Outpatient Drug Costs Research Articles

Randomised clinical trial: First-line infliximab biosimilar is cost-effective compared to conventional treatment in paediatric Crohn's disease.

Data on cost-effectiveness of first-line infliximab in paediatric patients with Crohn's disease are limited. Since biologics are increasingly prescribed and accompanied by high costs, this knowledge gap needs to be addressed. To investigate the cost-effectiveness of first-line infliximab compared to conventional treatment in children with moderate-to-severe Crohn's disease. We included patients from the Top-down Infliximab Study in Kids with Crohn's disease randomised controlled trial. Children with newly diagnosed moderate-to-severe Crohn's disease were treated with azathioprine maintenance and either five induction infliximab (biosimilar) infusions or conventional induction treatment (exclusive enteral nutrition or corticosteroids). Direct healthcare consumption and costs were obtained per patient until week 104. This included data on outpatient hospital visits, hospital admissions, drug costs, endoscopies and surgeries. The primary health outcome was the odds ratio of being in clinical remission (weighted paediatric Crohn's disease activity index<12.5) during 104 weeks. We included 89 patients (44 in the first-line infliximab group and 45 in the conventional treatment group). Mean direct healthcare costs per patient were €36,784 for first-line infliximab treatment and €36,874 for conventional treatment over 2 years (p = 0.981). The odds ratio of first-line infliximab versus conventional treatment to be in clinical remission over 104 weeks was 1.56 (95%CI 1.03-2.35, p = 0.036). First-line infliximab treatment resulted in higher odds of being in clinical remission without being more expensive, making it the dominant strategy over conventional treatment in the first 2 years after diagnosis in children with moderate-to-severe Crohn's disease. NCT02517684.

The optimal co-insurance rate for outpatient drug expenses of Iranian health insured based on the data mining method

ObjectiveA more equal allocation of healthcare funds for patients who must pay high costs of care ensures the welfare of society. This study aimed to estimate the optimal co-insurance for outpatient drug costs for health insurance.SettingThe research population includes outpatient prescription claims made by the Health Insurance Organization that outpatient prescriptions in a timely manner in 2016, 2017, 2018, and 2019 were utilized to calculate the optimal co-insurance. The study population was representative of the research sample.DesignAt the secondary level of care, 11 features of outpatient claims were studied cross-sectionally and retrospectively using data mining. Optimal co-insurance was estimated using Westerhut and Folmer's utility model.ParticipantsOne hundred ninety-three thousand five hundred fifty-two individuals were created from 21 776 350 outpatient claims of health insurance. Because of cost-sharing, insured individuals in a low-income subsidy plan and those with refractory diseases were excluded.ResultsInsureds were divided into three classes of low, middle, and high risk based on IQR and were separated to three clusters using the silhouette coefficient. For the first, second, and third clusters of the low-risk class, the optimal co-insurance estimates are 0.81, 0.76, and 0.84, respectively. It was equal to one for all middle-class clusters and 0.38, 0.45, and 0.42, respectively, for the high-risk class. The insurer's expenses were altered by $3,130,463, $3,451,194, and $ 1,069,859 profit for the first, second, and third clusters, respectively, when the optimal co-insurance strategy is used for the low-risk class. For middle risks, it was US$29,239,815, US$13,863,810, and US$ 14,573,432 while for high risks, US$4,722,099, US$ 6,339,317, and US$19,627,062, respectively.ConclusionsThese findings can improve vulnerable populations' access to costly medications, reduce resource waste, and help insurers distribute funds more efficiently.

The impact of China's zero markup drug policy on drug costs for managing Parkinson's disease and its complications: an interrupted time series analysis.

In April 2009, the Chinese government launched Zero Markup Drug Policy (ZMDP) to adjust medical institutions' revenue and expenditure structures. This study evaluated the impact of implementing ZMDP (as an intervention) on the drug costs for managing Parkinson's disease (PD) and its complications from the healthcare providers' perspective. The drug costs for managing PD and its complications per outpatient visit or inpatient stay were estimated using electronic health data from a tertiary hospital in China from January 2016 to August 2018. An interrupted time series analysis was conducted to evaluate the immediate change following the intervention (step change, β1) and the change in slope, comparing post-intervention with the pre-intervention period (trend change, β2). Subgroup analyses were conducted in outpatients within the strata of age, patients with or without health insurance, and whether drugs were listed in the national Essential Medicine List (EML). Overall, 18,158 outpatient visits and 366 inpatient stays were included. Outpatient (β1 = -201.7, 95%CI: -285.4, -117.9) and inpatient (β1 = -372.1, 95% CI: -643.6, -100.6) drug costs for managing PD significantly decreased when implementing ZMDP. However, for outpatients without health insurance, the trend change in drug costs for managing PD (β2 = 16.8, 95% CI: 8.0, 25.6) or PD complications (β2 = 12.6, 95% CI: 5.5, 19.7) significantly increased. Trend changes in outpatient drug costs for managing PD differed when stratifying drugs listed in EML (β2 = -1.4, 95% CI: -2.6, -0.2) or not (β2 = 6.3, 95%CI: 2.0, 10.7). Trend changes of outpatient drug costs for managing PD complications significantly increased in drugs listed in EML (β2 = 14.7, 95% CI 9.2, 20.3), patients without health insurance (β2 = 12.6, 95% CI 5.5, 19.7), and age under 65 (β2 = 24.3, 95% CI 17.3, 31.4). Drug costs for managing PD and its complications significantly decreased when implementing ZMDP. However, the trend in drug costs increased significantly in several subgroups, which may offset the decrease at the implementation.

