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Stanford Vaccine Algorithm Left Frontline Workers at Back of Line

Stanford Medicine officials also studied guidelines — then built a mathematical algorithm that prioritized people who on paper were at high risk for COVID-19, such as older employees. But not all who came into contact with patients were doctors and nurses.

Closeup of gloved hands preparing a vaccine.
(TNS) - Dec. 24—To choose who would be first in line for a coronavirus vaccine, UCSF Medical Center in San Francisco gathered a group of brainy people this fall to study guidelines and prioritize employees who came into the most contact with patients, including janitors. Kaiser Permanente did much the same across 21 medical centers.
Stanford Medicine officials also studied guidelines — then built a mathematical algorithm that prioritized people who on paper were at high risk for COVID-19, such as older employees, but not the health care workers who came into the most contact with patients, such as intensive care doctors and nurses.
It didn't take long for Stanford medical residents and fellows on the front lines of the crisis to see that they were being asked to risk their lives while a shot that would protect them was given to others. The doctors captured national attention as they staged an angry protest Friday and confronted Stanford Medicine leaders not only about the botched rollout, but about what they described as a secretive approach. The leaders quickly apologized, vowing to change their approach and make the vaccine distribution process more transparent.
Attention then turned to the algorithm Stanford created to guide their decision.
The private hospital has declined to discuss it. But the methodology that made Stanford an outlier in how it prioritized the vaccine has been puzzled over by scholars at MIT and belittled by math geeks on Twitter.
"What happens when you apply the age priority scheme ... to a population selected on the basis of their theoretical level of *exposure*?" tweeted Whitney Robinson, an epidemiologist at the University of North Carolina's school of public health. "You get ludicrous results like a wealthy 68-year-old Stanford Health Care radiologist and executives who work from home in spacious houses getting prioritized ahead of 29-year-old residents with two roommates who work in the (emergency department) every day."
An MIT Technology Review article on the Stanford kerfuffle points to a 2019 study in the journal Science revealing that algorithms commonly used by hospitals to guide health decisions tend to favor white patients over Black patients. In one case, where patients' health care spending is used as a proxy for how sick they are, the algorithm falsely concludes that Black patients, who tend to spend less, are healthier than equally sick white patients. The study's authors estimate that if the algorithm were fixed, the proportion of Black patients getting the care they need would rise by 29 percentage points, from 17.7% to 46.5%.
"Asking the algorithm to answer the wrong question results in all sorts of problems — racial bias in our study, and the issues (highlighted) at Stanford," said the study's author, Ziad Obermeyer, a physician and associate professor of health policy and management at UC Berkeley.
Algorithms can help in decision-making by assigning points to different variables. A graphic of Stanford's algorithm, published in MIT Technology Review, shows that employees were assigned points based on age (65 and older, 25 and younger), California Department of Public Health guidelines and job features. Jobs and departments got points based on prevalence of COVID-19, percentage positive for COVID-19 and percentage of coronavirus tests collected.
The Chronicle shared Stanford's algorithm with Obermeyer, who said that part of its problem appeared to be too much weight on the wrong variable: people at risk of getting sick (older employees), instead of people at risk of infection (employees working with intensive care or emergency room patients.)
"When there are scarce resources, any prioritization will always be open for debate," Obermeyer said. "But the goal of algorithms should be to make that prioritization fair, transparent and defensible. No one should hide behind 'an error in the algorithm,' as if the algorithm has a mind of its own, when they literally designed the algorithm."
UCSF took a different approach to its rollout, pulling together doctors, administrators and "equity experts and ethics experts" to make the decision, said Adrienne Green, the hospital's chief medical officer. The group looked first at guidelines recommending that employees at greatest risk be prioritized: those working in COVID-19 units and emergency rooms. Vaccinating them first might also protect vulnerable people those employees frequently come in contact with.
Dr. Jennifer Reid, a surgical fellow, is one of those employees. She's been on edge for nine months. When patients need emergency care, their surgery can't wait until their coronavirus test results come back, so Reid suits up with an N95 mask, protective eye wear — the works — and hopes she doesn't get sick. It's a huge concern, particularly because her mother, on chemotherapy, lives with her. Her husband, a physician's assistant at another hospital, is also at risk. He has slept in a hotel room more than once for everyone's safety.
On Dec. 13, Reid got an alert saying she had been selected by lottery to make one of the first vaccination appointments. Three days later, as the serum entered her arm, "I immediately felt relieved," she said. "I think it was just a weight lifted off my shoulders." Her second dose comes in January.
UCSF also considered employees from communities with a high rates of infection, such as the Mission District, Green said. That heavily Latino area includes many UCSF workers, including janitors, who also work in the emergency room and high-risk locations.
"We decided that everybody who worked in those areas would be in the same priority group for vaccination," Green said.
Just over half of the first 896 UCSF employees vaccinated with the Pfizer vaccine were nurses and medical residents. Technicians, respiratory therapists and other health care workers were about 19% of the total, and faculty (emergency room and intensive care doctors) were 17.5%. The remaining 8% included drivers, cleaners and other workers.
Reina Lopez, a UCSF housekeeper who wears heavy protection to work, was the second person vaccinated at UCSF, on Dec. 16.
"I felt all the emotions — happy, excited, scared — but most of all relieved that we are finally moving forward to getting back to some normalcy," she said.
Lopez and Reid said they appreciated UCSF's vaccination rollout. But not every employee initially agreed. Brittany Howze, a nurse in the COVID-19 unit at the Mount Zion campus, had griped that the process wasn't going fast enough.
So Howze was surprised last weekend when she learned her turn would be Monday of this week, and she would be among the first to be inoculated.
It nearly didn't happen. The serum has triggered bad allergic reactions in some people, so when asked if she had a history of such reactions, Howze hesitated. Then she answered no, keeping to herself the serious reactions she's had after eating pistachios and cashews.
"I was afraid I wouldn't be able to get it," she later told a reporter. "I have literally been having dreams at night about getting the vaccine. And then waking up to remember it isn't actually true. I'm so happy that this day is finally here."
On Tuesday, UCSF received 7,900 doses of the second FDA-approved vaccine, by Moderna, and expects to inoculate 11,800 employees and medical trainees at highest risk of infection, the hospital said.
Kaiser Permanente's Dr. Stephen Parodi, an infectious disease expert who leads the hospital system's COVID-19 response in Northern California and across the country, said Kaiser never considered using an algorithm.
"We felt that having the appropriate clinical expertise and operational leadership in the room was really important, and that that can't be delegated to anyone but our experts," Parodi said, adding that those experts have used "a lens of equity" to ensure fairness.
Parodi said he hasn't been vaccinated "because I'm not working in the intensive care unit, for example. We've tried to stick to this approach."
Stanford changed its approach the very evening of the protest.
" Stanford turned into a free-for-all," said Andrea Henkel, one of the doctors who participated in the protest. "It became a first-come, first-serve situation until they ran out of doses on Friday." Henkel, a resident, waited in line for 90 minutes before getting her injection in the hospital atrium.
In fact, Stanford Medicine has been on a vaccination spree since Friday, inoculating more than 2,000 health care workers through the weekend, said spokeswoman Julie Greicius.
A new Vaccine Governance Committee oversees the revised plan that "prioritizes health care workers in our clinical settings," from residents and nurses, to housekeepers, she said.
Sharif Vakili, another protesting doctor, said he was pleased with the hospital's response.
"It's clear they are working hard to rectify this mistake," he said. "And I do think they genuinely feel horrible about what happened."
Nanette Asimov is a San Francisco Chronicle staff writer. Email: Twitter: @NanetteAsimov
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