Average Wholesale Price Research Articles

Pharmacoeconomic savings associated with alternate dosing strategy of nivolumab and ipilimumab combination therapy.

79 Background: Nivolumab (NIVO) plus ipilimumab (IPI) is a commonly used therapy for advanced melanoma. Original weight-based dosing of NIVO 1 mg/kg plus IPI 3 mg/kg (NIVO1+IPI3) was approved in 2017. Recently, the CHECKMATE 511 trial demonstrated improved tolerability of NIVO 3 mg/kg plus IPI 1 mg/kg (NIVO3 + IPI1) compared to the original dosing regimen without observed differences in efficacy.Objective: To determine the pharmacoeconomic implications of NIVO1+IPI3 and NIVO3+IPI1 with a dose banding strategy applied. Methods: Patients with advanced melanoma (N = 21) who received IPI and NIVO in combination between 4/2019 – 7/2019 were evaluated via a single-center retrospective chart review. A total of 118 checkpoint inhibitor doses (59 NIVO, 59 IPI) were analyzed.Weapplied a dose banding strategy to both NIVO1+IPI3 and NIVO3+IPI1 regimens to examine pharmaceutical expenditures using the two dosing regimens, whichincluded our organization 10% dose-vial rounding policy. Pharmaceutical expenditure using average wholesale price (AWP), which was $32.42 per mg of NIVO and $180.03 per mg of IPI, was calculated for each dosing strategy (NIVO1+IPI3 and NIVO3+IPI1). Results: The anticipated cost savings of patients receiving NIVO3+IPI1 combination therapy compared to NIVO1+IPI3, (both with dose rounding strategy applied), was $1,459,473 or >$70,000 per patient, representing a 47.2% savings from the original NIVO1 +IPI3 regimen (Table). Conclusions: In addition to improved tolerability and comparable efficacy for NIVO3+IPI1 vs NIVO1+IPI3, our study shows that adoption of the NIVO3+IPI1 regimen results in significant savings in drug costs. Considerations should be made in future combination trials to compare NIVO3+IPI1 as a treatment arm to NIVO1+IPI3 to see if comparable clinical results can be obtained with less toxicity and decreased pharmaceutical spending. [Table: see text]

Applying the ASCO and ESMO Value Frameworks to nasopharyngeal cancer treatments: Is adding induction chemotherapy or adjuvant chemotherapy to concurrent chemoradiotherapy worthwhile?

67 Background: To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) added to RT and CC + adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC). Methods: We searched phase III randomized controlled trials (RCTs) which reported overall survival (OS) benefit with the use of IC, CC and CC+AC in LA-NPC. We quantified the ICB using the ASCO and ESMO value framework. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database. Results: We identified three RCTs on IC, three RCTs on CC and four RCTs on CC + AC. The ICB was judged to be Grade A based on the ESMO framework. The ASCO Net Health Benefit Score (NHBS) ranged from 17.43 to 57.39. The incremental drug costs ranged from 133.46 to 626.14. There were no statistically significant differences in the means of NHBS [39.37 (IC) vs 37.61 (CC) vs 33.98 (CC+AC), P = 0.89] and costs [383 (IC) vs 253 (CC) vs 460 (CC+AC), P = 0.27] between these three approaches. There was no statistically significant correlation between ICB and costs. Conclusions: The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT and CC + AC to RT for LA NPC are not significantly different.

Technical and economic potentials of the unconventional extruded dried Arabic bread wastes in broilers diets.

