposed method provides an optimal allocation scheme, given routine surveillance data that reflect ongoing transmissions. This approach to allocation is useful for providing plausible simulation scenarios for complex models, which give a more robust basis to determine intervention strategies.

Health care costs associated with hepatitis C virus infection in First Nations populations in Ontario: a retrospective matched cohort study.

BACKGROUND: Colonization and marginalization have affected the risk for and experience of hepatitis C virus (HCV) infection for First Nations people in Canada. In partnership with the Ontario First Nations HIV/AIDS Education Circle, we estimated the publicly borne health care costs associated with HCV infection among Status First Nations people in Ontario. METHODS: In this retrospective matched cohort study, we used linked health administrative databases to identify Status First Nations people in Ontario who tested positive for HCV antibodies or RNA between 2004 and 2014, and Status First Nations people who had no HCV testing records or only a negative test result (control group, matched 2:1 to case participants). We estimated total and net costs (difference between case and control participants) for 4 phases of care: prediagnosis (6 mo before HCV infection diagnosis), initial (after diagnosis), late (liver disease) and terminal (6 mo before death), until death or Dec. 31, 2017, whichever occurred first. We stratified costs by sex and residence within or outside of First Nations communities. All costs were measured in 2018 Canadian dollars. RESULTS: From 2004 to 2014, 2197 people were diagnosed with HCV infection. The mean net total costs per 30 days of HCV infection were $348 (95% confidence interval [CI] $277 to $427) for the prediagnosis phase, $377 (95% CI $288 to $470) for the initial phase, $1768 (95% CI $1153 to $2427) for the late phase and $893 (95% CI -$1114 to $3149) for the terminal phase. After diagnosis of HCV infection, net costs varied considerably among those who resided within compared to outside of First Nations communities. Net costs were higher for females than for males except in the terminal phase. INTERPRETATION: The costs per 30 days of HCV infection among Status First Nations people in Ontario increased substantially with progression to advanced liver disease and finally to death. These estimates will allow for planning and evaluation of provincial and territorial population-specific hepatitis C control efforts.

Impact of COVID-19 Pandemic on Liver Transplantation and Alcohol-Associated Liver Disease in the USA.

BACKGROUND AND AIMS: The surge in unhealthy alcohol use during the COVID-19 pandemic may have detrimental effects on the rising burden of alcohol-associated liver disease (ALD) on liver transplantation (LT) in the USA. We evaluated the effect of the pandemic on temporal trends for LT including ALD. APPROACH AND RESULTS: Using data from United Network for Organ Sharing, we analyzed wait-list outcomes in the USA through March 1, 2021. In a short-period analysis, patients listed or transplanted between June 1, 2019, and February 29, 2020, were defined as the "pre-COVID" era, and after April 1, 2020, were defined as the "COVID" era. Interrupted time-series analyses using monthly count data from 2016-2020 were constructed to evaluate the rate change for listing and LT before and during the COVID-19 pandemic. Rates for listings (P = 0.19) and LT (P = 0.14) were unchanged during the pandemic despite a significant reduction in the monthly listing rates for HCV (-21.69%, P < 0.001) and NASH (-13.18%; P < 0.001). There was a significant increase in ALD listing (+7.26%; P < 0.001) and LT (10.67%; P < 0.001) during the pandemic. In the COVID era, ALD (40.1%) accounted for more listings than those due to HCV (12.4%) and NASH (23.4%) combined. The greatest increase in ALD occurred in young adults (+33%) and patients with severe alcohol-associated hepatitis (+50%). Patients with ALD presented with a higher acuity of illness, with 30.8% of listings and 44.8% of LT having a Model for End-Stage Liver Disease-Sodium score ≥30. CONCLUSIONS: Since the start of COVID-19 pandemic, ALD has become the most common indication for listing and the fastest increasing cause for LT. Collective efforts are urgently needed to stem the rising tide of ALD on health care resources.

End-stage kidney disease and rationing of kidney replacement therapy in the free state province, South Africa: a retrospective study.

