Average Wholesale Price Research Articles

643. Evaluation of Rapid Blood Pathogen Identification Along with Antimicrobial Stewardship at an Academic Teaching Institution

BackgroundBloodstream infections are a major cause of morbidity and mortality in hospitalized patients. Prompt initiation of effective antimicrobials are essential to optimize patient outcomes. New diagnostic technologies rapidly identifying bacteria, viruses, fungi, and parasites in infections of various body sites. There is a paucity of literature determining if stewardship programs run by one trained pharmacist with rapid diagnostics decreases time to optimal antimicrobial therapy. MethodsThis was a retrospective chart review of positive bloodstream infections identified via rapid diagnostic technologies. The EHR of admitted adult patients with positive BSI identified by BioFire FilmArray Blood Culture Identification (BCID) Panel™ or Accelerate PhenoTest Blood Culture kit™2 between January 2018 – July 2019 were evaluated and pertinent data was collected.ResultsRapid diagnostic technologies identified 108 bloodstream infections due to gram positive, 56 due to gram negative, and 6 due to Candida organisms. Mean time to optimal antimicrobial therapy was significantly lower when pharmacist recommendation was accepted versus when primary care team consulted ID for recommendation or did not accept pharmacist recommendation. Mean time to optimal therapy was 14.7, 34.3, and 271.3 hours (p< 0.0001) respectively. Median total cost of visit per patient, calculated using the average wholesale price of antibiotics multiplied by the number of doses received, was significantly lower when pharmacist recommendations were accepted (&86.40, &147.95, and &239.41, respectively).Baseline characteristics Microbiological isolates Primary Outcome: Time to Optimal TherapyConclusionThe establishment of a pharmacist run antimicrobial stewardship program in conjunction with rapid diagnostic tools for identifying bacteremia led to a decrease in time to optimal antimicrobial therapy and cost savings. Introduction of similar services at community hospitals with limited ASP staffing is justified. Larger studies to further investigate whether ASP partnered with rapid diagnostics have an impact on patient-related outcomes such as mortality and length of stay is warrented. Secondary outcomes Missed cost savings Disclosures All Authors: No reported disclosures

870. Coverage, Cost Sharing, and Out-of-Pocket Costs for Single-Tablet HIV Antiretroviral Regimens in Qualified Health Plans in the United States, 2018-2020

BackgroundA key pillar of the US “Ending the HIV Epidemic” (EHE) plan is rapidly providing antiretroviral therapy (ART) to achieve viral suppression. However, access to ART is hindered by discriminatory benefit design through non-coverage, adverse tiering (including pricier cost sharing via coinsurance instead of copays), and excessive and arbitrary utilization management for ART, all of which make rapid access to HIV treatment challenging. To understand how ACA Qualified Health Plan (QHP) formularies adapt in response to new ART single tablet regimens (STRs), we analyzed QHP coverage of two first-line STRs: dolutegravir/abacavir/lamivudine (Triumeq; approved 2014) and bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy; approved 2018).MethodsFor all QHPs offered in the 2018-2020 ACA Marketplaces, we analyzed Biktarvy and Triumeq coverage, cost sharing, and out-of-pocket (OOP) costs at state, regional, and EHE priority jurisdiction levels.Figure 1. Qualified Health Plan Coverage of Triumeq and Biktarvy by State, 2018-2020 ResultsFor 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. In 2018, 26 states had < 50% of QHPs covering Biktarvy, and 9 states had 0%. Conversely, 41 states had 100% of QHPs covering Triumeq, and only 2 states had < 50% (Fig. 1). Biktarvy coverage improved from 2018-2020, especially in the Midwest (27% to 88%). Improvements were driven by increased coverage with copay except in the South, where coverage with copay remained stagnant and coverage with coinsurance increased (22% to 33%) (Fig. 2). Biktarvy coverage increased in EHE jurisdictions from 74% to 90%, driven by increased coverage with coinsurance (20% to 34%) (Fig. 3). Although Biktarvy had a higher national average wholesale price than Triumeq (&4,073 vs. &3,639 per month in 2020, respectively), monthly OOP cost trends only differed regionally in the Midwest and did not differ by EHE priority jurisdiction status (Fig. 4).Figure 2. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by Region, 2018-2020 Figure 3. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 Figure 4. Monthly Out-of-Pocket Cost for Qualified Health Plan Premium and Triumeq or Biktarvy by Cost Sharing Type and (A) Region or (B) “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 ConclusionSTR coverage remains heterogenous across the United States. Over time, coverage of the newer STR increased, but many QHPs in EHE jurisdictions still required coinsurance. Access to newer ART regimens may be slowed by delayed QHP coverage or complex negotiations with manufacturers about formulary inclusion as ART options become more competitive, even if patients are insulated from cost differences.Disclosures Kathleen A. McManus, MD, MSCR, Gilead Sciences, Inc. (Research Grant or Support, Shareholder)

Low-Dose Valganciclovir Prophylaxis Is Safe and Cost-Saving in CMV-Seropositive Kidney Transplant Recipients.