Food waste is one of the major global challenges that have adverse socioeconomic and environmental impacts. Therefore, studying food waste utilization potentials and minimizing its negative consequences becomes imperative. This study aims to assess the technical and economic potentials of substituting corn with unconventional extruded dried Arabic Bread waste (EDABW) in broilers’ diets, in terms of broilers’ performance, carcass characteristic, economic net returns, and income over feed cost (IOFC). One hundred eighty unsexed one-day-old broiler birds of Ross breed were distributed randomly in six treatments (0, 20, 40, 60, 80, and 100% EDABW group) of isocaloric and isonitrogenous diets in a completely randomized design with six replicated (5 chicks/replicate). The investigated traits were broilers’ performance (live body weight, total feed intake, total feed conversion ratio, and total weight gain. Other traits such as carcass weight, abdominal fat, edible offal (liver, heart, and gizzard), eviscerated (breast muscles, drum and thigh muscles, and wings) were weighed and expressed based on a live body weight. Results showed that the 20% replacement level of corn with EDABW generated the highest increase in the live body weight and the eviscerated carcass at about 4.24% g and 4.90%, respectively. On the other hand, the economic analysis showed potential reductions in the broilers’ diet cost and the total broilers' production cost as the levels of corn substitution with by unconventional EDABW increased. The reductions were estimated at 5.1%, 6.3%, 8.4%, 9.3%, and 9.9% at substitution levels of 20%, 40%, 60%, 80%, and 100%, respectively as compared to the control diet. The results also showed a potential increase in the net economic returns of broiler meat as the increase in substitution levels ranged between 3.5–06.8% and 4.3–8.3% as compared to the control diets using the average retail and wholesale prices of broiler meats, respectively. In addition, the maximum IOFC was estimated potentially at a 20% substitution level of corn with EDABW. Conclusively, the study results show promising technical and economic potentials for unconventional EDABW in broilers’ diets that could lead to a thriving industry of unconventional broilers’ diets with high net economic returns and maximum IOFC.

Pharmaceutical pricing benchmarks: governmental versus private sector.

Purpose: To explore the best pricing benchmark for workers'compensation drugs reimbursement at retail pharmacies. Materials & methods: We used California workers'compensation system (CAWCS) total cost of pharmacy dispensedmedications (2017-2019) as a proxy to estimate drug prices using alternative pricing mechanism fee schedules. Results: CAWCS paid 65.6% of the average wholesale price (AWP), 104.1% of Medi-Cal, 122.1% of the wholesaleacquisition cost (WAC), 140.1% of the national average drug acquisition cost (NADAC), and 253.5% of the federal upper limit. In addition, we found the AWP-based formulas: CAWCS=AWP -34.4%, Medi-Cal=AWP -36.9%, WAC=AWP -46.3%, NADAC=AWP -53.2%, and federal upper limit=AWP -74.1%. We found that AWP: 50% for generics and AWP -18.2% for brands are the lowest paying formulas. The estimated median cost savings were $8.7 million (by adapting 97% of the WAC) and $9.5 million (by adapting the NADAC) across all states. Conclusion: NADAC was the best pricing benchmark for reimbursement of pharmacy dispensed drugs.

Applying the ASCO and European Society for Medical Oncology Value Frameworks to Nasopharyngeal Cancer Treatments: Is Adding Induction Chemotherapy or Adjuvant Chemotherapy to Concurrent Chemoradiotherapy Worthwhile?

To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) when added to radiotherapy (RT), and CC plus adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC). We searched phase III randomized controlled trials (RCTs) that reported overall survival benefit with the use of IC, CC, and CC + AC in LA-NPC. We quantified the ICB using the ASCO and European Society for Medical Oncology (ESMO) value frameworks. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database. We identified three RCTs on IC, three RCTs on CC, and four RCTs on CC + AC. The ICB was judged to be grade A based on the ESMO framework. The ASCO Net Health Benefit score ranged from 17.43 to 57.39. The incremental drug costs ranged from $133.46 to $626.14. There were no statistically significant differences in the mean Net Health Benefit scores (39.37 for IC v 37.61 for CC v 33.98 for CC + AC; P = .89) and costs ($383 for IC v $253 for CC v $460 for CC + AC; P = .27) between the three approaches. There was no statistically significant correlation between ICB and costs. The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT, and CC + AC to RT for LA-NPC are not significantly different.

Impact of COVID-19 pandemic on agricultural wholesale prices in India: A comparative analysis across the phases of the lockdown

This paper attempts to analyse the impact of COVID-19 lockdown on wholesale prices of the agricultural commodities particularly fruits and vegetables in the Union Territory of Jammu and Kashmir, India. This study is based on the daily data collected from AGMARKNET of all major agricultural markets under the Agricultural Produce Market Committee (APMC). The difference in weighted wholesale prices has been analysed before and during COVID-19 and across various phases of the lockdown. The analysis of the difference in the weighted average wholesale prices across markets and commodities has shown a mixed response. The most hydrating perishable fresh fruits and vegetables with high water content have faced a significant decline in wholesale prices during the lockdown. On the contrary, other perishable fruits and vegetables have realized a gain in the average wholesale prices. The weighted average wholesale price has also declined over the phases of the lockdown. This study provides timely feedback for preparing all the stakeholders of the agricultural marketing chain to understand and formulate coping strategies to make the system resilient.

