Timbie Justin W, Ringel Jeanne S, Fox D Steven, Waxman Daniel A, Pillemer Francesca, Carey Christine, Moore Melinda, Karir Veena, Johnson Tiffani J, Iyer Neema, Hu Jianhui, Shanman Roberta, Larkin Jody Wozar, Timmer Martha, Motala Aneesa, Perry Tanja R, Newberry Sydne, Kellermann Arthur L
Evid Rep Technol Assess (Full Rep). 2012 Jun(207):1-305.
This systematic review sought to identify the best available evidence regarding strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the review addresses the following questions: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCEs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCEs? (3) What are the public's key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCEs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCEs?
We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of Systematic Reviews from 1990 through 2011. To identify relevant non-peer-reviewed reports, we searched the New York Academy of Medicine's Grey Literature Report. We also reviewed relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental organizations, and consensus statements published by professional societies. We included both English- and foreign-language studies.
Our review included studies that evaluated tested strategies in real-world MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which included a comparison group. We reviewed separately studies that lacked a comparison group but nonetheless evaluated promising strategies. We also identified consensus recommendations developed by professional societies or government panels. We reviewed existing State plans to examine the current state of planning for scarce resource allocation during MCEs. Two investigators independently reviewed each article, abstracted data, and assessed study quality.
We considered 5,716 reports for this comparative effectiveness review (CER); we ultimately included 170 in the review. Twenty-seven studies focus on strategies for policymakers. Among this group were studies that examined various ways to distribute biological countermeasures more efficiently during a bioterror attack or influenza pandemic. They provided modest evidence that the way these systems are organized influences the speed of distribution. The review includes 119 studies that address strategies for providers. A number of these studies provided evidence suggesting that commonly used triage systems do not perform consistently in actual MCEs. The number of high-quality studies addressing other specific strategies was insufficient to support firm conclusions about their effectiveness. Only 10 studies included strategies that consider the public's perspective. However, these studies were consistent in their findings. In particular, the public believes that resource allocation guidelines should be simple and consistent across health care facilities but should allow facilities some flexibility to make allocation decisions based on the specific demand and supply situation. The public also believes that a successful allocation system should balance the goals of ensuring the functioning of society, saving the greatest number of people, protecting the most vulnerable people, reducing deaths and hospitalizations, and treating people fairly and equitably. The remaining 14 studies provided strategies for engaging providers in discussions about allocating and managing scarce medical resources. These studies did not identify one engagement approach as clearly superior; however, they consistently noted the importance of a broad, inclusive, and systematic engagement process.
Scientific research to identify the most effective adaptive strategies to implement during MCEs is an emerging area. While it remains unclear which of the many options available to policymakers and providers will be most effective, ongoing efforts to develop a focused, well-organized program of applied research should help to identify the optimal methods, techniques, and technologies to strengthen our nation's capacity to respond to MCEs.
本系统评价旨在找出关于在大规模伤亡事件（MCE）期间分配稀缺资源策略的最佳现有证据。具体而言，该评价涉及以下问题：（1）政策制定者在MCE期间优化稀缺资源分配可采用哪些策略？（2）医疗服务提供者在MCE期间优化稀缺资源分配可采用哪些策略？（3）公众对MCE期间稀缺资源分配策略实施的主要看法和担忧是什么？（4）有哪些方法可促使医疗服务提供者参与关于MCE期间稀缺资源分配策略制定和实施的讨论？
我们检索了1990年至2011年期间的Medline、Scopus、Embase、CINAHL（护理学与健康相关文献累积索引）、Global Health、科学引文索引（Web of Science®）以及Cochrane系统评价数据库。为识别相关的非同行评审报告，我们检索了纽约医学院的灰色文献报告。我们还查阅了相关的州和联邦计划、非政府组织的同行评审报告和论文，以及专业协会发表的共识声明。我们纳入了英语和外语研究。
我们的评价纳入了评估在实际MCE中经过测试的策略以及在演练、演习或计算机模拟中测试的策略的研究，所有这些研究均包含一个对照组。我们分别查阅了缺乏对照组但评估了有前景策略的研究。我们还确定了专业协会或政府小组制定的共识性建议。我们查阅了现有的州计划，以审视MCE期间稀缺资源分配规划的现状。两名研究人员独立评审每篇文章、提取数据并评估研究质量。
我们在本次比较效果评价（CER）中考虑了5716份报告；最终纳入评价的有170份。27项研究聚焦于政策制定者的策略。在这组研究中，有研究探讨了在生物恐怖袭击或流感大流行期间更高效地分发生物对策的各种方法。它们提供了适度的证据表明这些系统的组织方式会影响分发速度。该评价纳入了119项涉及医疗服务提供者策略的研究。其中一些研究提供的证据表明，常用的分诊系统在实际MCE中表现并不一致。针对其他特定策略的高质量研究数量不足以支持就其有效性得出确凿结论。仅有10项研究纳入了考虑公众观点的策略。然而，这些研究结果一致。特别是，公众认为资源分配指南应简单且在各医疗机构保持一致，但应允许医疗机构根据具体的供需情况有一定灵活性来做出分配决策。公众还认为，一个成功的分配系统应在确保社会运转、拯救最多人数、保护最弱势群体、减少死亡和住院人数以及公平公正地治疗患者这些目标之间取得平衡。其余14项研究提供了促使医疗服务提供者参与关于分配和管理稀缺医疗资源讨论的策略。这些研究未明确指出一种参与方式明显更优；然而，它们一致指出广泛、包容和系统的参与过程的重要性。
确定在MCE期间实施的最有效适应性策略的科学研究是一个新兴领域。虽然尚不清楚政策制定者和医疗服务提供者可采用的众多选项中哪一个最有效，但持续努力制定一个重点突出、组织有序的应用研究计划应有助于确定最佳方法、技术和工艺，以增强我国应对MCE的能力。