Introduction: Observational studies suggest that low-dose valganciclovir prophylaxis (450 mg daily for normal renal function) is as effective as and perhaps safer than standard-dose valganciclovir (900 mg daily) in preventing CMV infection among kidney transplant recipients. However, this practice is not supported by current guidelines due to concerns for breakthrough infection from resistant CMV, mainly in high-risk CMV donor-seropositive/recipient-seronegative kidney transplant recipients. Standard-dose valganciclovir is costly and possibly associated with higher incidence of neutropenia and BKV DNAemia. Our institution adopted low-dose valganciclovir prophylaxis for intermediate-risk (seropositive) kidney transplant recipients in January 2018. Research Question: To analyze the efficacy (CMV DNAemia), safety (BK virus DNAemia, neutropenia, graft loss, and death), and cost savings associated with this change. Design: We retrospectively compared the above outcomes between CMV-seropositive kidney transplant recipients who received low-dose and standard-dose valganciclovir, transplanted within our institution, between 1/19/2014 and 7/15/2019, using propensity score-adjusted competing risk analyses. We also compared cost estimates between the two dosing regimens, for 3 months of prophylaxis, and for different percentage of patient-weeks with normal renal function, using the current average wholesale price of valganciclovir. Results: We studied 179 CMV-seropositive kidney transplant recipients, of whom 55 received low-dose and 124 standard-dose valganciclovir. The majority received nonlymphocyte depleting induction (basiliximab). Low-dose valganciclovir was at least as effective and safe as, and more cost-saving than standard-dose valganciclovir. Conclusion: This single-center study contributes to mounting evidence for future guidelines to be adjusted in favor of low-dose valganciclovir prophylaxis in CMV-seropositive kidney transplant recipients.

An integrated approach to evaluate different tetracycline derivatives for formulary decisions

Stenotrophomonas maltophilia has emerged as a critical opportunistic pathogen associated with significant morbidity and mortality. Tetracycline derivatives have been recognized as alternative treatment options, but they have varied pharmacokinetic properties. An integrated approach to different tetracycline derivatives for formulary decisions is reported. The minimum inhibitory concentration (MIC) data from clonally diverse bloodstream S. maltophilia isolates were examined, along with the pharmacokinetic profiles of 4 tetracycline derivatives, to predict achievable pharmacodynamic exposures with standard intravenous dosing regimens. Antimicrobial therapy was assessed using the ratio of daily drug acquisition cost relative to the ratio of the free-drug area under the time-concentration curve (fAUC) to minimum inhibitory concentration (MIC) for 90% of isolates (fAUC/MIC90). In our analysis, minocycline had the greatest fAUC/MIC90. Doxycycline was the most financially preferred agent, as calculated using 2020 average wholesale price for base-case estimates of drug acquisition cost. An integrated evaluation for antimicrobial formulary decision-making addressed local susceptibility data, pharmacokinetics, pharmacodynamics, dosing regimens, and drug acquisition costs. This comprehensive method is more objective than the conventional approach and warrants validation.

Cost minimization analysis of mainstay treatments in cutaneous lupus erythematous.

Cutaneous lupus erythematosus (CLE) can be treated with multiple oral immunosuppressants but cost analyses of these treatments are lacking. We aimed to assess the relative cost difference between various oral medications for CLE using a cost-minimization analysis. Annual direct costs for 10 oral medications used in CLE were calculated including cost of medications and patient monitoring, which include office visits, laboratory and radiological studies, and procedures. Medication costs were taken from the National Average Drug Acquisition Cost calculated by the Centers of Medicare and Medicaid Services or the Average Wholesale Price. Monitoring guidelines were obtained from expert consensus and FDA-approved recommendations. Methotrexate had the lowest total direct cost ($899.31), followed by hydroxychloroquine ($1007.38), mycophenolate mofetil ($1162.12), azathioprine ($1193.71), chloroquine ($2525.01), dapsone ($2750.68), cyclosporine ($2976.32), thalidomide ($75,831.44), and lenalidomide ($316,104.03). For medications used for CLE patients, the medication cost contributes the most to differences between direct costs. Limitations include insufficient patient outcome data to ascertain medication efficacy, exclusion of cost of medication-related adverse events and hospitalizations, and medication cost data not reflecting all payers. Clinicians can use this data to help discern which medication to prescribe CLE patients with financial constraints and reduce healthcare spending.

