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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
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Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD

Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics

Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Administration of immuno-oncology therapy for cancer diagnoses in the community clinic setting is associated with lower costs compared with administration in a hospital-based clinic setting.
Statistical Analysis

Patients in the CC cohort were matched 2:1 with replacement with those in the HC cohort based on cancer type (NSCLC vs SCCHN vs RCC vs bladder cancer vs melanoma); matched patients had only 1 of these diagnoses throughout the study period. Other characteristics used for matching included specific I-O therapy received, receipt of radiation therapy during follow-up, presence of metastatic disease (identified via diagnosis codes) (eAppendix Table 1), gender, age, and evidence of surgery (yes vs no) in the preindex period. Charlson Comorbidity Index (CCI) scores were computed to assess comorbidity burden between cohorts; mean CCI scores were similar in the 2 cohorts and not included in the match (eAppendix Table 2).

Categorical measures were presented as counts and percentages; continuous outcomes were presented as means and SDs. For testing the differences between the cohorts, the Wilcoxon signed rank sum test for continuous variables and McNemar’s test for categorical variables were conducted using SAS version 9.2 (SAS Institute; Cary, North Carolina).


A total of 6568 patients received 1 or more I-O therapy of interest during the study period; of these, 4183 patients met all the inclusion and exclusion criteria and 3135 patients were matched 2:1 (CC cohort, n = 2090; HC cohort, n = 1045) based on the characteristics previously described (eAppendix Figure).

The demographic and clinical characteristics for matched patients are described in Table 1. The mean (SD) age in both of the cohorts was 65 (9) years; the majority (91%) in both cohorts had metastatic disease. The mean (SD) CCI score was similar between cohorts: 4.2 (2.2) in the CC cohort and 4.8 (2.4) in the HC cohort. Across cohorts, NSCLC (78%) made up the majority of cancer diagnoses, followed by SCCHN (12%) and melanoma (10%). There were no differences in baseline demographics when patients were separated by cancer type (eAppendix Table 3).

Utilization Patterns of Immunotherapy Agents

Among the 3135 matched patients, nivolumab was the most common I-O agent (CC cohort: 89.1%; HC cohort: 89.1%); 5.5% of patients from both cohorts received pembrolizumab and 4% received ipilimumab. Only 1% received a combination of nivolumab and ipilimumab. The mean (SD) duration of therapy in each cohort was similar (CC cohort: 88 [59] days; HC cohort: 89 [61] days). When categorized by cancer type, nivolumab was the most commonly used agent in those with NSCLC (99%) and SCCHN (100%), and pembrolizumab and ipilimumab were the most commonly utilized agents in melanoma (45% and 41%, respectively) (eAppendix Table 4).

Cost of Care

Across all tumor types, the mean (SD) total cost (ie, medical plus pharmacy costs) PPPM during the postindex period was $23,904 ($18,753). The mean (SD) total cost PPPM was significantly lower in patients in the CC cohort compared with those in the HC cohort ($22,685 [$16,205] vs $26,343 [$22,832], respectively; P <.001). This trend remained the same for the subgroups of patients with NSCLC and melanoma (NSCLC: $20,697 [$14,781] vs $23,153 [$19,044]; melanoma: $34,586 [$23,077] vs $49,017 [$37,244]; P <.001 for all analyses) (Table 2). Within the subgroup of patients with SCCHN, although the mean cost was lower in the CC cohort, the difference between the cohorts was not statistically significant.

Overall, the major driver of the cost differential between the CC and HC cohorts was lower mean (SD) PPPM medical costs in the CC cohort compared with the HC cohort ($21,382 [$15,667] vs $24,831 [$22,102], respectively; P <.001), although the mean (SD) pharmacy PPPM costs were also slightly lower in the CC cohort versus the HC cohort ($1303 [$4142] vs $1512 [$4403]; P = .003).

The costs were also compared by the I-O therapy that was received on the index date. For patients who received ipilimumab, the mean (SD) total cost PPPM was significantly lower in the CC cohort compared with the HC cohort ($45,038 [$25,940] vs $58,360 [$41,873]; P = .043). Similar trends were observed for patients who received the other I-O therapies: nivolumab ($21,328 [$14,687] vs $23,761 [$18,978]; P <.001); nivolumab plus ipilimumab ($43,378 [$15,943] vs $66,152 [$36,691]; P = .013); and pembrolizumab ($22,899 [$14,778] vs $34,587 [$27,326]; P <.001).

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