Niraparib maintenance in frontline management of ovarian cancer: a cost effectiveness analysis

ObjectivesNiraparib maintenance after frontline chemotherapy for advanced ovarian cancer extends progression free survival. The objective of this study was to determine the cost effectiveness of niraparib maintenance therapy in patients...

Poor Cost Awareness Among Anesthesia Providers for Medications, Supplies, and Blood Products

The objective of this study was to determine if anesthesia providers can accurately estimate the cost of commonly used medications, supplies, and blood products. This study was conducted between April and June 2019 at an academic tertiary care hospital. Anesthesia providers (certified registered nurse anesthetists [CRNAs], residents, and fellows/attendings) were surveyed on their knowledge of the cost of commonly used therapies. Items were sorted into 12 categories: opioids, non-opioid analgesia, vasopressors, hypertension medications, antibiotics, neuromuscular blockers, reversals, anesthetics, supplies, kits, blood products, and blood-related products. Estimates were considered to be accurate if the median cost differed from the average wholesale price by < 25%, moderately inaccurate if between 25% and 50%, and severely inaccurate if by > 50%. A total of 107 surveys (CRNAs: 25, residents: 36, fellows/attendings: 46) were returned. The percentage of total items accurately estimated for cost was low (22% for all providers), and was not different between provider types (27% for CRNAs, 23% for residents, 20% for fellows/attendings; p = 0.69). The percentage of items with severe inaccuracies in cost estimation was high and was not different between provider types (56% for CRNAs, 60% for residents, 50% for fellows/attendings; p = 0.53). Rates of under- and overestimation varied widely, with greatest underestimation for vasopressors and blood-related products, and greatest overestimation for non-opioid analgesia and antibiotics. Low- and high-cost category items tended to be overestimated and underestimated, respectively (p < 0.0001). The majority of anesthesia providers have poor knowledge of cost. These findings suggest that cost awareness interventions may be necessary for promoting high-value health care.

Cost Reduction Associated with Comprehensive Medication Reviews in a Student-Run Free Clinic

Background: Patients taking multiple medications are at increased risk for drug-drug interactions, adverse drug effects, and increases in drug costs. Patients of low socioeconomic status and health literacy have further risk for experiencing these unwanted effects. This study aimed to determine if student-pharmacist led comprehensive medication reviews (CMRs) for patients of a student-run free clinic on multiple chronic medications decreased drug costs and inappropriate overprescribing of medications. Secondary objectives included determination of most overprescribed medication classes and the number and types of recommendations made by student-pharmacists.&#x0D; Methods: Student-pharmacists conducted CMRs on consenting patients seen during a weekly student-run free clinic at a rural university clinic. Included patients were taking six or more chronic medications for two or more chronic disease states at the start of the visit. Information from patient interviews was used to make drug therapy recommendations to interprofessional student teams and an attending provider. Accepted recommendations were implemented into patients’ care plans. The average 30-day drug costs of patients’ medications before and after receiving a CMR were calculated using average wholesale prices and compared using paired t-tests. The most common drug classes recommended to be deprescribed and the total number of accepted recommendations (in the categories of safety, efficacy, and indication) were collected from forms used during CMR.&#x0D; Results: A total of 31 CMRs were completed during the study period, with 92 recommendations made by students and 91% of recommendations accepted by the attending. Average drug costs for a 30-day supply of medication decreased from $698.16 pre-CMR to $619.31 post-CMR, a cost reduction of $78.85 (p = 0.049). The most common recommendations made by students were removal of an unnecessary drug (N = 27), dose too low (N = 15), and additional drug needed (N = 13). The two most overused classes of medications were selective serotonin reuptake inhibitors and proton pump inhibitors.&#x0D; Conclusions: Student-pharmacist led CMRs conducted in a rural free clinic population resulted in a significant decrease in drug spending and identification of drug therapy problems.

