Lower Total Health Care Costs Research Articles

Physiotherapy-led care versus physician-led care for persons with low back pain: A systematic review

Objective To summarise the evidence on the effect of physiotherapy-led versus physician-led care on clinical outcomes, healthcare use, and costs in persons with low back pain. Data sources PubMed, Web of Science, CINAHL, Embase, and PEDro were systematically searched with the latest search performed in July 2024. Reference lists of articles were hand-searched. Review methods Studies comparing clinical outcomes, healthcare use, or costs between adults with low back pain first consulting a physiotherapist and those first consulting a physician were included. Methodological quality was assessed with the Newcastle-Ottawa Scale. Study design, clinical setting, patient characteristics, and group effects were extracted. Findings on outcomes assessed in two or more studies were synthesised narratively. Certainty of evidence was determined using the GRADE approach. Results Eighteen studies comprising 1,481,980 persons with low back pain were included. Most studies were non-randomised retrospective or prospective cohort studies. In primary care (15 studies), consistent evidence, though of mostly very low certainty, indicated that physiotherapy-led care leads to higher patient satisfaction, less use of medication, injections and imaging, fewer physician's visits, lower total healthcare costs, and less sick leave compared to physician-led care, without increased harm. In emergency care (three studies), evidence of very low certainty showed that physiotherapy-led care leads to shorter waiting and treatment times, and fewer hospital admissions. Conclusion Physiotherapy-led care is a clinically, time- and cost-effective care pathway for low back pain, although the certainty of evidence was overall very low. Further high-quality research with a greater focus on clinical outcomes is warranted.

The Association of Ancillary Diagnostic Tests With Outcome in Dementia

ObjectivesDementia is a clinical diagnosis without curative treatment. It is uncertain whether ancillary testing is beneficial for patients. This study investigates the association between use of diagnostic tests and time to poor outcome and health care costs. DesignNationwide register-based cohort study using health care reimbursement data in the Netherlands. Setting and ParticipantsAll Dutch hospitals, including 13,312 patients diagnosed with dementia in 2018. MethodsDiagnostic testing included computed tomography or magnetic resonance imaging (CT/MRI), neuropsychological examination (NPE), nuclear imaging (PET/SPECT), electroencephalography (EEG), and cerebrospinal fluid (CSF) testing. We compared time to poor outcome (institutionalization or death) and costs per month from 2018 to 2021 between those who underwent a specific diagnostic test in previous years to controls, propensity score matched for age, sex, type of hospital, and comorbidity. ResultsTime to poor outcome in those who underwent CT/MRI, EEG, or CSF testing was similar to those who did not, but was longer for those who underwent NPE. Time to poor outcome was shorter in patients who underwent PET/SPECT. Patients who underwent CSF testing or PET/SPECT had higher mean total health care costs as compared to controls (CSF €248, 95% CI 64-433; PET/SPECT: €315, 95% CI 179-451). NPE during the diagnostic trajectory was associated with lower total health care cost (–€127, 95% CI –62, –193). Conclusion and ImplicationsNPE was associated with longer time to poor outcome and lower health care costs, potentially due to confounding by indication. Patients who underwent neuroimaging (CT, MRI, SPECT/PET), CSF testing, or EEG for dementia diagnostics did not experience a longer time to poor outcome or lower health care costs. This emphasizes the importance of clinical examination as anchor for the diagnosis of dementia.

Real-World Healthcare Cost Savings and Reduced Relapse Rate with Off-Label Rituximab versus Disease-Modifying Treatments Approved for Relapsing-Remitting Multiple Sclerosis: A Nationwide Cost-Effectiveness Study.

Although off-label use of rituximab is a common alternative to disease-modifying therapies (DMTs) approved for multiple sclerosis (MS) in several countries, the impact of this on treatment cost-effectiveness is not well known. We evaluated the relative cost-effectiveness of rituximab and MS-approved DMTs in a register-based cohort study of Swedish residents with relapsing-remitting MS, aged 18-65 years, starting treatment with rituximab, natalizumab, fingolimod, or dimethyl fumarate between January 2010 and July 2016, and followed through July 2021 (n = 5,924). By linking the population-based Swedish MS register to several Swedish health care and demographic registers, we estimated health care costs in relation to number of relapses, over 5 years from treatment start. Differences between treatments were estimated in inverse probability of treatment-weighted regression models, adjusting for a broad range of potential confounders covering demographics, medical history, and MS-related clinical characteristics. Off-label rituximab was associated with both lower total health care costs (mean cost savings ranged $35,000-$66,000 vs. each approved DMT), and fewer relapses (mean number of prevented relapses ranged 0.12-0.22), per started therapy over 5 years. Results were robust to variations in discounting and pricing of health care visits, with the main driver of cost-savings being the price of the index drug itself. The cost-effectiveness of rituximab dominated the MS-approved alternatives. Off-label, low-dose rituximab should be considered for persons with MS and could reduce barriers to treatment, especially in resource-limited settings. ANN NEUROL 2024;95:1099-1111.