Lenvatinib plus pembrolizumab in advanced recurrent endometrial cancer: a cost-effectiveness analysis

Objectives: To determine the cost-effectiveness of lenvatinib plus pembrolizumab (LP) in patients with endometrial cancer without microsatellite instability who failed first-line chemotherapy. Methods: A decision analysis model was created to evaluate the cost-effectiveness of LP relative to doxorubicin, pegylated liposomal doxorubicin (PLD), and bevacizumab in patients with recurrent microsatellite stable endometrial cancer who failed first-line chemotherapy. Clinical estimates were obtained from published data and drug cost estimates were obtained using average wholesale prices. Additional cost estimates were utilized to estimate cost of grade 3-4 toxicity treatment. The measure of effectiveness was quality-adjusted life years (QALYs). Due to the high rate of toxicity in the LP group, a health state utility (HSU) penalty of -0.05 was applied to this group. Incremental cost-effectiveness ratios (ICERs) were calculated to determine the cost per QALY. The willingness to pay threshold (WTP) was set at $100,000 per QALY saved. Sensitivity analyses were performed on cost, effectiveness, and HSU penalty for LP. Results: Costs of treatment with doxorubicin, PLD, and bevacizumab are $26.7 million (M), $51.1 M, and $225.1 M respectively. Cost of treatment with LP is $856.5M. Relative to doxorubicin, the ICER for PLD, bevacizumab, and LP are $46,279, $345,824, and $726,483 respectively. Two-way sensitivity analysis varying the cost of LP show that if the combined cost of these two drugs decreases from over $34,000 per cycle to less than $9,000 per cycle, this strategy would be cost-effective. At the current cost, even if the median overall survival was double the 16.7 months used in the base model, the ICER for LP remains above the WTP threshold. Eliminating the HSU penalty for LP decreased the ICER $567,000 while increasing the penalty to 0.10 increased the ICER to over $1M. Conclusions: LP is not cost-effective in patients with recurrent, MSS endometrial cancer who have failed first line therapy. A dramatic reduction in cost of LP is required for this novel strategy to be cost-effective. To determine the cost-effectiveness of lenvatinib plus pembrolizumab (LP) in patients with endometrial cancer without microsatellite instability who failed first-line chemotherapy. A decision analysis model was created to evaluate the cost-effectiveness of LP relative to doxorubicin, pegylated liposomal doxorubicin (PLD), and bevacizumab in patients with recurrent microsatellite stable endometrial cancer who failed first-line chemotherapy. Clinical estimates were obtained from published data and drug cost estimates were obtained using average wholesale prices. Additional cost estimates were utilized to estimate cost of grade 3-4 toxicity treatment. The measure of effectiveness was quality-adjusted life years (QALYs). Due to the high rate of toxicity in the LP group, a health state utility (HSU) penalty of -0.05 was applied to this group. Incremental cost-effectiveness ratios (ICERs) were calculated to determine the cost per QALY. The willingness to pay threshold (WTP) was set at $100,000 per QALY saved. Sensitivity analyses were performed on cost, effectiveness, and HSU penalty for LP. Costs of treatment with doxorubicin, PLD, and bevacizumab are $26.7 million (M), $51.1 M, and $225.1 M respectively. Cost of treatment with LP is $856.5M. Relative to doxorubicin, the ICER for PLD, bevacizumab, and LP are $46,279, $345,824, and $726,483 respectively. Two-way sensitivity analysis varying the cost of LP show that if the combined cost of these two drugs decreases from over $34,000 per cycle to less than $9,000 per cycle, this strategy would be cost-effective. At the current cost, even if the median overall survival was double the 16.7 months used in the base model, the ICER for LP remains above the WTP threshold. Eliminating the HSU penalty for LP decreased the ICER $567,000 while increasing the penalty to 0.10 increased the ICER to over $1M. LP is not cost-effective in patients with recurrent, MSS endometrial cancer who have failed first line therapy. A dramatic reduction in cost of LP is required for this novel strategy to be cost-effective.

Implementation of formal prescription guidelines reduces the economic cost of unused opioids after orthopedic surgery.

