It's always good to see a collaboration between physicians and economists on allocating scarce resources, and here's a case report of allocating monoclonal antibodies in Boston (with some resemblance to school choice), forthcoming in the journal CHEST.
A novel approach to equitable distribution of scarce therapeutics: institutional experience implementing a reserve system for allocation of Covid-19 monoclonal antibodies Emily Rubin, MD JD MSHP, Scott L. Dryden-Peterson, MD, Sarah P. Hammond, MD, Inga Lennes, MD MBA MPH, Alyssa R. Letourneau, MD MPH, Parag Pathak, PhD, Tayfun Sonmez, PhD, M. Utku Ünver, PhD.
DOI: https://doi.org/10.1016/j.chest.2021.08.003, To appear in: CHEST
"Background. In fall 2020, the Food and Drug Administration issued emergency use authorization for monoclonal antibody therapies (mAbs) for outpatients with Covid-19. The Commonwealth of Massachusetts issued guidance outlining the use of a reserve system with a lottery for allocation of mAbs in the event of scarcity that would prioritize socially vulnerable patients for 20% of the infusion slots. The Mass General Brigham (“MGB”) health system subsequently implemented such a reserve system.
"Research Question. Can a reserve system be successfully deployed in a large health system in a way that promotes equitable access to mAb therapy among socially vulnerable patients with Covid-19?
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"Results: Notwithstanding multiple operational challenges, the reserve system for allocation of mAb therapy worked as intended to enhance the number of socially vulnerable patients who were offered and received mAb therapy. A significantly higher proportion of patients offered mAb therapy were socially vulnerable (27.0%) than would have been the case if the infusion appointments had been allocated using a pure lottery system without a vulnerable reserve (19.8%) and a significantly higher proportion of patient who received infusions were socially vulnerable (25.3%) than would have been the case if the infusion appointments had been allocated using a pure lottery system (17.6%)
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"The reserve for vulnerable patients was a “soft” reserve, meaning that if there were not enough patients in either the high SVI or high incidence town categories to fill the vulnerable slots, those slots were allocated to patients who were next in line by overall lottery number. This was done in order to avoid unused capacity for a therapy that is time sensitive and requires significant infrastructure to provide. Once the lottery had been run, dedicated, primarily multilingual clinicians who had been trained to discuss the therapies with patients called patients to verify eligibility and engage in a shared-decision making conversation to determine whether the patient would like to receive an infusion.
Early experience with running the lottery prior to patient engagement revealed that a large number of patients declined the therapy once offered, were deemed ineligible once contacted, or wished to discuss the therapy with a trusted clinician. The process subsequently was changed to allow clinicians to enter referrals for their own patients once they established patient interest (“manual referrals”).
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"All of the 274 patients who were guaranteed slots and 206 of 368 patients on the wait list were called, for a total of 480 patients called. The number of wait list patients called on a given day was a function of both how many of the guaranteed slots were not filled and how much capacity there was in the system to make phone calls on any given day. Of those patients who were called, 132 (27.5%) declined, 33 (6.9%) were deemed ineligible by virtue of being asymptomatic, 19 (4.0%) were deemed ineligible by virtue of having severe symptoms, 11 (2.3%) had been or were planning to be infused elsewhere, 61 (12.7%) could not be reached, and 191 were infused (39.8% of those called and 9.7% of total referred patients).
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"Had we operated a pure lottery with no reserve for socially vulnerable patients, and all other factors had remained constant, 19.8% of patients offered therapy (88) would have been in the top SVI quartile as opposed to 27.0% (120) in our actual population, and 17.6% of infused patients (32) would have been in the top SVI quartile as opposed to 25.3% (46) in our actual population.
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"The system we describe is to our knowledge the first instance of a reserve system being used to allocate scarce resources at the individual level during a pandemic.
"A reserve system with lottery for tiebreaking within categories can be straightforward to operate if there are few or no steps between the assignment of lottery spots and the distribution of the good. This could be true, for example, of allocation of antiviral medications to inpatients with Covid-19. In the case of monoclonal antibody therapies, there were multiple factors that could and often did interrupt the trajectory between allocation and distribution. These included the complexity of administering infusion therapy, the time sensitive nature of the therapy, the relative paucity of evidence for the therapy at the time the mAb program started, and the dynamic nature of Covid-19. The conversations with patients about a therapy that held promise but did not yet have strong evidence to support its efficacy and had not been formally FDA approved were often challenging and time consuming. Many patients identified for allocation were difficult or impossible to reach. Others declined therapy once it was offered and discussed, or had become either too well or too sick to be candidates for the therapy once they were reached.
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"Notwithstanding significant challenges, the reserve system implemented in our health system for allocation of mAb therapy worked as intended to enhance the number of socially vulnerable patients who were offered the therapy. A significantly higher proportion of socially vulnerable patients were offered mAb therapy than would have been if the infusion appointments had been allocated using a pure lottery system without a vulnerable reserve. The intended enhancement of the pool of vulnerable patients who actually received monoclonal antibody therapy was counterbalanced to some extent by the disproportionate number of vulnerable patients who declined therapy, but even fewer socially vulnerable patients would have received the therapy if the lottery system had not included a vulnerable reserve.
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