Comparison of health care costs following sleeve gastrectomy versus Roux-en-Y gastric bypass among patients with type 2 diabetes.

The objective of this study was to compare the impact of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific health care costs among patients with type 2 diabetes. This retrospective cohort study examined patients with type 2 diabetes after SG and RYGB using data from Optum's deidentified Clinformatics® Data Mart database. The matched study group included 9608 patients who underwent SG or RYGB and were enrolled between 2007 and 2019. The primary outcomes assessed were overall and diabetes-specific health care costs. Health care costs associated with type 2 diabetes declined substantially in the first few years following both SG and RYGB. RYGB was associated with a larger decrease in pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs. SG was associated with lower total health care costs in the first three follow-up periods and lower acute care costs in the first 2 years after surgery. In this nationwide study, patients with type 2 diabetes at baseline undergoing RYGB appear to experience a reduced need for ambulatory type 2 diabetes monitoring and reduced requirements for antidiabetes medication but, despite this, did not experience an overall medical cost-benefit in the first few years after RYGB versus SG.

The Impact of Supplemental Nutrition Assistance Program (SNAP) Enrollment on Health and Cost Outcomes

Summary In the United States, food insecurity is prevalent in low-income households and is associated with elevated risk of chronic disease, poor health outcomes, and excess avoidable health care utilization and costs. Individuals dually eligible for Medicare and Medicaid are a unique low-income group with significant social challenges, complex health conditions, and higher-than-average health care costs. Interventions to address social determinants of health (SDOH) — such as food insecurity — have the potential to reduce avoidable health care utilization and cost, and the health insurers are increasingly integrating them into care delivery. Using Supplemental Nutrition Assistance Program (SNAP) data from the Pennsylvania Department of Human Services and health care claims data from an integrated health care delivery and finance system, this study reports findings of an innovative collaboration between a health care payer and a nonprofit organization to enroll dual-eligible individuals in SNAP. Data were collected prospectively from 661 SNAP-enrolled individuals and 1,320 individuals in a matched comparison group to explore the effect of SNAP enrollment on health care utilization (inpatient hospitalization, ED visits, and unplanned care) and health care costs (medical, pharmacy, and total cost of care) during the first and second years after SNAP enrollment. Data analysis was designed to answer questions that are important to payer and health care stakeholders, namely, when (i.e., how long after the start of SNAP benefits), how (i.e., what health outcome), and for whom (i.e., what population subgroups) is SNAP enrollment associated with health and cost outcomes. Compared with a propensity score–matched group not enrolled in SNAP, the SNAP enrollees had 16% and 21% lower total health care costs and pharmacy costs, respectively, within the first year postenrollment in SNAP. These group differences remained significant during the second year postenrollment, when SNAP enrollees had 16% and 20% lower total health care costs and pharmacy costs, respectively. Specifically, lower costs were seen among individuals who do not qualify for skilled nursing care. This study contributes to the growing evidence that novel payer-led interventions to address SDOH can influence positive changes in health care utilization and cost reduction, especially among disadvantaged populations.

Investigating Associations Between Access to Rheumatology Care, Treatment, Continuous Care, and Healthcare Utilization and Costs Among Older Individuals With Rheumatoid Arthritis.

To examine the association between rheumatologist access, early treatment, and ongoing care of older-onset rheumatoid arthritis (RA) and healthcare utilization and costs following diagnosis. We analyzed data from a population-based inception cohort of individuals aged > 65 years with RA in Ontario, Canada, diagnosed between 2002 and 2014 with follow-up to 2019. We assessed 4 performance measures in the first 4 years following diagnosis, including access to rheumatology care, yearly follow-up, timely treatment, and ongoing treatment with a disease-modifying antirheumatic drug. We examined annual healthcare utilization, mean direct healthcare costs, and whether the performance measures were associated with costs in year 5. A total of 13,293 individuals met inclusion criteria. The mean age was 73.7 (SD 5.7) years and 68% were female. Total mean direct healthcare cost per individual increased annually and was CAD $13,929 in year 5. All 4 performance measures were met for 35% of individuals. In multivariable analyses, costs for not meeting access to rheumatology care and timely treatment performance measures were 20% (95% CI 8-32) and 6% (95% CI 1-12) higher, respectively, than where those measures were met. The main driver of cost savings among individuals meeting all 4 performance measures were from lower complex continuing care, home care, and long-term care costs, as well as fewer hospitalizations and emergency visits. Access to rheumatologists for RA diagnosis, timely treatment, and ongoing care are associated with lower total healthcare costs at 5 years. Investments in improving access to care may be associated with long-term health system savings.