BACKGROUND: Prior literature has reported on the concerning emergence of opioid overprescribing, yet there remains a lack of knowledge in understanding the cost of waste of this over-prescription and underconsumption of opioids. As such, further investigating the cost of waste of opioids following orthopedic surgery is of interest to patients, providers, and payors. In one of the largest private orthopedic practices in the United States, opioid prescribing and consumption patterns were tracked prior to, and after the implementation of, formal prescription guidelines. OBJECTIVES: To (1) establish the cost of waste of unused opioids before the implementation of formal prescription guidelines and (2) examine how the cost of unused opioids may be reduced after implementation of formal internal prescription guidelines. METHODS: Two separate phases (Phase I and Phase II) were implemented at different time intervals throughout a two-year period. Implementation of prescription guidelines occurred between Phases I and II, and data from Phase I (pre-implementation) was compared to that from Phase II (postimplementation). Data collection included type, dosage, quantity of opioids prescribed and consumed after elective outpatient procedures in ambulatory surgery centers, in addition to patient interviews/surveys within two weeks after surgery to measure consumption. From these data, the cost of waste was calculated by taking the total cost of prescribed opioids (sum of each prescription × Average Wholesale Price (AWP) minus 60%) per 1,000 patients, and subtracting the total cost of consumed opioids per 1,000 patients, calculated in a similar manner. Further analysis was performed to describe differences in the cost of waste of individual opioids between each of the phases. RESULTS: In Phase I, prior to implementation of formal internal prescription guidelines, there was a sizable cost of waste of unused opioids (per 1,000 patients, AWP minus 60%) of $11,299.51. The cost of waste in Phase II, after implementation of formal internal prescription guidelines, was $6,117.12, which was a significant decrease of 45.9% ($5,182.39) from Phase I (P < 0.001). Furthermore, both the average number of morphine equivalent units prescribed and consumed per patient decreased from Phase I to Phase II (294.6 vs 187.8, P < 0.001; and 144.9 vs 96.0, P < 0.001, respectively). Finally, in describing individual medications, there was a significant decrease in cost of waste (per 1,000 patients, AWP minus 60%) between Phases I and II for- Hydrocodone with APAP 5/525 mg (P< 0.001), Oxycodone CR 10 mg (P< 0.001), Morphine CR 15 mg (P=0.001), and Tramadol 50 mg (P = 0.014). CONCLUSIONS: The results of this study suggest that there is a significant cost of waste associated with differences in prescribed versus consumed opioids following elective orthopedic surgery. This cost of waste was significantly reduced following the introduction and implementation of formal prescription guidelines. DISCLOSURES: This study was funded internally by Revo Health and Twin Cities Orthopedics. Giveans reports consulting fees from Medtrak, Inc., and Superior Medical Experts. The other authors have nothing to disclose.

Supplying the New York Market with High-Quality Puerto Rican Mangos

Improved varieties of mangos have been introduced to Puerto Rico for evaluation in several micro-climates and for market testing. During 1970, 20 consecutive weekly shipments of these mangos consisting of 1,926 flats were made to New York to acquire experience with export procedures, and to determine the extent of sales and fluctuation of prices as affected by season and size preferences. The fruit was shipped by ocean or air freight in ventilated cardboard flats containing approximately 12 pounds of mangos each. Marketing costs to New York City were estimated at $1.48 per flat. Wholesale prices varied from a high of $6.08 per flat in May to $2.67 during the flush of the season when heavy shipments of Florida mangos arrive on the market. Price differences between flats of large and medium fruit were minimal, but a sharp break in price occurred with small mangos. The average wholesale price received for the 20 shipments was $4.14 per flat. The results suggest that it would be advantageous to ship fruit to the New York market when prevailing wholesale prices are above $3.48 per flat. No deterioration of quality or spoilage were reported during the trial. Based on criteria of size, bearing season and productivity, Springfels may be rated first choice as a commercial variety, followed by Irwin, Haden, and Kent.

COVID-19 Challenging Period and Agriculture Sector in Sri Lanka: Way to Lead

Realizing the gravity of COVID-19 pandemic, the governments around the world have been putting in place a range of policies and strategies to resume their food security level. Among varies of agricultural productions, most affected sectors are livestock farming, horticulture production. In this line, understanding the impact of COVID-19 on horticulture system is likely to become more widely and deeply felt in agricultural sectors and national economies. This study aims to highlight potential risks faced by; outlines the overall functioning of Sri Lankan horticulture sector during the COVID-19 pandemic and discuss policies need to change going forward to safeguard Sri Lankan horticulture sector from similar shocks in the future. The production and market data gathered from Agricultural Statistics, Hector Kobbekaduwa Agrarian Research and Training Institute (HARTI), Department of Census and Statistics and Export Development Board which were gathered over years between 2016 and 2020. The data contain production quantity, average cultivated extent, retail and wholesale price per Kg, export quantity and value of fruit and vegetable products. Descriptive analysis methods used as the primary analysis techniques. The results imply that there is no declining pattern of all vegetables and fruits production volume. From the retail prices and wholesale prices, we can materialize that the supply chains in the agricultural products have strained to keep up, first with panic buying, followed by forced changes in food consumption patterns and immediate declined with the dropdown in purchasing power. The agricultural export sector is seemed to experience smaller trade impacts, most agricultural exports have continued to reach consumers in international markets. The pandemic is driving some changes that will likely remain part of the future agricultural practices. These include encouraging home garden practices, shifts in online marketing and selling platform, having higher demand for stable and safe food, a greater awareness of supply chain risks, increasing use of digital trade systems and the risk of creeping protectionism. Accordingly, agriculture policies need to change to safeguard of Sri Lankan horticulture sector from similar shocks in the future.

