Discussion
This novel initiative to optimize access to outpatient COVID-19 treatment demonstrated how the Mab team proactively screened and reached out to eligible veterans with COVID-19 promptly. This approach removed layers in the traditional referral process that could be barriers to accessing care. More than three-quarters of patients who received Mab were identified through this strategy, and the uptake was high at 46%. Conventional passive referrals were suboptimal for identifying candidates, which was also the case at a neighboring institution.
In an Emory University study, referrals to the Mab clinic were made through a traditional, decentralized referral system and resulted in a lower uptake of Mab treatment (4.6%).11 One of the key advantages of the AVAHCS program was that we were able to provide individual education about COVID-19 and counsel on the benefits and risks of therapy. Having a structured, telehealth follow-up plan provided additional reassurance and support to the patient. These personalized patient connections likely helped increase acceptance of the Mab therapy.
Our surveillance and outreach strategy had high uptake among Black patients (65%), which exceeded the proportion of AVAHCS Black veterans (54%).12 In the Emory study, just 30% of the participants were Black patients.11 In a study of bamlanivimab use in Chicago, Black individuals represented just 11% of the study population. White patients were more likely to receive bamlanivimab compared with others races, and the likelihood of receiving bamlanivimab was significantly worse for Black patients (odds ratio, 0.28) compared with White patients.13 These studies highlight the disparity in COVID-19 outpatient treatment that does not reflect the racial and minority group representation of the community at large.
Limitations
The VHA medication allocation system at times created a significant mismatch in supply and demand, which significantly limited the AVAHCS Mab program. VHA facilities nationwide with Mab programs received discrete allocations through the US Department of Health and Human Services via VHA pharmacy benefits management services. Despite our large catchment, AVAHCS was allocated 6 or fewer doses of Mab per week during the evaluated period.
Without formal national guidance in the early period of Mab, the AVAHCS Mab team conferred with Emory University Mab clinicians as well as at other VHA facilities in the country to develop an optimal approach to resource allocation. The Mab team considered all EUA criteria to be as inclusive as possible. However, during times of high demand, our utilitarian approach tried to identify the highest-risk patients who would benefit the most from Mab. The VACO index was validated in early 2021, which facilitated decision making when demand was greater than supply. One limitation of the VACO index is its exclusion of several original Mab EUA criteria, including weight, hypertension, and nonmalignancy-related immunosuppression, into its algorithm.3,8
Conclusions
Through proactive screening and direct outreach to patients, the AVAHCS was able to achieve timely administration of Mab infusion that was well within the initial EUA time frame of 10 days and comparable with the time frame in the REGN-COV2 and BLAZE-1 trials. Improving access to resources by changing the referral structure helped engage veterans who may have otherwise missed the time frame for Mab therapy. The experience of the Mab infusion program at the AVAHCS provided valuable insight into how a health care system could effectively screen a large population and distribute the limited resource of Mab therapy in a timely and proportionate fashion among its represented demographic groups.
Acknowledgments
The authors acknowledge the Veterans Health Administration VISN 7 Clinical Resource Hub and Tele Primary Care group for their support.