Complications and costs of patellofemoral arthroplasty versus total knee arthroplasty

BackgroundPatellofemoral arthroplasty (PFA) is an alternative to total knee arthroplasty (TKA) for the treatment of patellofemoral arthritis. Although PFA may preserve native kinematics and accelerate recovery, it has been associated with higher revision rates. The purpose of this study is to compare complication rates and costs between PFA and TKA. MethodsUsing the PearlDiver database, 6,179 patients with isolated patellofemoral arthritis treated with PFA or TKA from 2010-2015 were retrospectively reviewed with 5-year follow up. PFA and TKA patients were matched by age, sex, and Elixhauser Comorbidity Index via a 1:1 stepwise algorithm. Five-year costs and complications were compared between matched cohorts. The lifetime costs of PFA and TKA were evaluated with Markov decision modeling. ResultsCompared to TKA, PFA was associated with fewer Emergency Department (ED) visits (6.1% vs 3.9%, p = 0.004) but a higher 5-year revision rate (9.9% vs 4.2%, p < 0.001). After multivariate regression, PFA was independently more likely to require revision (odds ratio 2.60, 95% confidence interval 1.32–4.71, p = 0.003). PFA was associated with lower total healthcare costs at every time point between 3 months ($18,014 vs $26,473, p < 0.001) and 5 years ($20,837 vs $27,942, p < 0.001). On average, the lifetime cost of PFA per patient was $5,235 less than for TKA ($26,343 vs $31,578). ConclusionsPFA is a less expensive alternative to TKA with a similar risk of medical complications but is associated with a significantly higher 5-year revision rate. Future studies should examine the reasons for PFA failure and methods to mitigate this risk.

Association between oncology clinical pathway utilization and quality and cost outcomes in patients with metastatic solid tumors.

430 Background: Anticancer drug regimens that are approved by accepted drug compendia and also considered high value based on their efficacy, toxicity, and costs are designated as “on-pathway” for a national commercial payer. This study compared quality and cost of cancer care among patients with metastatic solid tumors treated in the first line setting who were prescribed on- vs. off-pathway regimens. Methods: Using administrative claims data and prior authorization data from a national commercial payer, we identified 8,357 commercially insured or Medicare Advantage adult patients with solid tumor cancers including breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, or uterine cancer, who were prescribed first-line anti-cancer regimens in the metastatic setting from 2018 to 2021. Patients were classified into on- vs. off pathway group based on the initial anticancer regimen that was prescribed. On-pathway status was prospectively defined by a panel of practicing oncologists based on review of curated evidence and general application of relative clinical value frameworks accepted in the field. We compared post–6-month quality-of-care outcomes including chemotherapy-related avoidable hospitalizations, emergency room (ER) visits, immune-related adverse events (IRAEs) such as endocrinopathies owing to immune checkpoint inhibitors, need for supportive drugs such as granulocyte colony stimulating factor, and cost outcomes between groups. Generalized linear models were used to assess the association between on-pathway regimens and outcomes adjusting for key patient demographics, clinical and provider characteristics. Results: A total of 5,453 (65.3%) patients were prescribed on-pathway regimens. Both groups had similar age (60.1 vs. 59.6, p = 0.06) and ECOG performance status (0.63 vs. 0.62, p = 0.40), with more females in the off-pathway group (54.6% vs. 57.3%, p = 0.02). There was no statistically significant difference in chemotherapy-related avoidable hospitalizations, IRAEs and need for supportive drugs between the two groups after modeling adjustment. However, patients treated on-pathway had higher rates of chemotherapy-related avoidable ER visits (18% vs. 15%, adjusted odds ratio: 1.16, 95% confidence interval (CI): 1.01 to 1.33, p = 0.03). Patients in the on-pathway group had significantly lower 6-month anticancer treatment cost (adjusted cost difference: -$10410, 95% CI: -$14935 to -$5886, p &lt; 0.01), resulting in an overall lower total healthcare costs (adjusted cost difference: -$12826, 95% CI: -$18879 to -$6773, p &lt; 0.01). Conclusions: Pathway regimens for metastatic solid tumors were associated with reduced total healthcare costs and similar quality of care compared with off-pathway regimens. These findings support the use of high value, evidence-based regimens for metastatic cancer patients.

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis.

In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.

Dasiglucagon demonstrates reduced costs in the treatment of severe hypoglycemia in a budget impact model.