Lenvatinib plus pembrolizumab in advanced recurrent endometrial cancer: A cost-effectiveness analysis

ObjectiveTo determine the cost-effectiveness of lenvatinib plus pembrolizumab (LP) in patients with microsatellite stable (MSS), recurrent, pretreated endometrial cancer (EC). MethodsA decision analysis model was created to evaluate the cost-effectiveness of LP relative to doxorubicin, pegylated liposomal doxorubicin (PLD), and bevacizumab in patients with recurrent pretreated MSS EC. Published data was used to estimate quality adjusted life years (QALYs) and drug cost estimates were obtained using average wholesale prices. A health state utility (HSU) penalty of −0.10 was applied to the LP group to account for treatment toxicity. Incremental cost-effectiveness ratios (ICERs) were calculated to determine cost/QALY. The willingness to pay threshold (WTP) was set at $100,000 per QALY saved. Sensitivity analyses were performed on cost, effectiveness, and HSU penalty for LP. ResultsCosts of treatment with doxorubicin, PLD, and bevacizumab are $23.7 million (M), $56.9 M, and $250.8 M respectively. Cost of treatment with LP is $1.8 billion. Relative to doxorubicin, the ICERs for PLD, bevacizumab, and LP are $56,808, $345,824, and $1.6 M respectively. A sensitivity analysis varying the cost of LP shows that if the combined drug cost decreases from over $58,000 to less than $11,000 per cycle, this strategy would be cost-effective. Eliminating the HSU penalty for LP decreased the ICER $1.0 M while increasing the penalty to −0.20 increased the ICER to $3.7 M. ConclusionsLP is not cost-effective in patients with recurrent pretreated, MSS EC. A dramatic reduction in cost of LP is required for this novel strategy to be cost-effective.

Conservation and trade of the endangered Hypancistrus zebra (Siluriformes, Loricariidae), one of the most trafficked Brazilian fish

Hypancistrus zebra, also known as the zebra pleco, is a small sucker-mouth catfish endemic to the Xingu River in Brazil where its survival in the wild is threatened by habitat modification and overfishing for the ornamental fish industry. It is a highly sought-after freshwater ornamental species and one of the most commonly trafficked from Brazil. To date, little is known about its global legal and illicit supply chains within the ornamental fish trade. Through a mixed methods approach (i.e., online survey, key informant interviews and web scraping), we examined the trade and trafficking of this species as well as the awareness of the international aquarist community and local and international stakeholders regarding its conservation. We also establish the historical timeline of zebra pleco keeping and breeding in captivity and assess whether commercial captive breeding can play an important role in the conservation of this species. The retail price of the zebra pleco increased worldwide after an export ban in 2004 but have since decreased to an average of $US 155 (+/- $US 23 based on geographical location) per fish. Fishermen have been consistently paid relatively little ($US 7–60) for each specimen compared to the average wholesale price of $US 100 (+/- $US 94 over time). We conservatively estimate ~100,000 specimens are trafficked out of Brazil annually, of which half or more die in transport, and only a small fraction is seized by law enforcement in Brazil or internationally. The fishes are primarily smuggled from Brazil to Peru and Colombia and then exported internationally with the majority sent to China. The majority of aquarists surveyed (representing 35 countries) were aware the zebra pleco is both endangered and highly endemic. There was less awareness that buying wild caught specimens shipped from Peru, Colombia or elsewhere implies supporting wildlife trafficking. Nevertheless, nearly three quarters of respondents preferred aquarium bred specimens, if available. The zebra pleco is being bred in captivity in high numbers in several countries, yet in Brazil it remains illegal to keep in private aquaria or to commercially breed them. Given the large success of hobby and commercial breeders around the world, H. zebra is well suited for indoor breeding facilities. We argue that implementing regulated local breeding facilities in Brazil to increase the already large numbers reproduced in captivity worldwide, could decrease the demand for trafficked specimens, one of the primary factors threatening its survival. Given its iconic status among freshwater fishes it should be recognized as a flagship species of the Xingu River’s conservation.

The Canadian pork industry and COVID‐19: A year of resilience

While COVID‐19 had the potential to be extremely disruptive to the Canadian pork supply chain, the sector showed resiliency by adjusting to market changes to ensure industry continuation. Unlike other non‐agricultural firms that were mandated to close at times, the pork sector was deemed an essential service and allowed to continue operating throughout the pandemic. Evidence of this resiliency is seen in three main ways. First, market access to the United States was maintained for both live pigs and pork exports. Second, Canada not only maintained market share in global pork exports, but it also actually increased shipments because of strong demand from China caused by African swine fever. Third, the challenges of processing plant closures and labour shortages were overcome in a variety of ways including increasing interprovincial shipments and increasing live pig exports to the United States. Pork consumption on a per capita basis continued the historical downward trend, and it is expected that consumers will return to their normal consumption patterns (e.g., dining at restaurants) despite job losses. At the meat processing level, it is anticipated that there will be an acceleration in the process to automate.

