May 14, 2021

Antibody treatments were supposed to revolutionize the Covid-19 fight. Why have so few patients gotten them?

Daily Briefing

By Regina Lohr

    Before vaccines were available to prevent Covid-19, the most promising treatments were monoclonal antibody therapies. In late 2020 and early 2021, the U.S. government purchased millions of doses of these treatments for patients. And yet Kaiser Health News reported that by January, only about 30% of the available doses had been administered to patients. Since then, many reports have documented patients struggling to get connected with a provider who is offering these services.

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    From the health system perspective, two key challenges hindered their ability to serve patients eligible for antibody treatments. First, no one had responsibility for identifying eligible patients and then following up to connect them with antibody treatments. Second, health systems' predominantly hospital-based infusion infrastructure created barriers to expanding access to these therapies.

    Fortunately, these patient challenges are improving as providers have found ways to connect patients with these medications. We can learn from the creative ways providers overcame these challenges. This creative problem solving may also advance the conversation around the need for an infusion infrastructure that includes non-hospital alternatives for infusion care.

    Challenge #1: No clear owner for patient identification and follow-up

    Early on, when antibody infusions became available, patients were on their own to self-identify as eligible for monoclonal antibody infusions and then to locate a provider willing to administer the treatment. The fragmented Covid-19 testing system often meant that neither providers nor public health officials had the information needed to identify eligible patients or connect them with available treatments. And these connections had to be made quickly—patients often had only a few days between receiving a positive test result and the cut-off for treatment eligibility at 10 days after symptom onset.

    Eskenazi Health in Indianapolis, Indiana was one health system that took a proactive approach to speed up their processes for identifying and notifying eligible patients. Pharmacy staff took on responsibility for calling all patients with positive test results within their health system. The IT team built out EHR functions that quickly identified Covid-positive patients with co-morbid conditions or other risk factors so that they could offer eligible individuals antibody treatments when they notified them of their positive status. In the midst of testing shortages, they worked with their labs team to determine when to keep Covid-19 tests in-house versus sending them to external labs. This allowed them to expedite tests for patients who, if they tested positive, would be ideal candidates for antibody treatments.

    Challenge #2: Hospital-based infusion infrastructure created Covid-19 exposure concerns

    Even when eligible patients reached out to their providers seeking antibody therapies, those providers working within larger health systems often struggled to provide these therapies to their communities. Antibody treatments need to be administered by a nurse in the outpatient setting, but existing hospital-based infusion centers did not want to offer these treatments because of Covid-19 exposure concerns. Within health systems, outpatient infusion centers mainly serve cancer patients, who are at high risk for complications if they develop Covid-19. In addition, these infusion centers are often located within the hospital campus, so Covid-positive patients walking the hallways to the clinic also create exposure risks.

    Some health systems have built infusion centers for non-oncology patients over the past few years, which are often located away from the hospital campus. Organizations with such off-campus infusion centers were better positioned to quickly create space to provide antibody treatments.

    Other health systems scrambled to build temporary infusion centers for their Covid-positive patients. In a well-publicized collaboration, Eli Lilly, manufacturer of a leading monoclonal antibody treatment, worked with health systems across Indiana to set up a temporary infusion centers in response to the Covid surge in early 2021.

    A last resort option for some health systems has been to provide infusions at the end of the day in the infusion center, one to two days per week. However, this strategy adds to the challenge of helping patients access the treatment within the short timeframe of applicability.

    Antibody treatment challenges spurred creative thinking from provider organizations, but some health systems are still lagging

    The need for non-hospital locations to administer monoclonal antibody treatments to patients has spurred innovation within provider organizations, from health systems to dialysis and home infusion providers. These innovations may give us a glimpse of where infusion care is headed as trends from both patients and health plans are pointing to more infusion care in convenient, non-hospital settings.

    For example, health systems without existing non-hospital infusion spaces often identified repurposed spaces that were already managing Covid-positive patients, such as observation units, emergency department bays, or urgent care centers, to offer antibody treatments. Co-locating infusion care with accessible non-hospital care locations, such as urgent care centers and ambulatory surgery centers, is a trend that may be picking up steam nationwide.

    Other providers serving high-risk patient populations, such as dialysis centers, also sprang into action to begin providing on-site infusions. Dialysis centers owned by U.S. Renal Care, Fresenius, and DaVita all began offering on-site antibody treatment to their existing dialysis patients who were diagnosed with Covid-19. With the rise of polychronic patients receiving regular treatment with infused or injectable medications, there may be increasing synergies between dialysis and infusion care in the future.

    Finally, two large home infusion providers, Optum and Coram, in partnership with Eli Lilly and the HHS respectively, pilot tested administration of Eli Lilly's Covid-19 antibody drug bamlanivimab via home infusion. (Editor's note: The Daily Briefing is published by Advisory Board, a division of Optum.) While home infusion seems like an ideal option for minimizing exposure between Covid-positive patients and others, reimbursement for home infusion is sometimes a challenge, especially for Medicare patients. The pilot studies ensured that home infusion providers would be paid for administering the medications.

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