BACKGROUND: Approximately 7.3 million people with type 1 or type 2 diabetes (T1D/T2D) are treated with insulin, placing them at higher risk of severe hypoglycemia (SH). SH requires assistance of another individual and often necessitates the prompt administration of intravenous glucose, injectable glucagon, or both. Untreated, SH can progress to unconsciousness, seizures, coma, or death. Before 2018, all glucagon rescue treatments required reconstitution. The complexity of reconstitution is often a barrier to successful administration during a severe hypoglycemic event. Studies suggest successful administration of glucagon emergency kits range from 6%-56% of the time. Second-generation glucagon treatments and glucagon analogs do not require reconstitution and have caregiver administration success rates ranging from 94%-100%. Dasiglucagon is a glucagon analog administered via autoinjector or prefilled syringe and has been shown to result in rapid hypoglycemia recovery. Moreover, the autoinjector can be administered successfully 94% of the time by trained caregivers. Previous evaluation of costs in budget impact models (BIMs) demonstrated the potential for second-generation glucagon treatments to reduce the cost of SH events (SHEs). The current model expands on those findings with a treatment pathway and accompanying assumptions reflecting important aspects of real-world SHE treatment. OBJECTIVE: To evaluate the economic impact of dasiglucagon compared with available glucagon treatments for SHE management, considering direct cost of treatment and health care resource utilization. METHODS: A 1-year BIM with a hypothetical US commercial health plan of 1 million lives was developed with a target population of individuals with diabetes at risk of SHE. The treatment pathway model included initial and secondary treatment attempts, treatment administration success and failure, plasma glucose (PG) recovery within 15 minutes, emergency medical services, emergency department (ED) visits, and hospitalizations. A 1-way sensitivity analysis was conducted to assess the sensitivity of the model to changes in parameter values. RESULTS: In a 1 million-covered lives population, it was estimated that 12,006 SHEs would occur annually. The higher rate of initial treatment success and PG recovery within 15 minutes associated with dasiglucagon treatment resulted in lower total health care costs. Total SHE treatment costs with dasiglucagon were estimated at $13.4 million, compared with $16.7 million for injectable native glucagon, $20.7 million for nasal glucagon, $35.3 million for reconstituted glucagon, and $43.8 million for untreated individuals. Compared with untreated people, the number needed to treat (NNT) with dasiglucagon was 6 individuals to avoid 1 hospitalization. NNT for this same comparison was 59 for injectable native glucagon and 27 for nasal glucagon. CONCLUSIONS: Treatment of SH with dasiglucagon decreased total direct medical costs by reducing health care resource utilization (emergency calls, emergency transports, ED visits, and hospitalizations) and accompanying costs associated with the treatment of SH. DISCLOSURES: This research was funded by Zealand Pharma. Bromley, Hinahara, and Goss are employed by Boston Healthcare Associates, Inc., which received funding from Zealand Pharma for development of the health economic model and the manuscript. Kendall and Hammer are employed by Zealand Pharma. Weinzimer has received consulting fees from Zealand Pharma.

Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018

Use of hospice has been demonstrated to be cost saving to the Medicare program and yet the extent to which hospice saves money across all payers, including whether it shifts costs to families, is unknown. To estimate the association between hospice use and total health care costs including family out-of-pocket health care spending. This retrospective cohort study of health care spending in the last 6 months of life used data from the nationally representative Medicare Current Beneficiary Survey (MCBS) between the years 2002 and 2018. Participants were MCBS participants who resided in the community and died between 2002 and 2018. Covariate balancing propensity scores were used to compare participants who used hospice (n = 2113) and those who did not (n = 3351), stratified by duration of hospice use. Total health care expenditures were measured across payers (family out-of-pocket, Medicare, Medicare Advantage, Medicaid, private insurance, private health maintenance organizations, Veteran's Administration, and other) and by expenditure type (inpatient care, outpatient care, medical visits, skilled nursing, home health, hospice, durable medical equipment, and prescription drugs). The study population included 5464 decedents (mean age 78.7 years; 48% female) and 38% enrolled with hospice. Total health care expenditures were lower for those who used hospice compared with propensity score weighted non-hospice control participants for the last 3 days of life ($2813 lower; 95% CI, $2396-$3230); last week of life ($6806 lower; 95% CI, $6261-$7350); last 2 weeks of life ($8785 lower; 95% CI, $7971-$9600); last month of life ($11 747 lower; 95% CI, $10 072-$13 422); and last 3 months of life ($10 908 lower; 95% CI, $7283-$14 533). Family out-of-pocket expenditures were lower for hospice enrollees in the last 3 days of life ($71; 95% CI, $43-$100); last week of life ($216; 95% CI, $175-$256); last 2 weeks of life ($265; 95% CI, $149-$382); and last month of life ($670; 95% CI, $530-$811) compared with those who did not use hospice. Health care savings were associated with reductions in inpatient care. In this population-based cohort study of community-dwelling Medicare beneficiaries, hospice enrollment was associated with lower total health care costs for the last 3 days to 3 months of life. Importantly, we found no evidence of cost shifting from Medicare to families related to hospice enrollment. The magnitude of lower out-of-pocket spending to families who enrolled with hospice is meaningful to many Americans, particularly those with lower socioeconomic status.