PMS17 COST EFFECTIVENESS ANALYSIS OF UPADACITINIB AND METHOTREXATE FOR PATIENTS WITH METHOTREXATE-RESISTANT RHEUMATOID ARTHRITIS

The purpose of this study was to determine the cost-effectiveness of upadacitinib (an oral, reversible JAK inhibitor) versus methotrexate (cDMARDs) as a first-line monotherapy in the treatment of rheumatoid arthritis (RA) in the US. A decision analysis model was constructed with a time horizon of 3 months and a US payer’s perspective was assumed. The effectiveness measure was based on probability of achieving a score of less than or equal to 3.2 on the 28 joint Disease Activity Score (DAS28). The effectiveness data was derived from published clinical trial information. Costs of the drugs were based on average wholesale price and were obtained from Redbook 2019. Cost of hospitalization, outpatient cost and treatment cost for adverse events were considered and were obtained from published literature. All costs were adjusted to 2019 US Dollars using the medical care component of the Consumer Price Index from the Bureau of Labor Statistics. TreeAge Pro 2019 was used to construct the model. A series of one-way sensitivity analyses were performed to assess the robustness of the model results. Treatment of RA with upadacitinib ($19,826) is more expensive than that with the methotrexate ($662) for a given time horizon of 3 months. The percentage for achieving a score of <= 3.2 on DAS 28 was 73% for upadacitinib and 27% for methotrexate. The incremental cost-effectiveness ratio of Drug A vs. Drug B was $ 225,687.13 per additional patient achieving a score of <= 3.2 on DAS28 over the period of 3 months. One-way sensitivity analysis findings showed the robustness of the results. The results suggest that upadacitinib appears to be cost-effective compared to methotrexate for achieving a score of <= 3.2 on DAS28. These findings were robust for plausible ranges of effectiveness and drug acquisition costs.

PSY8 HYDROXYUREA (SIKLOS) VERSUS OFF-LABEL GENERIC HYDROXYUREA FOR AVERTING SICKLE CELL-RELATED HOSPITALIZATIONS: A COST-EFFECTIVENESS ANALYSIS

Novel therapeutic options for managing vaso-occlusive crises in pediatric sickle cell disease (SCD) have entered the market recently. However, evidence of their cost-effectiveness is lacking. This study presents a cost-effectiveness analysis of L-glutamine oral powder, hydroxyurea (Siklos) and off-label, generic hydroxyurea; compared to standard of care with chronic blood transfusions. Using a decision-tree model, we compared economic and clinical outcomes of novel SCD drugs and generic hydroxyurea over one-year time horizon in a hypothetical cohort of pediatric (≥ 2 years) SCD patients from a US payer perspective. The main outcome is incremental cost per number of SCD-related hospitalizations averted (ICER). Model inputs were derived from published literature and clinical trials. Drug average wholesale price (AWP) was obtained from Wolters Kluwer Medi-Span®. All costs were converted to 2019 US dollars using the consumer price index (CPI) health care cost component. Off-label, generic hydroxyurea was associated with both reduced costs and higher SCD-related hospitalizations averted, and dominated the novel drugs. L-glutamine oral powder and Siklos had incremental costs of $23,793 and $35,986; and averted 0.4 versus 0.2 SCD-related hospitalizations/year, respectively when compared to standard care. L-glutamine oral powder dominated Siklos. The ICER for L-glutamine oral powder compared to standard care was $55,816 while Siklos cost $153,634/averted SCD-related hospitalization. Generic hydroxyurea and L-glutamine powder, but not Siklos were cost-effective at a willingness-to-pay threshold of $100,000 per SCD-related hospitalization averted. This model was robust to a deterministic one-way sensitivity analysis wherein the hospitalizations prevented in Siklos users was increased by 50%. Generic hydroxyurea remained dominant and the resultant ICER for Siklos was $137,068/SCD-hospitalization averted. The cost-effectiveness of hydroxyurea (SIKLOS) for SCD is dependent on drug cost, budget and willingness-to-pay per sickle cell hospitalization averted. L-glutamine oral powder may represent a cost-effective option for children who fail to respond to generic hydroxyurea.