Abstract PS7-49: Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer

Abstract Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancerBackground:Palbociclib has demonstrated improved outcomes in patients with advanced hormone receptor positive (HR+)/human epidermal growth factor 2 (HER2) negative breast cancer when used in combination with endocrine therapy 1,2. The current average wholesale price of therapy with this medication class exceeds $190,000 per year (at full dose). Financial toxicity is a major concern in the oncology population and can decrease patient quality of life and may result in non-adherence 3,4. Our objective was to describe the out-of-pocket cost burden for patients treated with palbociclib. Methods:A retrospective review of patients newly initiated on palbociclib therapy between May 5, 2018 and May 30, 2019 was completed at our institution. Patients were included if they were 18 years of age and older, newly starting palbociclib for advanced or metastatic HR+/HER2- breast cancer, had US-based insurance, and received palbociclib from our internal specialty pharmacy. Cost information was collected utilizing dispensing reports and additional patient-specific information was obtained from the EHR. Descriptive statistics were performed on the collected data. Results:A total of 44 patients were included in the cost analysis. Primary sources of coverage for these patients included commercial insurance (n=13), Medicare (n=25), and state/federal insurance (n=6). We first assessed costs with primary insurance coverage alone. The sum of all the initial cycle out-of-pocket copays after primary insurance totaled $49,108. The median individual copay was $291, the range was $0 to $2,943, and 9 of the 44 patients had no copay after the primary insurance was applied. The impact of assistance programs, which include independent grant funding, copay cards, vouchers, and secondary Medicaid plans, was significant. After applying primary insurance and aid from assistance programs, the sum of all initial cycle out-of-pocket copays reduced from $49,108 to $3,172. After assistance, 33 of the 44 patients had an initial copay cost of $0. Over 90% of the out-of-pocket total was from two patients (one each with a copay of $2,467 and $497). Ultimately, Mayo Clinic Specialty Pharmacy helped patients avoid $45,851 in first cycle out-of-pocket copays, of which $41,079 and $4,772 were for Medicare and commercially-insured patients, respectively. Copay cost by type of insurance was assessed. All patients with commercial insurance (n=13) had no actual copay for the first cycle. Medicare patients (n=25) are not eligible for copay cards and had larger pre-assistance copays compared to commercial patients (median $2,454 vs. $45). Vouchers or grants were utilized by 16 out of 25 Medicare covered patients. State/Federal insurance included 2 Tricare and 4 Medicaid patients. While ineligible for copay card assistance, the copays for these patients were low, ranging from $0-$28. Standard Medicare D plans do not have an out of pocket maximum for the year. The catastrophic phase requires an ongoing copay of 5% of the total claim cost, resulting in approximately a $600 per month copay for the remainder of the calendar year during the study period. When combined with the first cycle cost of approximately $2500, the yearly out-of-pocket cost for a patient with a standard Medicare D plan is roughly $10,000. Conclusion:Patients initiating therapy with palbociclib are commonly faced with high out-of-pocket costs. The availability, eligibility, and use of financial assistance programs are imperative in decreasing the financial toxicity. Specialty pharmacies play an important role in obtaining financial assistance which leads to decreased out-of-pocket expenses for patients. Citation Format: Allison P Golbach, Matthew D Smith, Jodi L Taraba, Karthik V Giridhar. Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-49.

Status of Price Variations of Fish, Livestock and Poultry Products: A Case Study in Gazipur District of Bangladesh

This study examined the pattern of price variations of major fish, livestock and poultry products in Gazipur district of Bangladesh. The secondary data on the average wholesale and retail prices of ten important commodities for a period of six years (June 2014 to June 2019) were collected from the Department of Agricultural Marketing (DAM) under the Ministry of Agriculture of the Government. The averages were calculated from a total of 1900 wholesalers and 2450 retailers in Gazipur district. Polynomial trend model was used to understand the nature of changes in the prices of the selected commodities and to make short-term forecasting. The model revealed a different pattern of price change for different commodities in both wholesale and retail markets. In case of mutton, egg (chicken), egg (duck), beef, and silver carp fish, it was highly upward sloping which indicates that price of these commodities will increase at an increasing rate in the upcoming years. A moderately increasing rate of price change was observed for katla fish in both the markets while for broiler, indigenous chicken and rohu fish, it was found a downward sloping. On the contrary, the projection indicates that the price of tilapia fish would remain stable in the near future. Such a scenario suggest that market monitoring system should be strengthened by the government to control the extreme increase or decrease in prices so that none of the stakeholders would be the gainer nor looser from the pricing policy in Bangladesh.&#x0D; Ann. Bangladesh Agric. (2020) 24(1) : 99-112

