Monday, September 4, 2023

Covid medication: allocation, information, hesitancy, and uptake: what are some things we have learned?

 I've posted before about how informational advertising about vaccine availability and safety seems to have had a positive effect on vaccination rates among disadvantaged populations. There was particular concern in the U.S. at one point that Black people were less likely to receive vaccines and other medications than other Americans.

Today's post collects several papers about the effect of randomly allocating invitations for temporarily scarce Covid medications, while giving members of disadvantaged groups a higher probability of receiving an invitation.  Included will be an editorial warning us that we shouldn't be satisfied to judge the outcome of a market design by its intended outcome ("Moving Beyond Intent and Realizing Health Equity").

There are market design lessons in these last few years of Covid experience that I hope will help make the responses to future pandemics more effective. Not least of these is that the allocation of public health  and medical resources turns out to be quite different from  the allocation of other kinds of resources, in many important ways that reflect the broader economic and social environments in which different kinds of allocation takes place.


Here's a paper in the most recent issue of JAMA Health Forum, by a team that includes both medical professionals and market designers.

Weighted Lottery to Equitably Allocate Scarce Supply of COVID-19 Monoclonal Antibody , by Erin K. McCreary, PharmD1; Utibe R. Essien, MD, MPH2,3; Chung-Chou H. Chang, PhD4,5; Rachel A. Butler, MHA, MPH6; Parag Pathak, PhD7; Tayfun Sönmez, PhD8; M. Utku Ünver, PhD8; Ashley Steiner, BS9; Maddie Chrisman, PT, DPT10; Derek C. Angus, MD, MPH11; Douglas B. White, MD, MAS11, JAMA Health Forum. 2023;4(9):e232774. Sept. 1, doi:10.1001/jamahealthforum.2023.2774 

"Objective  To describe the development and use of a weighted lottery to allocate a scarce supply of tixagevimab with cilgavimab as preexposure prophylaxis to COVID-19 for immunocompromised individuals and examine whether this promoted equitable allocation to disadvantaged populations.

"Design, Setting, and Participants  This quality improvement study analyzed a weighted lottery process from December 8, 2021, to February 23, 2022, that assigned twice the odds of drug allocation of 450 tixagevimab with cilgavimab doses to individuals residing in highly disadvantaged neighborhoods according to the US Area Deprivation Index (ADI) in a 35-hospital system in Pennsylvania, New York, and Maryland. In all, 10 834 individuals were eligible for the lottery. Weighted lottery results were compared with 10 000 simulated unweighted lotteries in the same cohort performed after drug allocation occurred.

"Main Outcomes:  Proportion of individuals from disadvantaged neighborhoods and Black individuals who were allocated and received tixagevimab with cilgavimab.

"Results:  Of the 10 834 eligible individuals, 1800 (16.6%) were from disadvantaged neighborhoods and 767 (7.1%) were Black. Mean (SD) age was 62.9 (18.8) years, and 5471 (50.5%) were women. A higher proportion of individuals from disadvantaged neighborhoods was allocated the drug in the ADI-weighted lottery compared with the unweighted lottery (29.1% vs 16.6%; P < .001). The proportion of Black individuals allocated the drug was greater in the weighted lottery (9.1% vs 7.1%; P < .001). Among the 450 individuals allocated tixagevimab with cilgavimab in the ADI-weighted lottery, similar proportions of individuals from disadvantaged neighborhoods accepted the allocation and received the drug compared with those from other neighborhoods (27.5% vs 27.9%; P = .93). However, Black individuals allocated the drug were less likely to receive it compared with White individuals (3 of 41 [7.3%] vs 118 of 402 [29.4%]; P = .003).


"Conclusions and Relevance:  The findings of this quality improvement study suggest an ADI-weighted lottery process to allocate scarce resources is feasible in a large health system and resulted in more drug allocation to and receipt of drug by individuals who reside in disadvantaged neighborhoods. Although the ADI-weighted lottery also resulted in more drug allocation to Black individuals compared with an unweighted process, they were less likely to accept allocation and receive it compared with White individuals. Further strategies are needed to ensure that Black individuals receive scarce medications allocated."


"The lottery was repeated over several weeks, but we chose to examine only the first assignment. The interpretation of later rounds is problematic because eventually all individuals were offered tixagevimab with cilgavimab. By focusing on the first draw, we can specifically evaluate whether the intent of the lottery was met."