Healthcare Resource Utilization and Costs in Patients with EGFR-Mutated Advanced Non-Small Cell Lung Cancer Receiving First-Line Treatment in the United States: An Insurance Claims-Based Descriptive Analysis.

An estimated 10-15% of non-small cell lung cancer (NSCLC) cases present with epidermal growth factor receptor mutation (EGFRm). While EGFR tyrosine kinase inhibitors (EGFR-TKIs) such as osimertinib have become first-line (1L) standard of care for these patients, limited chemotherapy use still occurs in real-world practice. Studies of healthcare resource use (HRU) and cost of care provide a means by which the value of various treatment regimens, healthcare efficiency, and disease burden can be assessed. These studies are important for population health decision makers and health systems that prioritize value-based care to drive population health. The aim of this study was to descriptively assess HRU and costs among patients with EGFRm advanced NSCLC initiating 1L therapy in the United States. IBM MarketScan Research Databases (January 1, 2017 to April 30, 2020) were used to identify adult patients with advanced NSCLC, based on a diagnosis for lung cancer (LC) and initiation of 1L therapy or diagnosis of metastases within 30 days of the first LC diagnosis. All patients had ≥ 12 months of continuous insurance eligibility prior to the first LC diagnosis and initiated (in 2018 or after) an EGFR-TKI during any line of therapy to proxy EGFRm status. Per-patient-per-month all-cause HRU and costs were described during 1L for patients initiating 1L osimertinib or chemotherapy. A total of 213 patients with advanced EGFRm NSCLC were identified (mean age at 1L initiation: 60.9 years; 69.0% female). In 1L, 66.2% initiated osimertinib, 21.1% chemotherapy, and 12.7% another regimen. Mean 1L therapy duration was 8.8 months (osimertinib) and 7.6 months (chemotherapy), respectively. Among osimertinib recipients, 28% had an inpatient admission, 40% an emergency room (ER) visit, and 99% an outpatient visit. Among chemotherapy recipients, these proportions were 22%, 31%, and 100%. Mean monthly all-cause healthcare costs among osimertinib and chemotherapy patients were US$27,174 and US$23,343, respectively. Among osimertinib recipients, drug-related costs (including pharmacy and outpatient antineoplastic drug and administration costs) made up 61% (US$16,673) of total costs, inpatient costs 20% (US$5462), and other outpatient costs 16% (US$4432). In chemotherapy recipients, 59% (US$13,883) of total costs were drug-related, 5% (US$1166) were inpatient costs, and 33% (US$7734) other outpatient costs. Higher mean total cost of care was observed among patients receiving 1L TKI (osimertinib) than 1L chemotherapy in EGFRm advanced NSCLC. However, descriptive differences in type of spending and HRU were identified: higher inpatient costs and inpatient days for osimertinib versus higher outpatient costs for chemotherapy. Findings suggest that significant unmet needs may remain for 1L treatment of EGFRm NSCLC, and despite significant advances in targeted care, further individualized therapies are needed to balance benefits, risks, and total cost of care. Furthermore, observed descriptive differences in inpatient admissions may have implications for quality of care and patient quality of life, for which additional research is warranted.