BACKGROUND: End-stage kidney disease (ESKD) and the required kidney replacement therapy (KRT) are significant public health challenges for low-and-middle-income countries. The South African government adopted a KRT rationing policy to balance the growing need for KRT and scarce resources. We aimed to describe the epidemiology and KRT access in patients with ESKD referred to the main public sector hospital in the Free State Province, South Africa. METHODS: A retrospective study of adult patients with ESKD admitted to Universitas Academic Hospital for KRT, was conducted between 1 January 2016 and 31 December 2018. A review of the KRT committee decisions to offer or deny KRT based on the KRT rationing policy of the Free State was undertaken. Demographic information, KRT committee outcomes, laboratory test results, and clinical details were collected from assessment tools, KRT committee meeting diaries, and electronic hospital records. RESULTS: Of 363 patients with ESKD referred for KRT access, 96 with incomplete records were excluded and 267 were included in the analysis. Median patient age was 40 (interquartile range, 33‒49) years, and male patients accounted for 56.2 % (150/267, p = 0.004) of the cohort. The average annual ESKD incidence was 49.9 (95 % confidence interval [CI], 35.8‒64.0) per-million-population. The most prevalent comorbidities were hypertension (42.3 %; 113/267), human immunodeficiency virus (HIV) (28.5 %; 76/267), and diabetes mellitus (19.1 %; 51/267). The KRT access rate was 30.7 % (82/267), with annual KRT incidence rates of 8.05 (95 % CI, 4.98‒11.1), 11.5 (95 % CI, 7.83‒15.1), and 14.1 (95 % CI, 10.3‒18.0) per-million-population in 2016, 2017, and 2018, respectively. Advanced organ dysfunction was the commonest reason recorded for KRT access denial (58.9 %; 109/185). Age (odds ratio [OR], 1.04; 95 % CI, 1.00‒1.07; p = 0.024) and diabetes (OR, 5.04; CI, 1.69‒15.03; p = 0.004) were independent predictors for exclusion from KRT, while hypertension (OR, 1.80; 1.06‒3.04; p = 0.029) independently predicted advanced organ dysfunction resulting in KRT exclusion. CONCLUSIONS: Non-communicable and communicable diseases, including hypertension, diabetes, and HIV, contributed to ESKD, highlighting the need for improved early prevention strategies to address a growing incidence rate. Two-thirds of ESKD patients were unable to access KRT, with age, diabetes mellitus, and advanced organ dysfunction being significant factors adversely affecting KRT access.

Equitably Allocating Resources during Crises: Racial Differences in Mortality Prediction Models.

Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.

Stressors, coping, and resources needed during the COVID-19 pandemic in a sample of perinatal women.

BACKGROUND: Psychological stress and coping experienced during pregnancy can have important effects on maternal and infant health, which can also vary by race, ethnicity, and socioeconomic status. Therefore, we assessed stressors, coping behaviors, and resources needed in relation to the COVID-19 pandemic in a sample of 162 perinatal (125 pregnant and 37 postpartum) women in the United States. METHODS: A mixed-methods study captured quantitative responses regarding stressors and coping, along with qualitative responses to open-ended questions regarding stress and resources needed during the COVID-19 pandemic. Logistic and linear regression models were used to analyze differences between pregnant and postpartum participants, as well as differences across key demographic variables. Qualitative content analysis was used to analyze open-ended questions. RESULTS: During the COVID-pandemic, food scarcity and shelter-in-place restrictions made it difficult for pregnant women to find healthy foods. Participants also reported missing prenatal appointments, though many reported using telemedicine to obtain these services. Financial issues were prevalent in our sample and participants had difficulty obtaining childcare. After controlling for demographic variables, pregnant women were less likely to engage in healthy stress-coping behaviors than postpartum women. Lastly, we were able to detect signals of increased stressors induced by the COVID-19 pandemic, and less social support, in perinatal women of racial and ethnic minority, and lower-income status. Qualitative results support our survey findings as participants expressed concerns about their baby contracting COVID-19 while in the hospital, significant others missing the delivery or key obstetric appointments, and wanting support from friends, family, and birthing classes. Financial resources, COVID-19 information and research as it relates to maternal-infant health outcomes, access to safe healthcare, and access to baby supplies (formula, diapers, etc.) emerged as the primary resources needed by participants. CONCLUSIONS: To better support perinatal women's mental health during the COVID-19 pandemic, healthcare providers should engage in conversations regarding access to resources needed to care for newborns, refer patients to counseling services (which can be delivered online/via telephone) and virtual support groups, and consistently screen pregnant women for stressors.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era.

