key: cord-0719714-0v92pvs5
authors: Makhoul, Alan T.; Drolet, Brian C.
title: Reserve System Implementation During the COVID-19 Pandemic
date: 2021-09-06
journal: Chest
DOI: 10.1016/j.chest.2021.08.067
sha: 96b411d9d89354f990e8527fad9fbbc6ab28e18a
doc_id: 719714
cord_uid: 0v92pvs5

nan

Reserve systems enable the equitable allocation of a resource by partitioning its total supply into multiple "categories," each allocated according to a separate principle. 1, 2 Categories may be designed to differ in size, eligibility criteria, and allocation order. Effective implementation of reserve systems demonstrates that multiple ethical considerations can be prioritized concurrently to mitigate disparities across a population, all within a single framework. 4 In response, some U.S. cities and states implemented reserve systems to prioritize vaccine allocation among socially vulnerable communities and areas experiencing high COVID-19 incidence. [5] [6] [7] In this issue of CHEST, Rubin et al., examine the viability of a reserve system to equitably allocate COVID-19 monoclonal antibody (mAb) therapies to outpatients in a large urban health system. 8 Following guidance from the Commonwealth of Massachusetts, 9 3% vs. 17.6% ). This work contributes to a growing body of evidence that reserve systems offer a pragmatic framework for equitably allocating scarce resources. 10, 11 This work is the first to examine reserve system implementation on an individual patient level during a pandemic. 8 As reserve systems become more prevalent, it is important to acknowledge and understand the psychological effects on participants. Not only do reserve systems enable policymakers to allocate resources equitably, but they also signal to participants that expert judgement has been used to design a system for maximal societal benefit. Participants eligible for prioritized categories (e.g., patients from high-SVI zip codes) may feel more adequately Moreover, participant-reported outcomes should be regarded as a distinct endpoint from resource allocation outcomes. Health equity must not only be demonstrated objectively but must also be felt by participants in the system. Rubin et al. reported that patients in the top SVI quartile (i.e., the most vulnerable patients) declined mAb infusion appointments at a disproportionately higher rate (31.7% of those who declined vs. 19.9% of total referrals).

Unfortunately, this dampens the intended prioritization of patients from socially vulnerable communities 8 and may reflect socioeconomic differences in access to transportation or paid sick leave, trust in the healthcare system, or skepticism regarding novel therapeutics. 12 Ultimately, this disparity highlights an opportunity for improved patient outreach and education by clinicians and public health experts. Nevertheless, patients in the prioritized category may have felt sufficiently safeguarded by virtue of being offered mAb therapies, despite not receiving it. In such instances, offering the resource to a greater number of participants is inherently beneficial.

Despite challenges related to administering a time-sensitive, novel therapeutic during a pandemic, Rubin et al. demonstrate that a reserve system can be used effectively on an individual patient level to prioritize access for certain groups. Additional qualitative research would improve our understanding of how reserve systems are experienced by participants in prioritized and non-prioritized categories. We believe this innovative work may serve as a model for the future use of reserve systems by health systems in the U.S. and abroad.

J o u r n a l P r e -p r o o f

Categorized Priority Systems: A New Tool for Fairly Allocating Scarce Medical Resources in the Face of Profound Social Inequities

A Reserve System for the Equitable Allocation of a Severe Acute Respiratory Syndrome Coronavirus 2 Vaccine

Triage protocol design for ventilator rationing in a pandemic: Integrating multiple ethical values through reserves (No. w26951)

Board on Population Health and Public Health Practice; Board on Health Sciences Policy; Committee on Equitable Allocation of Vaccine for the Novel Coronavirus

Tennessee Department of Health

Ending the Pandemic Through Equitable Vaccine Administration

A novel approach to equitable distribution of scarce therapeutics: institutional experience implementing a reserve system for allocation of Covid-19 monoclonal antibodies

Executive Office of Health and Human Services

Monoclonal Antibodies Therapeutic Infusions, Bamlanivimab/Etesevimab and REGEN-COV (Casirimab/Imdevimab)

Covid-19: how to prioritize worse-off populations in allocating safe and effective vaccines

Fairly Prioritizing Groups for Access to COVID-19

Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity -United States

Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) Monoclonal antibody (mAb) Mass General Brigham (MGB)