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Evidence-Based Oncology January 2018

Cost of Care

Various presenters at the 59th Annual Meeting of the American Society of Hematology in Atlanta, Georgia discussed the cost of care involved in several different cancer treatments. 

Significant Economic Burden Associated With Various AML Treatment Episodes 

Jaime Rosenberg

There is a substantial economic burden associated with multiple acute myeloid leukemia (AML) treatment episodes, according to an analysis presented at the 59th Annual Meeting of the American Society of Hematology in Atlanta, Georgia.

AML is estimated to affect over 20,000 people in the United States in 2017, according to the authors of the analysis.

“Detailed real-world cost estimates and comparisons of key AML treatment episodes such as high-intensity chemotherapy (HIC), low-intensity chemotherapy (LIC), hematopoietic stem cell transplant (HSCT) and relapsed-refractory (R/R) patient episodes in the US commercially insured population are scarce and diffcult to assemble,” wrote the authors.

The authors examined a large US healthcare claims database, PharMetrics Plus, and linked charge detail master (CDM) hospital data to identify patients with an AML diagnosis between January 1, 2008, and March 31, 2016. Patients with 2 or more outpatient claims or 1 or more inpatient claims were included.

Participants were required to have continuous health plan enrollment for ≥ 6 months pre and ≥ 3 months post the first diagnosis date. The authors evaluated:
  • HIC induction: evidence of inpatient high dose cytarabine+anthracycline use within 3 months of diagnosis
  • HIC consolidation: evidence of cytarabine +/- anthracycline use within 2 months following prior HIC
  • LIC: evidence of low-intensity cytarabine, anthracycline, 5-azacytidine, decitabine, clofarabine, hydroxyurea or gemtuzumab ozogamicin in the outpatient setting within 3 months of diagnosis
  • HSCT: transplant specific diagnosis/procedure codes
  • R/R patients: record of an ICD-9 diagnosis code (205.02) for relapsed AML after a prior treatment of HIC, LIC, or HSCT
The study consisted of 1542 HIC induction, 591 consolidation, 628 LIC, 1000 HSCT, and 119 R/R patients. The total mean (SD) episode cost was the highest among HSCT patients, costing $329,621; followed by HIC induction cost of $198,528; R/R cost of $145,634; and HIC consolidation cost of $73,304. The lowest episode cost was associated with LIC ($53,081).

Other findings included:
  • Hospitalization costs accounted for $244,801 for HSCT.
  • All HIC induction required hospitalization and accounted for most of the HIC cost, with $2843 attributed to physician’s office visits and $2868 attributed to outpatient pharmacy.
  • Hospitalization occurred in 74.8% of R/R patients at a cost of $101,420; physician’s office visits costs were $3340, and outpatient pharmacy costs were $6108.
  • Although LIC patients had a relatively low hospitalization rate (35.8%), hospitalization was a major cost contributor at $17,764.
“This resource utilization and direct healthcare cost analysis establishes a substantial economic burden associated with various AML treatment episodes, notable during the HIC induction, HSCT and R/R episodes in the US,” the authors concluded. “Hospitalization is a major cost driver across all episodes. New therapeutic strategies associated with less economic burden are needed.”

References:

Medeiros BC, Pandya BJ, Chen CC, et al. Economic burden of treatment episodes in acute myeloid leukemia (AML) patients in the US: a retrospective analysis of a commercial payer database. Presented at the 59th Annual Meeting of the American Society of Hematology; December 9-12, 2017; Atlanta, Georgia. Abstract 4694. ash.confex.com/ ash/2017/webprogram/Paper106052.html.

 

Financial Incentives May Lead to Overuse of Rituximab Maintenance

Kelly Davio

Receiving Lymphoma care in the community-based setting is associated with guideline-discordant use of rituximab, according to investigators.1 Scott Huntington, MD, MPH, presented his research team’s ndings December 9 at the 59th American Society of Hematology Annual Meeting and Exposition in Atlanta, Georgia.

Maintenance rituximab monotherapy has been shown to improve progression- free survival in some lymphoma settings, but current guidelines support just 2 years of rituximab maintenance. Data from studies in other disease states suggest that financial incentives may influence the use of infused therapies in US patients, and Huntington and colleagues sought to determine whether community providers (who may have financial incentives to provide rituximab beyond guideline-based time periods) were more likely than hospital-employed providers to prescribe extended maintenance rituximab.

Using the Surveillance, Epidemiology, and End Results (SEER)–Medicare database, the researchers identi ed older adults who were diagnosed with B-cell non-Hodgkin lymphoma between 2004 and 2011 and had at least 1 claim for rituximab through 2013. Patients were included in the study if they had more than 7 months of claims without a 200-day gap.

The number of rituximab monotherapy claims and the duration of maintenance therapy were calculated for each patient until the receipt of chemotherapy, a 200- day gap in rituximab claims, or death, and the site of administration was classified as community or hospital-outpatient (as identified on Medicare claims). A logistic regression model was used to assess the association between care setting and prolonged use of rituximab monotherapy.

The investigators identified 2620 patients with 2 years of available follow-up after initiation of rituximab maintenance; 75.1% received their therapy in a community setting. The median number of maintenance doses received was 9 (range, 1-103), and the median duration was 14 months (range, 0-92), with 261 (10.0%) patients receiving uninterrupted rituximab maintenance for more than 2 years.

