managers

7 Habits of Effective COVID-19 Rx Managers

The extraordinary amount of scientific activity marshalled to fight COVID-19 has led to a full pipeline of medications and vaccines— and an opportunity for pharmacists to help deliver the potentially lifesaving treatments to the right patients.

G. Caleb Alexander, MD, MS, a professor of epidemiology and medicine at Johns Hopkins Bloomberg School of Public Health, in Baltimore, proposed guiding principles to help pharmacists navigate the evolving landscape of COVID-19 medical management.

“The evidence base remains completely dynamic and staying up-todate with treatment guidelines is a must, but there are some overarching principles of effective treatment that can help us achieve the holy grail, which is getting the right drug to the right patient at the right time,” Dr. Alexander said at the Academy of Managed Care Pharmacy’s 2021 virtual annual meeting.

To help pharmacists in their decision-making process, Dr. Alexander suggested these seven strategies:

Know the evidence base. “Not all evidence is equal,” he said, pointing to reliable syntheses of evidence such as the Infectious Diseases Society of America’s COVID-19 treatment guidelines (bit.ly/3nT6Vvj). He encouraged pharmacists not to be afraid to challenge convention, saying that “if I had a nickel for every time I’ve seen things done clinically because ‘that’s what we do,’ rather than because of good evidence, I could retire a little earlier.”

Initial enthusiasm about hydroxychloroquine, despite a lack of evidence, and the subsequent decline in its use after data became available, is a good example of how clinical practice changes as data arise. “There are lots of opportunities to take a close look at the evidence base and improve our application of it,” Dr. Alexander said.

Understand the limits of evi-

dence. In his own survey of the COVID-19 literature, Dr. Alexander found significant study design limitations. For example, during the early stages of the pandemic, he found that: • roughly one-third of clinical trials of COVID-19 therapeutics excluded clinical end points; • nearly 50% of trials enrolled fewer than 100 patients; and • roughly two-thirds were open-label.

“Once complete, many of these studies are likely to yield only preliminary evidence of a given treatment’s safety and effectiveness,” he said. Other limitations include the use of “usual care” arms—a grab bag of approaches not always defined in a study. Outcomes in these groups can vary widely, he indicated. For example, he pointed to a meta-analysis of corticosteroids for COVID-19 that found mortality rates in control arms ranged from 16% to 59% (JAMA 2020;324[13]:1330-1341).

Stratify treatments based on patient characteristics and

Managed Care Seeking More Equity in COVID-19 Therapy

Addressing disparities in access to COVID-19 vaccinations and care should be a top priority for managed care pharmacists.

“Building disparity and vulnerability data—from social determinants of health to socioeconomic status, lifestyle and patient health care access preferences—into our reporting tools at Kaiser Permanente has translated to more effective approaches to vaccinating our populations and improving the provision of care,” said Dan Kent, PharmD, a clinical pharmacy quality coordinator at Kaiser Permanente of Washington, in Kent.

The Kaiser team has found that a subset of its patients who are Latinx agricultural workers and have a body mass index over 35 kg/m2 are less likely to travel to one of the organization’s vaccine clinics, largely because of difficulty taking time off work. That barrier to care is compounded by the fact that Latinx individuals are twice as likely as the general population to develop COVID-19, three times as likely to be hospitalized and 2.3 times more likely to die from COVID-19, Dr. Kent noted, citing a report from the CDC (bit.ly/3xBrlO6).

“Now, instead of waiting for them to come to the vaccine clinics, we’ve taken the vaccines to them, to their places of employment,” he said during the Academy of Managed Care Pharmacy’s 2021 virtual annual meeting.

However, racial factors aren’t the only ones to affect the management of COVID-19. Patients with obesity, cancer, HIV and diabetes—independent of race—as well as those receiving treatment with steroids and immunosuppressants, are at higher risk for COVID-19 and poorer outcomes, Dr. Kent noted. Analyzing these factors can help pharmacists not only develop more targeted vaccination campaigns and treatments, but also create “new decision pathways, internal guidelines and care methods, and find better ways of reaching out to those that are isolated or have barriers to care,” he said.

In addition to including COVID-19 risk factors when building vaccine and care interventions, Kaiser Permanente also continuously monitors its patients to detect who is not receiving vaccinations and providing these individuals with additional education, “whether it’s by phone, through mail, email, text messaging, video calls and even automated calls,” Mr. Kent said.

“It’s been important to share the evolving evidence regarding both vaccines and treatments with our members.” severity. “This is a fundamental concept that’s important for us to consider in selecting treatments,” Dr. Alexander said. Rather than being homogeneous, different groups have different prognoses and “incredibly different mortality rates. We should be thinking about these as we steward what are invariably scarce, and in some cases, incredibly costly treatments.”

Recognize the role of virus

variants. Variants affect not just the effectiveness of vaccines, but “they may [also affect] some therapeutics.” This has led the FDA to issue revisions to fact sheets on monoclonal antibodies, addressing possible resistance of SARSCoV-2 variants to this class of drugs.

Be familiar with vaccine adverse

events. Although COVID-19 vaccines are a boon to public health and individual care, instances of thrombocytopenia in patients receiving vaccines manufactured by AstraZeneca and Johnson & Johnson are examples of the challenges of vaccine selection.

Don’t skimp on prevention.

“We can’t let use of therapeutics come at the expense of preventive intervention,” Dr. Alexander said. In their interactions with patients, pharmacists should underline the importance of wearing masks, social distancing and handwashing in COVID-19 prevention and highlight their importance in helping communities achieve a return to normalcy as soon as possible, he said.

Keep an eye out for inequality.

Various racial, ethnic and socioeconomic groups have seen stark differences in rates of infection, hospitalization and death, as well as in vaccine access (sidebar). “While these differences are multifactorial, they are important for health systems to acknowledge and address when designing interventions,” Dr. Alexander said.

—David Wild