Transit use and health care costs: A cross-sectional analysis

IntroductionGreater transit use is associated with higher levels of physical activity, which is associated with lower health risks and better health outcomes. However, there is scant evidence about whether health care costs differ based on level of transit ridership. MethodsA sample (n = 947) of members of Kaiser Permanente in the Portland, Oregon area were surveyed in 2015 about their typical use of various modes of travel including transit. Electronic medical record-derived health care costs were obtained among these members for the prior three years. Analysis examined proportional costs between High transit users (3+ days/week), Low transit users (1–2 days/week), and Non-users adjusting for age and sex, and then individually (base models) and together for demographic and health status variables. ResultsIn separate base models across individual covariates, High transit users had lower total health care costs (59–69% of Non-user's costs) and medication costs (31–37% of Non-users’ costs) than Non-users. Low transit users also had lower total health care (69%–76% of Non-users’ costs) and medication costs (43–57% transit of Non-user's costs) than Non-users. High transit users' outpatient costs were also lower (77–82% of Non-users). In fully-adjusted models, total health care and medication costs were lower among High transit users' (67% and 39%) and Low transit users' (75% and 48%) compared to Non-users, but outpatient costs did not differ by transit use. ConclusionsFindings have implications for the potential cost benefit of encouraging and supporting more transit use, although controlled longitudinal and experimental evidence is needed to confirm findings and understand mechanisms.

Early buprenorphine-naloxone initiation for opioid use disorder reduces opioid overdose, emergency room visits and healthcare cost compare to late initiation

ABSTRACT Background Although the effectiveness of buprenorphine-naloxone (BUP-NX) has been established, real-world evidence on the benefits of early treatment initiation is limited. Objective To evaluate the association between early BUP-NX initiation and health-related outcomes among insured adults with opioid use disorder (OUD). Methods We conducted a cross-sectional analysis using the Optum’s de-identified Clinformatics® Data Mart Database from 2010 to 2018. Patients who initiated BUP-NX within 30 days of OUD diagnosis were classified as early initiators. Patients who initiated BUP-NX later, but within the one-year follow-up, were defined as late initiators. Outcomes included opioid overdose, opioid overdose-related emergency department (ED) visits, and all-cause healthcare cost during the year after OUD diagnosis. We employed generalized linear models to compare outcomes between early and late initiators, adjusting for baseline covariates and accounting for missing information for covariates using multiple imputation. Results A total of 8,388 patients with OUD were identified; mean age was 39.9 years; 36% were female; and 67.6% were early initiators. Early initiators had an estimated 42% lower rate of opioid overdose (adjusted rate ratio (aRR) = 0.58; 95% confidence interval (CI): 0.52, 0.64); 51% lower rate of opioid overdose-related ED visits (aRR = 0.49; 95% CI: 0.44, 0.55); and 31% lower total healthcare cost (adjusted cost ratio = 0.69; 95% CI: 0.66, 0.72), compared to late initiators. Conclusion Compared to late BUP-NX initiation, early initiation was associated with a lower risk of opioid overdose and opioid overdose-related ED visits, and reduced total healthcare cost among insured adult patients with OUD.

Effects of early vs delayed progression on clinical and economic outcomes in patients with metastatic renal cell carcinoma treated with tyrosine kinase inhibitors as first-line therapy: results from the IMPACT RCC claims data analysis.

