A Proposed Lottery System to Allocate Scarce COVID-19 Medications
Promoting Fairness and Generating Knowledge
(From Jama Network)
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On May 1, 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization for the unapproved drug remdesivir to treat hospitalized patients with severe coronavirus disease 2019 (COVID-19). The authorization was based on a preliminary report from a randomized clinical trial in 1063 patients that found that remdesivir shortened the median time to recovery from 15 days to 11 days.
Anticipating immediate worldwide demand, the maker of remdesivir, Gilead Sciences, donated 1.5 million doses of remdesivir to countries affected by the pandemic, including the US, which received 607 000 doses (enough to treat approximately 100 000 patients). However, the US and other countries have 2 major problems related to this drug.
- First, the supply of remdesivir is insufficient to treat all eligible patients, which has required hospitals to ration the drug.
- Second, there remain major gaps in knowledge about the efficacy of remdesivir, including whether it reduces mortality and what subgroups of patients may benefit the most.
When there is an insufficient supply of newly approved antiviral agents (including remdesivir), the drug should be allocated to patients using a lottery system overseen by state health departments. In this model, states would create a central registry into which hospitals report the demographics and clinical outcomes of all patients entered into the lottery, including those who are not allocated the drug. This approach could simultaneously accomplish fair allocation (via the lottery) and rapid learning, because the lottery creates a natural experiment that achieves random allocation in which some patients receive the drug while others do not; researchers can use the lottery’s registry to assess the effectiveness of the scarce drug.
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