Optimization of Ventilation Therapy Prioritization Strategies among Patients with COVID-19: Lessons Learned from Real-World Data of nearly 600,000 Hospitalized Patients
Authors: Abbasi-Kangevari Mohsen , Ghanbari Ali , Malekpour Mohammad-Reza , Ghamari Seyyed-Hadi , Azadnajafabad Sina , Moghaddam Sahar Saeedi , Keykhaei Mohammad , Haghshenas Rosa , Golestani Ali , Rashidi Mohammad-Mahdi , Rezaei Nazila , Ghasemi Erfan , Rezaei Negar , Jamshidi Hamid Reza , Larijani Bagher 
Published: August 2022

SummaryObjectiveTo investigate the benefit of ventilation therapy among various patient groups with COVID-19 admitted to hospitals, based on the real-world data of hospitalized adult patients.MethodsData used in the longitudinal study included 599,340 records of hospitalized patients. All participants were categorized based on demographics and their date of hospitalization. Two models were used in this study: firstly, participants were assessed by their probability of receiving ventilation therapy during hospitalization using mixed-effects logistic regression. Secondly, the clinical benefit of receiving ventilation therapy among various patient groups was quantified while considering the probability of receiving ventilation therapy during hospital admission, as estimated in the first model.FindingsAmong participants, 60,113 (10.0%) received ventilation therapy, 85,158 (14.2%) passed away due to COVID-19, and 514,182 (85.8%) recovered. Among all groups with sufficient data for analysis, patients aged 40-64 years who had chronic respiratory diseases (CRD) and malignancy benefitted the most from ventilation therapy; followed by patients aged 65+ years who had malignancy, cardiovascular diseases, and diabetes; and patients aged 18-39 years who had malignancy. Patients aged 65+ who had CRD and cardiovascular disease gained the least benefit from ventilation therapy.ConclusionThis study promotes a new aspect of treating patients for ventilators: it could be suggested that rather than focusing on the scarcity of ventilators, guidelines focus on decision-making algorithms to also take the usefulness of the intervention into account, whose beneficial effect is dependent on the selection of the right time in the right patient.FundingThis work was supported by the World Health Organization (WHO) Eastern Mediterranean Regional Office (EMRO) (Grant No. 202693061). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Research in contextWhat was already knownResearch has been ongoing to investigate the main principles for allocating scarce medical resources during pandemics. Medical experts working at the COVID-19 care units interact with patients of different socioeconomic, clinical, paraclinical, and overall health statuses. While physicians should not be faced with situations where they would be obliged to decide which patient to treat due to the risk of human error as well as the double-burden of life-long emotional toll, the pandemic has increased the likelihood of such dilemmas, especially in settings with limited resources. Serious discussions on the ethical considerations of ventilator allocation were also raised during the pandemic. Utility (maximizing benefits) and equity (distributive justice) were two concerns raised in decision making in such dilemma which has also been considered to be “the toughest triage”.What new knowledge the manuscript contributesThis longitudinal study provides new insights on optimizing the strategies for ventilation therapy prioritization among patients with COVID-19, based on the real-world data of nearly 600,000 hospitalized patients with COVID-19. So far, there has been focus on how to prioritize patients with COVID-19 for ventilation therapy. Nevertheless, there has not been much evidence on how much patients of different age groups with various underlying conditions actually benefitted from ventilation therapy based on real-world data. The results of this study could have a significant message: should the prioritization guidelines for ventilators allocation take no notice of the real-world data, patients might be deprived of ventilation therapy, who could benefit the most from it. This would pave the way to capture clearer picture in the possible future pandemics.