BACKGROUND: A key therapeutic goal of metastatic renal cell carcinoma (mRCC) treatment is delayed disease progression. The degree to which early therapeutic success affects downstream outcomes is not well established. OBJECTIVE: To assess the clinical and economic impact of early vs delayed disease progression in patients with mRCC treated with first-line (1L) tyrosine kinase inhibitors (TKIs) followed by second-line (2L) therapy in the US Veterans Health Administration (VHA) database. METHODS: Adult patients newly diagnosed with mRCC who were treated with a TKI as 1L therapy and who progressed to 2L therapy from October 1, 2013, through March 31, 2018, were identified from the US VHA database. Patients were stratified by median time from initiation of 1L therapy to initiation of 2L therapy into early (median time or sooner)and delayed (longer than the median) progression cohorts. Clinical outcomes (time to 2L therapy discontinuation, time to third-line [3L] treatment initiation, and overall survival) were assessed descriptively, and health care resource utilization and costs were compared between patients in the early and those in the delayed progression cohorts. Survival analyses (Kaplan-Meier curves) were used to estimate descriptively the median time to discontinuation, time to next line of treatment, and time to death for each cohort. Multivariate analysis was performed to adjust for the influence of differences in cohort characteristics, and Cox proportional hazards models were used to descriptively assess the impact of predictive factors on clinical outcomes. RESULTS: 289 patients were included in the analysis: 145 in the early progression cohort and 144 in the delayed progression cohort. Baseline characteristics were similar between the early and delayed progression cohorts. Median time from 1L therapy initiation to 2L therapy discontinuation was 7.9 months in the early progression cohort and 18.0 months in the delayed progression cohort, whereas time from 1L therapy initiation to 3L therapy initiation was 9.4 and 21.8 months, respectively; overall survival was 19.7 and 36.4 months, respectively. Descriptive analysis revealed generally lower risks for 2L therapy discontinuation (HR = 0.40, 95% CI = 0.31-0.52), 3L therapy initiation (HR = 0.42, 95% CI = 0.32-0.55), and death (HR = 0.46, 95% CI = 0.33-0.64) for those with delayed progression. After adjustment for possible confounding factors, comparative analysis during the follow-up period showed that delayed progression was associated with a shorter median all-cause hospital length of stay (0.4 days vs 0.8 days for early progression; P = 0.0004), fewer pharmacy visits (3.57 vs 4.08 visits; P = 0.0266), and lower total health care costs ($10,342 vs $13,388; P = 0.0347) per patient per month. CONCLUSIONS: In patients with mRCC, early progression after 1L therapy initiation is associated with generally worse clinical outcomes and statistically significantly greater health care resource utilization and costs than delayed progression. This finding highlights the importance of initiating therapy with an optimal 1L treatment regimen that has been proven to delay disease progression. DISCLOSURES This study was sponsored by EMD Serono Inc., an affiliate of Merck KGaA, and Pfizer Inc. EMD Serono Inc. and Pfizer Inc. were involved in the study design; the collection, analysis, and interpretation of the data; the writing of the report; and the decision to submit the report for publication. Liu and Bhanegaonkar are employed by EMD Serono Inc., an affiliate of Merck KGaA. Kasturi was employed by EMD Serono Inc., an affiliate of Merck KGaA, at the time of this study. Kim and Krulewicz are employed by Pfizer Inc. Dieyi is an employee of STATinMED Research, which received consulting fees from EMD Serono Inc. and Pfizer Inc. Hutson has received grants from Pfizer Inc., Astellas Pharma Inc., Janssen Pharmaceuticals, Exelixis, Inc., and Eisai Co., Ltd., outside of this work. Data from this analysis were presented at the Virtual International Society for Pharmacoeconomics and Outcomes Research 2020 conference, May 18-20, 2020; the virtual American Society of Clinical Oncology Annual Meeting, May 29-31, 2020; and AMCP Nexus 2020 Virtual, October 20-23, 2020.

Sustained long-term benefits of patient support program participation in immune-mediated diseases: improved medication-taking behavior and lower risk of a hospital visit.

BACKGROUND: Patient support programs (PSPs) improve medication-taking behavior in the first 12 months of treatment for patients with immune-mediated diseases, but it is unknown if these benefits ar...

Hospitalizations and healthcare costs associated with rifaximin versus lactulose treatment among commercially insured patients with hepatic encephalopathy in the United States

Aims To assess healthcare costs and hospitalization rates associated with rifaximin therapy versus lactulose alone among patients at risk for hepatic encephalopathy (HE). Methods and materials IBM Marketscan Commercial and Optum’s de-identified Clinformatics Data Mart databases were used separately to identify commercially insured HE patients treated with rifaximin or lactulose alone, using an algorithm developed with clinical experts. HE-related hospitalizations were defined based on an algorithm using diagnosis codes and diagnosis-related group codes. HE-related/all-cause hospital admissions/days and healthcare costs were compared between rifaximin and lactulose episodes using incidence rate ratios and adjusted cost differences. Results In Marketscan, there were 13,515 [Optum: 5,217] rifaximin episodes and 9,946 [4,897] lactulose alone episodes included. Yearly rates of HE-related hospital admissions decreased by 33% [34%] when treated with rifaximin versus lactulose alone, and rates of HE-related hospital days similarly decreased by 43% [57%]. Yearly rates of all-cause hospital admissions decreased by 27% [27%]; rates of all-cause hospital days decreased by 33% [37%] during rifaximin episodes versus lactulose alone. This translated to $2,417 [$2,301] and $173 [$397] lower total mean medical costs and HE-related hospital costs per-patient-per-month, respectively (p < .05). Despite increased pharmacy costs associated with rifaximin, there was no change in total healthcare costs. Patients adherent to rifaximin incurred $2,891 [$2,340] lower total healthcare costs than non-adherent patients. In a simulated plan of 1 million lives, if 50% of HE patients treated with lactulose alone had rifaximin added on and were adherent to rifaximin therapy, the total cost savings would be $7.5 [$6.1] million per year ($0.62 [$0.50] per-member-per-month). Conclusions Patients incurred significantly lower rates of HE-related and all-cause hospitalizations during rifaximin versus lactulose episodes, resulting in lower facility and professional costs. Cost savings may be possible if rifaximin adherence is improved in HE patients. Limitations The study is subject to limitations common to claims-based analyses.