Abstracts of the 29th Annual Pediatric Pharmacy Association (PPA) Meeting April 29 to May 3, 2020

Abstracts of the 29th Annual Pediatric Pharmacy Association (PPA) Meeting April 29 to May 3, 2020

Costs of cannabis testing compliance: Assessing mandatory testing in the California cannabis market.

Most U.S. states that have regulated and taxed cannabis have imposed some form of mandatory safety testing requirements. In California, the country's largest and oldest legal cannabis market, mandatory testing was first enforced by state regulators in July 2018, and additional mandatory tests were introduced at the end of 2018. All cannabis must be tested and labeled as certified by a state-licensed cannabis testing laboratory before it can be legally marketed in California. Every batch that is sold by licensed retailers must be tested for more than 100 contaminants, including 66 pesticides with tolerance levels lower than the levels allowable for any other agricultural product in California. This paper estimates the costs of compliance with mandatory cannabis testing laws and regulations, using California's testing regime as a case study. We use state government data, data collected from testing laboratories, and data collected from lab equipment suppliers to run a set of Monte Carlo simulations and estimate the cost per pound of compliance with California's new cannabis testing regulations. We find that cost per pound is highly sensitive to average batch size and testing failure rates. We present results under a variety of different assumptions about batch size and failure rates. We also find that under realistic assumptions, the loss of cannabis that must be destroyed if a batch fails testing accounts for a larger share of total testing costs than does the cost of the lab tests. Using our best estimates of average batch size (8 pounds) and failure rate (4%) in the 2019 California market, we estimate testing cost at $136 per pound of dried cannabis flower, or about 10 percent of the reported average wholesale price of legal cannabis in the state. Our findings explain effects of the testing standards on the cost of supplying legal licensed cannabis, in California, other U.S. states, and foreign jurisdictions with similar testing regimes.

Cost Comparison of Bivalirudin versus Unfractionated Heparin for Children on Left Ventricular Assist Devices

Intravenous unfractionated heparin (UFH) has been the traditional immediate post-operative anticoagulant for pediatric ventricular assist device (VAD) recipients. In recent years, bivalirudin has been increasingly used as an alternative agent and may confer advantages over UFH. However, bivalirudin may be cost-prohibitive, due to the price of the drug. The aim of this study was to compare early post-operative costs for patient cohorts receiving UFH versus bivalirudin. Patients supported on the Berlin EXCOR® at Primary Children's Hospital (PCH) and Lucile Packard Children's Hospital (LPCH) from 01/2016 and 12/2018 were included. Patients treated with bivalirudin were matched by underlying diagnosis and implant weight to patients treated with UFH. The cost of heparin therapy included the cost of Heparin Activity Levels (HAL, Anti-Xas), antithrombin activity levels, and antithrombin drug cost. The cost of bivalirudin therapy included drug cost and cost of activated partial thromboplastin times (aPTTs). Drug pricing was based on average wholesale price. Laboratory costs were based on PCH cost. Cost analysis was based on post-operative day 0 - 14, the time frame of greatest anticoagulant lability. Twelve matched patients were included; 5 cardiomyopathy and 1 congenital heart disease per cohort with similar median implant weights (9 kg UFH vs 12 kg bivalirudin, p = 0.58). For the UFH cohort, median cost per patient day of support was $1,025.07/day; labs comprised 69% of total costs, and drug 31%. Bivalirudin median cost per patient day of support was $740.49/day, with 97% drug cost and 3% lab cost. Cost per patient day of support was not significantly different between the groups (p = 0.38). HALs were obtained a median of 2.1 times per patient day for the UFH cohort, while aPTTs were obtained a median of 4.4 times per patient day in the bivalirudin cohort (p=0.006). Bivalirudin and UFH have similar costs during the first 14 days after Berlin EXCOR® implant, when therapeutic drug monitoring is included, thus illustrating noninferiority of bivalirudin from a cost perspective.