Patients in the community setting were more likely to receive rituximab maintenance for longer than the guideline-recommended period; 11% of patients in the community setting versus 6.9% in the hospital setting received it for more than 2 years. Furthermore, treatment in a community setting was significantly associated with a patient’s receipt of more than 2 years of maintenance (adjusted odds ratio [OR], 1.56; 95% CI, 1.10-2.20; P = .012), as well as with receipt of more than 12 doses of rituximab as monotherapy (adjusted OR = 2.01; 95% CI, 1.63-2.48; P <.001).

The authors concluded that receiving lymphoma care in the community setting is associated with guideline-discordant use of rituximab, with financial incentives for using anticancer therapies possibly contributing to the overuse. “Providers practicing in the physician office setting are more likely to derive income directly from chemotherapy administration compared [with] hospital-employed physicians,” Huntington told The Center for Biosimilars® in an e-mail. “Prior research suggests physicians in community settings are more responsive to reimbursement changes in their choice of chemotherapy regimens compared with hospital-employed providers.”

While it is not known whether changes to reimbursement translate into treatment that is discordant with guidelines, Huntington said that “financial incentives likely contribute to overutilization during rituximab maintenance, and future studies should consider treatment setting when evaluating cancer-therapy utilization. Our findings support ongoing efforts to minimize financial incentives tied to chemotherapy administration to better align payment with high quality care.”

References:

1. Huntington S, Hoag J, Zhu W, Gross CP, Davido , AJ. Financial incentives and rituximab maintenance: association of treatment location with prolonged maintenance in non-Hodgkin lymphoma patients treated in the United States. Abstract presented at: 59th ASH Annual Meeting & Exposition; December 9-12, 2017; Atlanta, GA. Abstract 2120. ash.confex.com/ash/2017/ webprogram/Paper103349.html.

 

Kymriah More Cost-Effective in Pediatric Patients With Acute Lymphoblastic Lymphoma

Jaime Rosenberg 

According to results from 2 studies presented at the 59th Annual Meeting & Exposition of the American Society of Hematology in Atlanta, Georgia, CTL019, sold as Kymriah by Novartis, shows promising potential in providing significant benefit and cost-effectiveness for pediatric and young-adult patients with B-cell acute lymphoblastic leukemia (ALL).

Studying populations in the United States and the United Kingdom, investigators assessed the efficacy of CTL019 (tisagenlecleucel), a chimeric antigen receptor T-cell therapy, in pediatric and young-adult patients with relapsed or refractory (r/r) ALL.

Currently, treatments for r/r pediatric ALL include: clofarabine monotherapy (Clo-M), clofarabine combination therapy (Clo-C), blinatumomab (Blin), other salvage chemotherapies (SCs), and allogeneic stem cell transplant (SCT). SCT is considered the only potentially curative option, according to the authors of the US study.1

“However, less than 50% of patients with multiple relapses achieve complete remission from existing treatments, and even fewer are eligible for and ultimately receive SCT,” the authors wrote.

The authors developed a partitioned survival model to assess the incremental cost-effectiveness of CTL019 compared with Clo-M, Clo-C, Blin, SC, and second SCT over a 20-year period. The model included 3 health states: event-free survival, progressive disease, and death. Incremental life-years (LYs), incremental quality-adjusted life-years (QALYs), and incremental cost per QALY gained were estimated comparing CTL019 with each comparator.

The results showed that over the 20-year span, treatment with CTL019 provided an increase of 4.62, 3.79, 3.68, 2.08, and 2.05 in discounted LYs and an increase of 4.29, 3.64, 2.23, and 2.31 in discounted QALYs relative to Clo-M, Clo-C, Blin, SC, and SCT, respectively. Using incremental cost-effectiveness ratios (willingness-to-pay thresholds) from $100,000/QALY to $300,000/ QALY, the value-based prices for treatment with CTL019 ranged from $488,470 to $1,364,525.

The UK National Institute for Health and Care Excellence (NICE) recently conducted a cost-effectiveness analysis that modeled the benefits of CTL019 relative to the costs using early trial data.

The authors of the UK study2 expanded on the NICE model to quantify the economic value compared with clofarabine by assessing the economic value of the incremental QALYs gained for 10 incident cohorts including 380 patients. The authors calculated the economic value of each QALY gained as £50,000 ($67,000 US). Costs for other factors such as conditioning, hospitalizations, adverse events, and hematopoietic stem cell transplantation and follow-up costs were also included.

Building on the NICE report, the authors calculated the patients’ expected productivity using nationally representative data and calculated the consumer surplus accruing to patients from the use of CTL019.

Results showed that patients gained 3294 QALYs from CTL019 relative to clofarabine, which translated to £164,690,866 ($220,950,348 US) of total value; £49,525,920 ($66,444,299 US) was attributable to added patient productivity from employment gains. Using the 3 prices considered by NICE (£250,000, £356,100, and £528,600 [$335,401, $477,746, and $709,173 US]), the consumer surplus accruing to patients was £91,847,131, £57,142,661, and £719,276 ($123,222,714, $76,662,969, and $964,985), respectively. This amounts to an average of £280,799, £174,699, and £2199 ($376,721, $234,377, and $2950 US) of consumer surplus accruing to each patient, according to the authors.

 
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