Abstract 13412: Electronic Consultation for the Management of Atrial Fibrillation is Associated With Higher Healthcare Costs

Introduction: A study of 42,000 cardiology consults within the Veterans Health Administration (VHA) in 2016 found that patients who received electronic consultation (e-consults) had similar healthcare costs at 6 months compared to those who received face-to-face (F2F) consults. However, results may have been confounded if patients with less costly conditions received e-consults. Our aim was to compare costs between those receiving F2F vs. e-consults for a similar indication. Hypothesis: Electronic rather than F2F consultation for atrial fibrillation (AF) management will be associated with lower total healthcare costs. Methods: We conducted a retrospective cohort study of a national sample of VHA patients who received cardiology consultation in 2016. We used a natural language processing script to identify consults for AF management. Primary outcomes were total healthcare costs at 3 and 6 months. Secondary outcomes included inpatient and outpatient costs. We compared costs between groups using a generalized linear model with a gamma distribution and log link. We adjusted for community wage and Charlson comorbidity indices, distance to nearest facility, age, and gender. Standard errors were clustered at the facility level. Results: We sampled 176 F2F and 136 e-consults from 43 facilities. Mean total 6-month costs were $12,928 (95% confidence interval [CI]: 1,377; 40,644) and $8,286 (95% CI: 959; 31,320) among e-consult and F2F groups, respectively. The e-consult group had 12.3% higher 3-month (p&lt;0.001) and 41.5% higher 6-month total healthcare costs (p&lt;0.001) in comparison to the F2F group. At 3 months, the e-consult group had 25.1% lower inpatient costs (p&lt;0.001) and 32.5% higher outpatient costs (p&lt;0.001). At 6 months, the e-consult group had 6.3% higher inpatient costs (p&lt;0.001) and 48.4% higher outpatient costs (p&lt;0.001). Conclusions: Use of e-consults for AF management is associated with reduced inpatient costs at 3 months, but higher total costs, which were largely driven by outpatient costs. Improving our understanding of healthcare utilization after initial consultation, or in differences in reasons for consultation within AF management may help explain these differences.

Psoriatic arthritis treatment patterns and costs among pharmacologic treatment-naïve patients.

Pharmacologic treatment for psoriatic arthritis (PsA) includes traditional oral small molecules (OSMs), tumor necrosis factor inhibitors (TNFis), and newer oral therapies such as a phosphodiesterase-4 (PDE4) inhibitor and a Janus kinase inhibitor. We aimed to describe treatment patterns and health care costs for treatment-naïve patients with active PsA initiating pharmacologictreatment. This was an observational, retrospectivestudy. We assessed treatment patterns and health care costs from the IBM MarketScan Research databases. We calculated costs during the 12-month follow-up period for inpatient and outpatient medical health care, including outpatient prescription costs. A total of 3491 patients were identified for the study. Incident therapies included OSMs methotrexate (58.3%), sulfasalazine (9.8%), hydroxychloroquine (2.3%), and other OSMs (1.9%); TNFis adalimumab (12.3%), etanercept (8.6%), infliximab (1.9%), and other TNFis (1.4%); and the PDE4 inhibitor apremilast (2.6%). Persistence ranged from 15.2% to 34.6% with OSM monotherapy and from 42.9% to 58.2% with TNFi monotherapy. Percentage of patients with a gap of at least 60 days in therapy ranged from 42.9% to 48.5% with OSMs and from 17.9% to 29.9% with TNFis. Mean first-line unadjusted per-patient per-month total health care costs for OSMs ranged from $1029 to $1456 and mean total health care costs ranged from $19,173 to $25,013. Mean unadjusted per-patient per-month total health care costs for TNFis ranged from $4203 to $7063 and mean total health care costs ranged from $45,635 to $60,933. Although patients using OSMs had generally lower total health care costs, they also had the highest rates of treatment modifications such as low persistence and medication gaps of at least 60 days.