Cytomegalovirus Immune Globulin (CMV-Ig): An Old Drug with Fewer Tricks - Removal of Prophylactic CMV-Ig Administration in CMV Mismatched Lung Transplant Recipients

The routine use of cytomegalovirus immune globulin (CMV-Ig) to provide passive immunity to cytomegalovirus (CMV) in patients is not supported in published literature. International guidelines do not advocate for the use of CMV-Ig alone in thoracic transplant and provide only weak recommendations for its role in combination with antiviral therapy for prevention of CMV. The utilization of CMV-Ig incurs significant cost, and carries the potential for infusion related toxicities. Furthermore, in 2012, an international survey reported only 38 % of thoracic transplant centers utilized CMV-Ig as part of a universal prophylaxis protocol. We evaluated the safety and cost efficiency of the removal of CMV-Ig from standard practice. Prior to September 2018, CMV-Ig 150mg/kg x1 was given to all CMV high-risk lung transplant recipients on postoperative day two in conjunction with intravenous ganciclovir (GCV) followed by prophylaxis with oral valganciclovir (vGCV) for 12 months per institution protocol. After September 2018, CMV-Ig was removed from our institution protocol and high-risk patients received GCV/vGCV prophylaxis alone. Serum CMV PCRs were monitored per institution protocol. All patients post-intervention were retrospectively reviewed for occurrence of CMV viremia, seroconversion, and a cost savings analysis was performed. Twelve CMV high-risk lung transplant recipients were observed after the removal of CMV-Ig administration from standard practice. None of these patients experienced a detectable serum CMV PCR. Median follow up time was 163 days (IQR 111-301) post-transplant. All patients received antiviral prophylaxis immediately post-operatively, and had at least 8 weeks of follow up. Seroconversion was observed in three patients at post-operative day 7, 76, and 80 respectively. Using average wholesale price, the calculated cost savings was approximately $5,700 per patient and $68,400 across the entire cohort. Our results demonstrate that removal of CMV-Ig administration from standard practice, even in CMV high-risk patients, did not increase the risk of CMV viremia and led to significant cost savings. These data allude to the decreasing utility of CMV-Ig for CMV prophylaxis in the GCV/vGCV era.

4:03 PM Abstract No. 189 Transradial arterial access vasodilation cocktail: is the calcium channel blocker needed?

Transradial access (TRA) for arterial procedures in interventional radiology (IR) continues to grow in popularity. During IR radial arterial access it is standard to give a cocktail of Heparin, Nitrates, and a calcium channel blocker (Verapamil) through the vascular sheath to prevent arterial vasospasm. However, data within Interventional Cardiology radial access literature questions the need of Verapamil. This study was completed to evaluate the safety, efficacy, and cost of TRA without the use of Verapamil in the vasodilation cocktail at a single institution. Retrospective review of all TRA cases completed in the department of IR at a single institution were reviewed from September 2014 to July 2019. A total of 244 TRA cases were identified. Verapamil was used in the TRA vasodilation cocktail for 32 patients until May 14, 2015. No Verapamil was used for the remaining 212 TRA cases through July 2019. Electronic medical record chart review was completed on all procedures to evaluate complication rates and technical success rates. In addition, the average wholesale price of Verapamil was obtained via the vendor. Technical success rates for TRA completed with and without Verapamil in the vasodilation cocktail were 100% and 98%, respectively. The technical failures that occurred in TRA cases without Verapamil were secondary to an anatomical variant of the left radial artery and an inability to cannulate a superselective hepatic artery branch. Neither failure was impacted by the lack of Verapamil. The complication rate from TRA intervention without Verapamil was 0.8%. Both the technical success and complication rates of TRA without Verapamil compare favorably to current literature. The average wholesale price of Verapamil is $12.60 per 5 mg vial, for a total savings of $2,671.20 over the time period. Elimination of Verapamil from the TRA vasodilation cocktail showed similar safety, efficacy, and decreased hospital costs for TRA arterial IR interventions.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

The rising cost of commonly used emergency department medications (2006-15).

