Weighted Lottery to Equitably Allocate Scarce Supply of COVID-19 Monoclonal Antibody

Abstract

Importance: Equitable allocation of scarce medications is an important health policy goal. There are few data about attempts to achieve equitable allocation in the community setting.

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.

Figure.. Treatment Status of First 450 Patients Allocated to Tixagevimab With Cilgavimab in Weighted Lottery

EHR indicates electronic health record. ^aAt the time of the lottery, the University of Pittsburgh Medical Center health system required patients to be 20 or more days from infection and have 2 negative polymerase chain reaction tests before receiving routine outpatient treatment, due to the risk of prolonged viral shedding in this population. ^bDuring the lottery period, the US Centers for Disease Control and Prevention recommended a waiting period between previous antibody therapy and/or COVID-19 vaccination and receipt of tixagevimab with cilgavimab. ^cPatients were ineligible to receive tixagevimab with cilgavimab if they were inpatients in an acute care hospital at the time of contact.