Real-world healthcare resource utilization and costs among relapsed/refractory (R/R) mantle cell lymphoma (MCL) patients receiving ibrutinib or chemoimmunotherapy (CIT).

e19408 Background: Ibrutinib is a targeted oral therapy indicated for MCL patients who received ≥1 prior line of therapy (LOT) (conditional approval on 11/13/2013 in the US). This study compared healthcare resource utilization (HRU) and costs of R/R MCL patients treated with ibrutinib ± rituximab (I±R) or CIT in a US-managed care population. Methods: Optum Clinformatics Extended DataMart De-Identified Databases (05/13/2013-6/30/2019) were used to identify adults with MCL receiving I±R or CIT (index date) following ≥1 prior LOT. Patients’ baseline characteristics were balanced using inverse probability of treatment weighting (IPTW). Monthly HRU and costs (plan paid amount) were evaluated during the first Oncology Care Model (OCM) episode (i.e., first 6 months) post-index and during the observed index I±R or CIT LOT (index LOT); and compared using rate ratios (RRs) and mean monthly cost differences (MMCDs), respectively. Results: A total of 146 I±R and 158 CIT patients were identified. Given the small sample size and to ensure outliers were not driving the results, 2 patients with total healthcare costs ≤0.5th and ≥99.5th percentile were excluded from each cohort. After IPTW, 149 and 151 patients were included in the weighted I±R and CIT cohorts, respectively (mean length of index LOT: 12.0 vs 11.0 months). During the first OCM episode and during the index LOT, the I±R cohort had significantly fewer monthly days with outpatient services compared to the CIT cohort (OCM: RR= 0.63, P&lt;0.001; index LOT: RR= 0.73, P=0.004). The I±R cohort incurred significantly higher monthly pharmacy costs that were offset by lower monthly medical costs, yielding a monthly total cost reduction of $9,435 (p&lt;0.001) during the first OCM episode and $4,628 (p=0.010) during the index LOT, compared to the CIT cohort (Table). Conclusions: In this study, patients with R/R MCL treated with ibrutinib ± rituximab had significantly fewer days with outpatient services and lower total healthcare costs per month versus those treated with CIT during the first OCM episode and the index LOT. [Table: see text]

Lower Hospitalization and Total Healthcare Costs Among Patients with Heart Failure When Treated with Sacubitril/Valsartan Versus Angiotensin-Converting Enzyme Inhibitor or Angiotensin-Receptor Blocker: A Retrospective Study of Managed Care Claims

Background In the PARADIGM-HF trial, sacubitril/valsartan (SAC/VAL) was superior to enalapril in reducing risks of cardiovascular death and heart failure (HF) hospitalization in patients with HF and reduced ejection fraction (HFrEF); however, there is limited knowledge of the impact of SAC/VAL on real-world clinical outcomes and costs compared to angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB). Objective To compare hospitalization and healthcar e costs among patients with HFrEF treated with SAC/VAL vs. ACEI/ARB. Methods De-identified claims data of adults in a large US managed care health plan (commercial and Medicare Advantage [MA]) were used from Oct 2014 to Sep 2016. Stable patients were identified with claims-based proxy for HFrEF and >=1 claim for SAC/VAL (identified first), ACEI or ARB during Oct 2015 to Jun 2016. Index therapy with >=80% proportion of days covered for first 3 months was required. SAC/VAL and ACEI/ARB cohorts were matched for demographics, baseline characteristics and length of follow-up using propensity scores. Per-patient-per-month (PPPM) hospitalization and healthcare costs (health plan + patient paid amounts) were calculated during a variable follow-up period (3-12 months). Robust variance estimation was used to compare hospitalization and healthcare costs between matched cohorts. Results Post-match, 279 patients/cohort were identified (mean [SD] age, 67.9 [12.6] years; 73.5% MA enrollee; 68.1% male; 90.9% hypertension; 56.1% diabetes; 46.1% atrial fibrillation; mean (SD) follow-up, 185.0 [70.1] days). Patients in the SAC/VAL cohort, compared with the ACEI/ARB cohort, experienced lower mean (SD) PPPM HF hospitalizations (0.01 [0.06] vs. 0.03 [0.10], p=.003) and all-cause hospitalizations (0.05 [0.11] vs. 0.11 [0.20], p Conclusions Compared to ACEI/ARB-treated patients, patients initiated with SAC/VAL within the first year of US market approval experienced fewer monthly hospitalizations, which may have been associated with lower medical costs. Reduced monthly medical costs among patients initiated with SAC/VAL offset increased outpatient pharmacy costs, resulting in lower total healthcare costs. This study was supported by Novartis Pharmaceuticals Corporation.