We determine how aggregate costs have changed for commonly used emergency department (ED) medications, and assess drivers of cost increases. Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we identified the top 150 ED medications administered and prescribed at discharge in 2015. We used average wholesale prices (AWP) for each year from 2006 to 15 from the Red Book (Truven Health Analytics Inc.). Average wholesale price per patient (AWPP) was calculated by dividing AWP by drug uses. This was then multiplied by the total drug administrations or prescriptions to estimate the total cost in a given the year. All prices were converted to 2015 dollars. Aggregate costs of drugs administered in the ED increased from $688.7 million in 2006 to $882.4 million in 2015. For discharge prescriptions, aggregate costs increased from $2.031 billion in 2006 to $4.572 billion in 2015. AWPP for drugs administered in the ED in 2015 was 14.5% higher than in 2006 and 24.3% higher at discharge. The largest absolute increase in AWPP for drugs administered was for glucagon, which increased from $111 in 2006 to $235 in 2015. The largest AWPP increase at discharge was for epinephrine auto-injector, which increased from $124 in 2006 and to $481 in 2015. Over the course of the study period, the aggregate costs of the most common medications administered in the ED increased by 28% while the costs of medications prescribed at discharge increased 125%.

Application of the ASCO Value Framework and ESMO Magnitude of Clinical Benefit Scale to Assess the Value of Abiraterone and Enzalutamide in Advanced Prostate Cancer.

As novel hormonal therapies, such as abiraterone and enzalutamide, move into earlier stages of treatment of advanced prostate cancer, there are significant cost implications. We used the ASCO Value Framework (AVF) and European Society of Medical Oncology (ESMO) Magnitude of Clinical Benefit Scale (MCBS) to quantify and compare the incremental clinical benefit and costs of these agents in the metastatic castration-resistant prostate cancer (mCRPC) and metastatic castration-sensitive prostate cancer (mCSPC) settings. We searched PubMed for randomized phase III trials of abiraterone and enzalutamide in mCRPC and mCSPC. Incremental clinical benefit was quantified using the AVF and ESMO-MCBS by 2 independent assessors. Incremental drug costs were calculated using average wholesale prices (AWPs) from the RED BOOK Online. In mCRPC, 2 abiraterone trials (COU-AA-301 and COU-AA-302) and 2 enzalutamide trials (AFFIRM and PREVAIL) met search criteria. AVF scores ranged from 46.3 to 66.6, suggesting clinical benefit; ESMO-MCBS scores ranged from 3 to 5, with lower clinical benefit in the mCRPC predocetaxel setting. The overall incremental AWP ranged from $83,460.94 to $205,128.85. In mCSPC, 4 trials met criteria (LATITUDE, STAMPEDE, ENZAMET, and ARCHES; AVF scores were 79.8, 33.3, 59, and 17, respectively). All of the studies showed benefit except ARCHES. By ESMO-MCBS, both LATITUDE and STAMPEDE showed benefit (score for 4 for both studies); ENZAMET and ARCHES were not evaluable. The overall cost of treatment was significantly higher in the mCSPC setting. The AVF and ESMO-MCBS frameworks generated slightly different results but suggested that abiraterone and enzalutamide show clinical benefit in both mCRPC and mCSPC but trended to lower clinical benefit and increased costs in earlier disease stages. Further refinement of the AVF and ESMO-MCBS is needed to facilitate their use and their ability to inform clinical practice in a rapidly changing treatment landscape.

Market Power and Renewables: The Effects of Ownership Transfers

The introduction of renewable energy sources (RES) in an electricity market changes the shape of the system’s supply curve. In a perfectly competitive market, this causes a downward pressure on equilibrium prices called the merit order effect (MoE). However, when introducing or transferring RES assets to firms with market power, effects on inframarginal rents are ambiguous and depend on the share of RES capacity in the firms’ portfolios. We quantify this effect empirically in the Ontario electricity market by finding equilibria under different counterfactual scenarios of RES ownership transfers and expansions. First, we identify the effect of market power in isolation by keeping the system’s capacity fixed, but we transfer RES capacity from the fringe (competitive) to firms with market power. These transfers yield increases in prices of up to 24% relative to average wholesale prices. Then, in order to measure the interaction of market power with the MoE, we introduce new RES capacity to the system by giving it to different players with varying levels of market power. We find that, following a net expansion of RES capacity of 5% relative to total capacity, wholesale prices decrease by up to 30% in the case of perfect competition. However, if capacity is assigned to the largest firm the decrease in prices is only 7%. These findings suggest that the MoE can be largely mitigated by market power, hence the key importance of the nature of the owner of new capacity when designing uniform incentives for RES adoption.