ACCESSING THE EFFECT OF RENEWABLES ON THE WHOLESALE POWER MARKET

The purpose of this paper is to examine how rising wind energy generation (in MWh) impact the wholesale power market's volatility (in SEK) across four bidding regions in Sweden. Prior investigations show that though the increase in electricity production from wind energy lowers the average day-ahead electricity wholesale prices, however, uncertainty and volatility of market price could rise due to wind energy's intermittent nature. This study results show that Swedish power market experiences higher price volatility in long-run frequency when the generation of wind electricity increases. The reason for this high and volatile electricity price might be found from inflexible baseload power generation. The paper further suggests that volatility in the Swedish power market could be increased due to ambitious renewable electricity target by the Swedish government. The analysis concludes by providing the evidence that further adjustment in regard to the energy and regulatory policies might foster the better integration of a higher share of renewables into the power system.Keywords: Renewable Electricity, Wind Energy, Electricity Market, Price Volatility, Regulatory PoliciesJEL Classification: Q470DOI: https://doi.org/10.32479/ijeep.10756

Trends in Within-Class Changes in US Average Wholesale Prices for Brand-Name Medications for Common Conditions From 2015 to 2020

Trends in Within-Class Changes in US Average Wholesale Prices for Brand-Name Medications for Common Conditions From 2015 to 2020

Analysis of Seasonal Price Fluctuations of Paddy (Boro) in Bangladesh

This paper has focused on seasonal variations of price and trend of the price escalation of paddy in Bangladesh using monthly average wholesale price of Boro paddy over a period from 2001 to 2019. Secondary data were used in this study and collected from different secondary sources. The multiplicative model was exercised in this study; the least square method was applied to find out the long-term changes occurring in the price of paddy and the ratio to moving average method was used to measure seasonal fluctuations in price of paddy. It was evidently observed from the study that seasonal fluctuations in price of paddy prevail in Bangladesh as seasonal indices were deviated from hundred in different months. April to August, the price of paddy was lower compare to other months’ price because April and Mayare the harvesting period of Boro paddy and resulted in more supply to the market. From August, it was increasing gradually and reached to the highest position on March with 112.15. Long-term trend analysis showed that prices of paddy will increase Tk. 72.80 per quintal higher annually compare to the country’s average price.&#x0D; SAARC J. Agri., 18(2): 219-226 (2020)

992. Rethinking the 28-day HIV nPEP Dispensing Practice: A Pediatric ID Clinic Analysis

BackgroundIn July 2017, The University of Chicago Comer Children’s Hospital Emergency Department (ED) transitioned from a 5-day to a 28-day HIV nPEP (non-occupational post-exposure prophylaxis) dispensation model in an effort to increase adherence. Anecdotal reports of patients lost to follow-up after ED discharge called into question the utility and cost-effectiveness of this practice. We analyzed HIV nPEP follow-up rates in our clinic, explored reasons for nonadherence, and performed basic cost-savings analyses to inform potential changes to our dispensation model.MethodsA retrospective review of both electronic health and pharmacy records was conducted for patients prescribed 28-days of HIV nPEP in the ED and scheduled for outpatient follow-up in Pediatric ID clinic from July 2017-June 2019. Clinic provider documentation of nPEP adherence and reasons for nonadherence were examined. Patients were given an initial dose of nPEP regimen in the ED and provided all subsequent doses to complete at home. Using average wholesale price (AWP), we calculated the total cost of each regimen and potential savings if a shorter duration of HIV nPEP supply was dispensed.Results50 patients received a 28-day supply of HIV nPEP. Please refer to Table 1 regarding baseline patient characteristics. Of these, only 19 (38%) patients had documented outpatient follow-up after nPEP initiation. Median time to follow-up was 6 days (IQR: 3.0-9.0 days). Of the 19 patients with follow-up, 3 admitted to medication non-adherence. Although side effects were elicited in a total of 9 patients (18%), only 1 cited medication intolerance as the reason for discontinuing their nPEP. Given the relatively short time to follow-up, a potential savings of $1720-2211/patient could be achieved if a 10-14 day supply was dispensed. ConclusionOutpatient follow-up after 28-day HIV nPEP dispensation in our ED was < 40%, calling into question the cost-effectiveness of this dispensation model. While our current practice alleviates nPEP interruption due to potential insurance issues and pick-up delays, follow-up and adherence are not assured. The significant cost-savings with a shorter supply at the outset may encourage more robust follow-up and adherence.Disclosures All Authors: No reported disclosures

Review of cyclin-dependent kinase 4/6 inhibitors in the treatment of advanced or metastatic breast cancer