Closely related reports:

White, D.B., McCreary, E.K., Chang, C.C.H., Schmidhofer, M., Bariola, J.R., Jonassaint, N.N., Persad, G., Truog, R.D., Pathak, P., Sonmez, T. and Unver, M.U., 2022. A multicenter weighted lottery to equitably allocate scarce COVID-19 therapeutics. American Journal of Respiratory and Critical Care Medicine, 206(4), pp.503-506.

Rubin, E., Dryden-Peterson, S.L., Hammond, S.P., Lennes, I., Letourneau, A.R., Pathak, P., Sonmez, T. and Ünver, M.U., 2021. A novel approach to equitable distribution of scarce therapeutics: institutional experience implementing a reserve system for allocation of COVID-19 monoclonal antibodies. Chest, 160(6), pp.2324-2331.*

White, D.B. and Angus, D.C., 2020. A proposed lottery system to allocate scarce COVID-19 medications: promoting fairness and generating knowledge. Jama, 324(4), pp.329-330.


And here's an editorial in the same issue of JAMA Health Forum as the most recent article, pointing out that less-disadvantaged patients among those living in census blocks identified as disadvantaged (in particular  commercially insured and White patients) were much more likely to receive the treatment:

Moving Beyond Intent and Realizing Health Equity, by Atheendar S. Venkataramani, MD, PhD, Invited Commentary, September 1, 2023, JAMA Health Forum. 2023;4(9):e232525. doi:10.1001/jamahealthforum.2023.2525

"In a study published in this issue of JAMA Health Forum, McCreary and colleagues3 report on a landmark effort at the University of Pittsburgh Medical Center (UPMC) to distribute equitably a scarce monoclonal antibody resource, tixagevimab with cilgavimab, for COVID-19 preexposure prophylaxis in immunocompromised individuals. In December 2021, UPMC received an allotment of 450 doses of tixagevimab with cilgavimab from the Pennsylvania Department of Health to cover a large health system with 35 hospitals and 800 outpatient facilities through February 2022. In an ex ante effort to mitigate health disparities and respond to guidance from the Commonwealth of Pennsylvania to allocate scarce resources in a manner that accounts for multiple ethical objectives, UPMC convened an advisory group of clinicians, community stakeholders, and experts in community outreach.


"The lottery was constructed using the Area Deprivation Index (ADI) to ensure that patients in highly disadvantaged neighborhoods had an equal opportunity to access tixagevimab with cilgavimab. Patients living in neighborhoods with ADIs above a specific cutoff that has been shown to best target less affluent, rural, and Black patients received 2 entries in the lottery, compared with 1 entry for patients in more advantaged neighborhoods. In their study, McCreary and colleagues3 found that this process resulted in equitable access: similar proportions of individuals in more advantaged and more disadvantaged neighborhoods (about 28% in each group) received tixagevimab with cilgavimab during the study period, although Black patients who were allocated the drug in the lottery were significantly less likely to receive it compared with White patients (7.3% vs 29.4%).


"Having identified its patient population, UPMC required only patient addresses as well as publicly available data on ADIs to implement the lottery intervention. The ADIs are defined at the census block group level, which include about 1000 residents on average. Thus, UPMC was able to achieve equitable opportunity to access tixagevimab with cilgavimab across small localities with very different socioeconomic profiles.


On the other hand, higher-resolution data that specifically measure the types of intersecting, reinforcing, and cumulative disadvantages faced by historically marginalized groups5 may be needed to achieve equitable outcomes across other dimensions, such as race and ethnicity. Within census blocks, patients assigned the same ADI levels but who may have faced relatively fewer structural barriers compared with Black patients or patients receiving Medicaid—namely, commercially insured and White patients—were more likely to access tixagevimab with cilgavimab conditional on being allocated to receive it in the lottery


"The lower rates of drug receipt among Black patients also underscores the importance of complementary investments and operational decisions to address additional structural barriers to accessing medical technology.


"The study by McCreary and colleagues3 represents the type of courageous and rigorous work that is needed to chart a path forward in determining how best to bridge the access gap for leading-edge medical technology. Future work would benefit from the same type of clarity demonstrated in this study by including clear definitions for how equity should be operationalized, attempting to address fragmentation between clinical services and services that address social drivers of health, aligning incentives, and addressing historical barriers that have made it difficult to achieve health equity."



Saturday, August 14, 2021

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