Predictors of nirmatrelvir-ritonavir receipt among COVID-19 patients in a large US health system

Abstract

A clear understanding of real-world uptake of nirmatrelvir-ritonavir for treatment of SARS-CoV-2 can inform treatment allocation strategies and improve interpretation of effectiveness studies. We used data from a large US healthcare system to describe nirmatrelvir-ritonavir dispenses among all SARS-CoV-2 positive patients aged ≥ 12 years meeting recommended National Institutes of Health treatment eligibility criteria for the study period between 1 January and 31 December, 2022. Overall, 10.9% (N = 34,791/319,900) of treatment eligible patients with SARS-CoV-2 infections received nirmatrelvir-ritonavir over the study period. Although uptake of nirmatrelvir-ritonavir increased over time, by the end of 2022, less than a quarter of treatment eligible patients with SARS-CoV-2 infections had received nirmatrelvir-ritonavir. Across patient demographics, treatment was generally consistent with tiered treatment guidelines, with dispenses concentrated among patients aged ≥ 65 years (14,706/63,921; 23.0%), and with multiple comorbidities (10,989/54,431; 20.1%). However, neighborhoods of lower socioeconomic status (upper third of neighborhood deprivation index [NDI]) had between 12% (95% CI: 7-18%) and 28% (25-32%) lower odds of treatment dispense over the time periods studied compared to the lower third of NDI distribution, even after accounting for demographic and clinical characteristics. A limited chart review (N = 40) confirmed that in some cases a decision not to treat was appropriate and aligned with national guidelines to use clinical judgement on a case-by-case basis. There is a need to enhance patient and provider awareness on the availability and benefits of nirmatrelvir-ritonavir for the treatment of COVID-19 illness.

Figure 1

Proportion of treatment eligible SARS-CoV-2 positive patients receiving nirmatrelvir–ritonavir treatment dispense over time, by clinical risk factor and neighborhood deprivation index (NDI). (A) Proportion of patients with a confirmed SARS-CoV-2 infection and documentation of at least one treatment eligibility-criteria receiving a nirmatrelvir–ritonavir treatment dispense, by time period of infection; (B) Proportion of patients with a confirmed SARS-CoV-2 infection and at least one high risk condition (defined as an underlying risk factor for severe COVID-19 illness in the year prior to the date of SARS-COV-2 test [Appendix A]) or aged ≥ 65 years receiving a nirmatrelvir–ritonavir treatment dispense, by time of infection; (C) Odds Ratio (95% CI) of treatment dispense among patients with a confirmed SARS-CoV-2 infection and documentation of at least one treatment eligibility-criteria, by time period of infection and NDI. Q1 of NDI is the reference across all time periods, respectively. NDI Neighborhood Deprivation Index, OR Odds Ratio, Q1 Tertile 1, Q2 Tertile 2, Q3 Tertile 3.