Objective The purpose of this study is to review CDK 4/6 inhibitors used to treat metastatic breast cancer for patient safety, cost and utilization. By evaluating patient outcomes and payer influence, this study will provide critical information to aid prescribers in therapeutic decisions. Methods This retrospective cohort study included patients from a national specialty pharmacy with a diagnosis of breast cancer and received either palbociclib, abemaciclib, or ribociclib for treatment. Patients were stratified into four subgroups based on their total oncolytic regimen at the time of their first eligible study medication dispense. Pharmacy claims data were reviewed to determine cost and therapy adherence. Results The mean proportion of days covered was highest in patients on combination therapy with a hormone agent, 81.0%. While secondary insurances largely affected final patient out-of-pocket costs, final copays were significantly lower than the average wholesale price (AWP) of each CDK 4/6 inhibitor. When analyzing patient reported side effects, over 60% of the study population did not experience an adverse drug event (ADE) during the study time period. Ribociclib had the fewest number of reported side effects with abemaciclib patients reporting the most. Although reported ADE profiles were similar across all three study medications, difference in frequency should be evaluated when considering medication choice with specific comorbidities. Conclusion CDK 4/6 inhibitors have demonstrated safety and tolerability in HR-positive/HER2-negative breast cancer patients. Real world safety data and out-of-pocket patient costs in addition patient specific comorbidities should be considered when developing a treatment plan that includes a CDK 4/6 inhibitor selection.

Impact of Treatment Sequencing on Outcomes and Costs in Relapsed Follicular or Other Low Grade B-Cell Non-Hodgkin Lymphoma - Results of an Evidence-Based Budget Impact Model

Introduction: The choice of initial therapy in follicular lymphoma can be a key determinant in future therapy, as irreversible toxicities with first line regimens can impact the patient's ability to tolerate future treatment. Minimizing drug exposure will result in less frequent occurrence of significant adverse events and associated treatment costs. In the era of COVID-19 pandemic, there is additional benefit to minimizing the number of patient visits and hospital admissions. Limited information exists related to the outcomes and associated costs of existing treatment sequences. Additionally, treatment administration at different types of clinical sites results in varied reimbursement models, making informed evaluation of clinical and financial evidence challenging. Methods: The current study applies a budget impact model methodology in order to describe the associated impact of treatment selection and sequencing on outcomes and costs in the treatment of relapsed or refractory low-grade follicular lymphoma in first line therapy followed by Consolidation and also in first line therapy to second line therapy. Key model inputs included: Number of treatment cycles, number of days a treatment was received, duration of response (DOR), rate of side effects and associated costs, and total treatment costs, including drugs, medical treatment, laboratory testing and adverse event costs. Treatment outcomes were based on the published literature that summarized the overall response rate, median DOR, and toxicity. Treatment regimen costs were evaluated based on payer pricing, Wholesale Acquisition Cost (WAC), Average Selling Price (ASP) and Average Wholesale Price (AWP) and modified to adjust for weight-based dosing and negotiate payer reimbursement rates. Associated medical costs for medical treatment and supportive care were estimated using current Medicare fee schedule rates. Included were seven options for first line therapy of follicular lymphoma from 2020 NCCN Guidelines - (Bendamustine + rituximab (BR); Bendamustine + Obinutuzumab (OB); CHOP rituximab (RCHOP); CHOP + Obinutuzumab (OCHOP); CVP+ rituximab (RCVP); CVP + Obinutuzumab (OCVP); Lenalidomide + rituximab (R2)), followed by three for Consolidation (Rituximab maintenance (RM); Obinutuzumab maintenance (O); Radioimmunotherapy (RIT with 90 Y-ibritumomab tiuxetan (Y90-IT, Zevalin)) and three Second Line therapy options (RIT; Lenalidomide only; Lenalidomide + Obinutuzumab (LO)). Results: The treatment sequence of first line BR followed by Consolidation with RIT Y90 (Zevalin) had the longest predicted DOR (2586 days). The associated treatment sequence costs were $212,485 for BR followed by Y90-IT, compared with $233, 388 for BR followed by rituximab maintenance, which had a predicted DOR of 2478 days. The predicted DOR for treatment sequences starting with OCHOP, OCVP and RCHOP and followed by RIT with Y90-IT was approximately 1000 days less than BR followed by Y90-IT for a cost difference of $4,421, $12,914 and $25,826, respectively. The treatment sequence of first line BR followed by Second Line RIT Y90-IT had the second longest predicted DOR of 2586 days at costs of $212,485, compared to 2778 days for BR followed by LO, at a total sequence costs of $796,695. Conclusion: The use of Y90-IT in Consolidation or Second Line treatment demonstrated desired patient outcomes at one of the lowest cost profiles. Additionally, Y90-IT administration can be completed in only two clinic visits, reducing patient travel and contact, improving safety in an era of COVID-19 precautionary measures and reducing cost. Figure 1. Duration of Response and Total Sequence Costs for Twelve First Line to Consolidation and First Line to Second Line Treatment Regimens. Disclosures McBride: Merck: Speakers Bureau; Coherus BioSciences: Consultancy, Speakers Bureau; Pfizer: Consultancy; Bristol-Myers Squibb: Consultancy; MorphoSys: Consultancy; Sandoz: Consultancy.