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The American Journal of Managed Care Special Issue: Pharmacy Benefits
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Cost of Biologic Treatment Persistence or Switching in Rheumatoid Arthritis
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Cost of Biologic Treatment Persistence or Switching in Rheumatoid Arthritis

Tao Gu, PhD; Alex Mutebi, PhD; Bradley S. Stolshek, PharmD; and Hiangkiat Tan, MS, BSPharm
Patients with rheumatoid arthritis who switched biologics incurred higher costs than patients who persisted on biologics. Etanercept appeared to be associated with the lowest costs.

Objectives: To estimate total costs among patients with rheumatoid arthritis (RA) who persisted on or switched from newly initiated biologic therapy.

Study Design: A retrospective claims database analysis.

Methods: This analysis included adults in the HealthCore Integrated Research Database with RA who initiated treatment with a biologic for RA (abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, or tocilizumab) between January 2009 and November 2014. Total healthcare costs (plan- and patient-paid) were estimated for 1 year post index. Treatment persistence was defined as no discontinuation (ie, no refill gap >45 days) and no biologic switch.

Results: Of 7468 patients, 45.2% persisted on the index biologic for at least 1 year without a refill gap and 16.7% switched to another biologic in the first year; other patients discontinued the index biologic (23.2%) or restarted after a refill gap (15.0%). Mean 1-year total healthcare costs per patient were $41,901 (95% CI, $40,855-$42,947) among persistent patients and $44,244 (95% CI, $40,820-$47,668) among switchers. In a multivariable analysis of all patients, switchers had 5% higher postindex costs on average than persistent patients (exp(β) = 1.05; 95% CI, 1.01-1.08), and etanercept had the lowest postindex costs (exp(β) ranged from 1.03 to 1.51 for other biologics relative to etanercept).

Conclusions: Patients with RA who switched biologic therapy incurred higher 1-year total postswitch healthcare costs compared with patients who were persistent on the index biologic. Healthcare costs were lowest for patients who started on etanercept, particularly those who persisted on etanercept.

Am J Manag Care. 2018;24(Spec Issue No. 8):SP338-SP345
Takeaway Points

We examined treatment persistence (no refill gap >45 days) and total healthcare costs among nearly 7500 commercially insured patients in the United States who initiated treatment with a biologic for rheumatoid arthritis (abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, or tocilizumab) between January 2009 and November 2014. Mean 1-year total healthcare costs per patient were $41,901 among persistent patients and $44,244 among switchers. Switchers had 5% higher postindex costs on average than persistent patients.
  • Patients with rheumatoid arthritis often switch from one biologic to another for either medical or nonmedical reasons.
  • Switching biologics is associated with higher costs than persistence on treatment.
Approximately 1.48 million adults in the United States have rheumatoid arthritis (RA),1 a chronic inflammatory joint disease leading to severe disability and premature mortality.2 Treatment guidelines for RA recommend methotrexate—or another conventional synthetic disease-modifying antirheumatic drug (DMARD), such as hydroxychloroquine, leflunomide, or sulfasalazine—alone for a patient with early RA and no prior DMARD therapy.3,4 Patients with an inadequate response to conventional synthetic DMARDs may benefit from initiation of biologic therapy, consisting of either a tumor necrosis factor inhibitor (TNFi), such as adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab, or a non-TNFi biologic, such as abatacept, rituximab, or tocilizumab.3,4

Many studies have examined treatment patterns for biologic therapy in clinical practice, such as persistence, switching to another biologic, restarting the same biologic after a gap in therapy, or discontinuation of biologic therapy.5-14 Nonpersistence on biologic therapy may occur due to medical reasons, such as inadequate response or medication intolerance,15-17 or due to payer policies or changes in coverage18 that lead to nonmedical switching to another biologic.19,20 Systematic reviews have concluded that interventions to improve adherence and persistence need to be identified6,8 and that large studies are needed to draw consistent conclusions about predictive factors for biologic treatment adherence and persistence.13

Several studies have compared medication costs or total healthcare costs across biologics21-33 or the cost-effectiveness of biologics34-45 in patients with RA. There is limited information comparing healthcare costs between patients with RA who switch biologics and those who persist on biologic therapy.46 The objective of this study was to estimate total healthcare costs among patients with RA in the first year after they initiated biologic therapy, according to biologic treatment patterns and the index biologic.


Study Design

This was a retrospective cohort study of administrative claims data from the HealthCore Integrated Research Database (HIRD). HIRD contains a broad and geographically diverse spectrum of longitudinal claims data that represents the largest commercially insured population in the United States. HIRD is comparable with US Census data (American Community Survey) by age and gender, with slight underrepresentation of adults 65 years and older.47

Eligibility Criteria

To be included in the analysis, a patient needed to have at least 1 claim for a biologic of interest (abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, or tocilizumab), with an index date (the first biologic claim) between January 1, 2009, and November 30, 2014. Other key inclusion criteria were continuous enrollment in the health plan for at least 180 days preindex and at least 365 days post index, age of 18 to 63 years on the index date, at least 1 diagnosis for RA (based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes) in the preindex period, and an index claim after FDA approval for RA treatment for that biologic.

Patients could not receive more than 1 biologic of interest on the index date or any biologic dose greater than twice the approved maximum dose. To limit the analysis to patients newly initiating biologic therapy, patients were required to have no claim for any biologic of interest in the 180-day preindex period (ie, before the first claim for their index biologic). Patients were excluded from the analysis if during the preindex period they had any of the following conditions that are indications for at least 1 biologic of interest: psoriasis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, ulcerative colitis, Crohn disease, non-Hodgkin lymphoma, or chronic lymphocytic leukemia. Patients were excluded from the analysis if they had either no cost in the claims line for a biologic of interest or an inappropriate source of claims (eg, J-code for a self-administered biologic or a prescription claim for an intravenously administered biologic).

Study approval by an institutional review board and collection of informed consent from patients were not necessary for this retrospective claims-based analysis. No identifiable protected health information was collected or used in this study.

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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