Two-third of those who receive a chronic lymphocytic leukemia (CLL) diagnosis are age 65 or older, so the ease with which drugs are covered in Medicare has an outsized role in patient access to care.
An analysis of Medicare claims by investigators from the University of Maryland found that only 16% of beneficiaries who have a diagnosis of chronic lymphocytic leukemia (CLL) ever receive treatment, and the likelihood of receiving therapy declines as patients reach advanced age or if they are female.
Researchers from the Departments of Pharmaceutical Health Services Research and Medicine at the University of Maryland, along with researchers from BeiGene, examined these patterns through a claims study that involved Medicare beneficiaries who received a diagnosis of CLL from 2017 to 2019. Their results were presented in a poster during a session on health outcomes research on Saturday, December 11, at the 63rd Annual American Society of Hematology Meeting and Exposition in Atlanta.
According to the authors, 67% of patients with a new diagnosis of CLL are at least 65 years old. Thus, Medicare reimbursement policy has an outsized effect on access to care for the majority of the CLL patient population in the United States.
“While new agents and treatment combinations have been approved for CLL and treatment guidelines take into consideration age, frailty, and comorbidity status, limited information exists on current prescribing patterns or the demographic and clinical characteristics of individuals receiving them,” the study authors wrote.
Investigators used the Chronic Conditions Data Warehouse and identified Medicare beneficiaries with billing codes. Patients were included in the study if: (1) they were at least 65 years old and (2) they were not treated for CLL during a continuous 6-month period when they were also enrolled in Medicare Parts A, B, and D at baseline, with no evidence of enrollment in Medicare Advantage.
An index date was triggered by the date of first claim with a CLL diagnosis code during the cohort identification period, which ran from July 1, 2017, to June 30, 2019. Individuals were followed from the index date until they lost Medicare eligibility, until death, or until the end of the study, whichever came first. CLL treatments were evaluated based on whether they were included in the National Comprehensive Cancer Network guidelines; individuals were grouped by which treatment they received first.
CLL treatments included rituximab monotherapy, ibrutinib monotherapy, bendamustine/rituximab (BR), obinutuzumab, and other treatments. Data points included share of patients who received first course of treatment, top-ranked regimens in the first course, median time to starting first course, and time in days from index date to initiation. The team created a visual representation of individual data points, adding in demographic data, preventive health scores, and Charlson Comorbidity Index scores to see which factors made treatment more or less likely.
Results. The investigators reported a covariate-adjusted odds ratio (AOR), and an AOR less than 1 shows that “the comparison was negatively associated with the receipt of CLL treatment.”
Investigators identified 3440 CLL patients for evaluation; of these, only 16% (550) received CLL treatment, and the mean follow-up time was 540 days. Of the overall group, the mean age was 77 years; 49% were male.
Of the 556 treated patients, the first course of treatment was rituximab in 34%, BR in 12%, obinutuzumab in 4%, and other treatment in 14%. The mean (interquartile range) time to receipt of CLL treatment was 61 days; the median time to receipt of different therapies was as follows: ibrutinib, 109 days; rituximab, 49 days; BR, 53 days; and obinutuzumab, 140 days.
Less than half the patients in the BR group completed the recommended 6 doses. Compared with those in the rituximab group, a larger share of those in the ibrutinib and BR groups remained on their first treatment course.
The oldest patients (≥85 years) had an AOR of 0.69 (95% CI, 0.53-0.91) compared with those aged 65 to 74. Male patients had an AOR of 1.28 (95% CI, 1.06-1.54) compared with females. “No other statistically significant differences based on baseline measures were observed,” the investigators wrote.
They concluded, “Among Medicare beneficiaries diagnosed with CLL, less than 2 out of 10 patients received CLL treatment. The most common treatments administered during this time period were ibrutinib or rituximab. Younger age and male gender were factors associated with increased receipt of treatment.”
All study authors either receive research funding from BeiGene or are employed by BeiGene, the developer of zanubrutinib, which is being studied in patients with a new diagnosis of CLL.
Onukwugha E, Lee TY, Abree J, et al. Factors associated with treatment among older adults diagnosed with chronic lymphocytic leukemia: an analysis using Medicare claims data. Presented at: The 63rd Annaul American Society of Hematology Meeting and Exposition; December 11-14, 2021; Atlanta, Georgia. Abstract 1968. https://ash.confex.com/ash/2021/webprogram/Paper148727.html