BACKGROUND: COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers. METHODS: A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers. RESULTS: If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births. CONCLUSIONS: Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

COVID-19 Pandemic Planning: Simulation Models to Predict Biochemistry Test Capacity for Patient Surges.

BACKGROUND: Patient surges beyond hospital capacity during the initial phase of the COVID-19 pandemic emphasized a need for clinical laboratories to prepare test processes to support future patient care. The objective of this study was to determine if current instrumentation in local hospital laboratories can accommodate the anticipated workload from COVID-19 infected patients in hospitals and a proposed field hospital in addition to testing for non-infected patients. METHODS: Simulation models predicted instrument throughput and turn-around-time for chemistry, ion-selective-electrode, and immunoassay tests using vendor-developed software with different workload scenarios. The expanded workload included tests from anticipated COVID patients in 2 local hospitals and a proposed field hospital with a COVID-specific test menu in addition to the pre-pandemic workload. RESULTS: Instrumentation throughput and turn-around time at each site was predicted. With additional COVID-patient beds in each hospital, the maximum throughput was approached with no impact on turnaround time. Addition of the field hospital workload led to significantly increased test turnaround times at each site. CONCLUSIONS: Simulation models depicted the analytic capacity and turn-around times for laboratory tests at each site and identified the laboratory best suited for field hospital laboratory support during the pandemic.

The Impact of the COVID-19 Pandemic on Surgical Management of Breast Cancer: Global Trends and Future Perspectives.

INTRODUCTION: The rapid spread of COVID-19 across the globe is forcing surgical oncologists to change their daily practice. We sought to evaluate how breast surgeons are adapting their surgical activity to limit viral spread and spare hospital resources. METHODS: A panel of 12 breast surgeons from the most affected regions of the world convened a virtual meeting on April 7, 2020, to discuss the changes in their local surgical practice during the COVID-19 pandemic. Similarly, a Web-based poll based was created to evaluate changes in surgical practice among breast surgeons from several countries. RESULTS: The virtual meeting showed that distinct countries and regions were experiencing different phases of the pandemic. Surgical priority was given to patients with aggressive disease not candidate for primary systemic therapy, those with progressive disease under neoadjuvant systemic therapy, and patients who have finished neoadjuvant therapy. One hundred breast surgeons filled out the poll. The trend showed reductions in operating room schedules, indications for surgery, and consultations, with an increasingly restrictive approach to elective surgery with worsening of the pandemic. CONCLUSION: The COVID-19 emergency should not compromise treatment of a potentially lethal disease such as breast cancer. Our results reveal that physicians are instinctively reluctant to abandon conventional standards of care when possible. However, as the situation deteriorates, alternative strategies of de-escalation are being adopted. IMPLICATIONS FOR PRACTICE: This study aimed to characterize how the COVID-19 pandemic is affecting breast cancer surgery and which strategies are being adopted to cope with the situation.

Cataract service redesign in the post-COVID-19 era.

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

OBJECTIVE: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN: Quality improvement initiative. METHODS: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:S1-S10, 2021.

Public attitudes toward allocating scarce resources in the COVID-19 pandemic.

The general public is subject to triage policies that allocate scarce lifesaving resources during the COVID-19 pandemic, one of the worst public health emergencies in the past 100 years. However, public attitudes toward ethical principles underlying triage policies used during this pandemic are not well understood. Three experiments (preregistered; online samples; N = 1,868; U.S. residents) assessed attitudes toward ethical principles underlying triage policies. The experiments evaluated assessments of utilitarian, egalitarian, prioritizing the worst-off, and social usefulness principles in conditions arising during the COVID-19 pandemic, involving resource scarcity, resource reallocation, and bias in resource allocation toward at-risk groups, such as the elderly or people of color. We found that participants agreed with allocation motivated by utilitarian principles and prioritizing the worst-off during initial distribution of resources and disagreed with allocation motivated by egalitarian and social usefulness principles. At reallocation, participants agreed with giving priority to those patients who received the resources first. Lastly, support for utilitarian allocation varied when saving the greatest number of lives resulted in disadvantage for at-risk or historically marginalized groups. Specifically, participants expressed higher levels of agreement with policies that shifted away from maximizing benefits to one that assigned the same priority to members of different groups if this mitigated disadvantage for people of color. Understanding these attitudes can contribute to developing triage policies, increase trust in health systems, and assist physicians in achieving their goals of patient care during the COVID-19 pandemic.