Total Costs of Care during Chimeric Antigen Receptor T-Cell Therapy in Patients with Relapsed/Refractory B Cell Non-Hodgkin Lymphoma: A Large Private Insurance Claim-Based Analysis

Background Chimeric antigen receptor T (CAR-T) cell therapy has been shown to be efficacious in heavily pre-treated patients with relapsed/refractory (r/r) B cell non-Hodgkin lymphoma (BCL) and provides a potential for durable remissions. Despite the encouraging efficacy, the use of CAR-T therapy is associated with high upfront cost, with published estimates of approximately 450,000 USD (based primarily on Medicare data). However, little is known about reimbursed costs related to CAR-T especially among those with private insurance. Therefore, we examined the costs of care around the time of CAR-T therapy using the Blue Cross Blue Shield (BCBS) Axis database of deidentified administrative claims including commercially insured members across the United States. Methods We used deidentified insurance claims from the BCBS Axis database to select individuals with BCL who had claims for CAR-T therapy during 01/2018-06/2021 (Healthcare Common Procedure Coding System [HCPCS] Codes: 0537T, 0538T, 0539T, 0540T, Q2040, Q2041, Q2042, Q2053, Q2054, C9073, C9076). We required the individuals to have continuous enrollment 2 calendar months prior to through at least the calendar month of CAR-T infusion, with age ≥18 years, and to have had claims for diffuse large B cell lymphoma (DLBCL), follicular lymphoma (FL), or mantle cell lymphoma (MCL), but not B-cell acute lymphoblastic leukemia. We defined a "peri-CAR-T” period extending from 41 days prior to through 154 days after CAR-T index date, summarized in 28-day intervals (e.g., Month 0 included 13 days prior to through 14 days after CAR-T index, Figure 1). We estimated the costs of care from allowed amounts on claims (including inpatient, outpatient, professional and associated drug costs in 2018 USD [using CPI-U]) during the peri-CAR-T period and by month. To minimize inclusion of individuals that may have had apheresis or CAR-T therapy manufactured but not administered, our main analytic cohort required a total cost ≥ 250,000 USD reimbursed, a cost substantially lower than the wholesale acquisition costs of CART cell products for BCL and used in a previous cost analysis. We report mean with 95% confidence interval (CI) and median with interquartile range (IQR) for the full sample as well as by BCL sub-types. Results We identified 473 beneficiaries with at least one claim for CAR-T, with 305 having peri-CAR-T cost ≥ 250,000 USD (median age 58, 68% men) and included in our main analysis. Among the 305 patients, 269 had DLBCL (88%), 6 had FL (2%), and 30 had MCL (10%). The mean of total costs during the peri-CAR-T period was 618,100 USD (95% CI: 591,800-644,500 USD), with a median of 573,300 USD and IQR of 495,900 to 694,900 USD. Nearly 6% patients had total costs above 1,000,000 USD. The total costs were similar among different types of BCL (mean in USD: 611,900 in DLBCL, 743,100 in FL, 649,100 in MCL). The mean monthly costs were the highest during the month of and following CAR-T infusion (month 0: 377,300 USD; month 1: 128,300 USD), and less than 41,000 USD in any other month (Figure 2). Notably, 168 beneficiaries met the inclusion criteria except having costs < 250,000 USD during the peri-CAR-T period (median age: 57, 62% men, 89% DLBCL, 4% FL, 7% MCL). The mean of total costs in these patients (mean: 110,300 USD, with 75% having total costs ≤ 145,900 USD) was substantially lower than those included in our cost analysis. This population likely represented CAR-T candidates who did not receive the actual CAR-T cell infusion. Conclusions As the largest real-world cost analysis on CAR-T therapy in the commercially insured population thus far, we report total reimbursed expenditures for CAR-T therapies used in all FDA approved BCL settings. The average expenditure during the peri-CAR-T period was over 600,000 USD, a value substantially greater than what is commonly utilized in cost-effectiveness modeling for CAR-T products. Further, approximately 1/3 of beneficiaries with CAR-T claims had payments <250,000 USD, likely reflecting that a considerable number of individuals do not receive intended CAR-T therapy during real-world practice. As the next step, we will examine average expenditures for CAR-T product, outpatient, and inpatient services, which will be reported at the annual meeting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Economic burden of atherosclerotic cardiovascular disease: costs related to healthcare and loss of productivity; a matched case-control study in more than 450,000 Swedish individuals

Abstract Introduction Atherosclerotic cardiovascular disease (ASCVD) is associated with significant morbidity and mortality. We aimed to quantify the impact of ASCVD on healthcare costs, risk of cardiovascular (CV) events and mortality. Purpose To examine the progression of direct healthcare costs, indirect costs and other outcomes over 5 years in people with ASCVD and matched controls in Sweden. Methods In this 5-year retrospective closed cohort study, adults (aged ≥18 years) living in Sweden on 1/1/2012 were identified in an existing database,1,2 and those with ASCVD (≥1 inpatient admission/outpatient visit with a main or sub-diagnosis relating to stroke, ischaemic heart disease or peripheral artery disease, or procedure codes related to revascularization or amputation, in the National Patient Register [1997–2011]) were propensity score matched to controls without ASCVD by birth year, sex and educational status. Study variables included costs of selected hospital-based care and prescription drugs, and mortality from the National Board of Health and Welfare; demographic and socioeconomic information from Statistics Sweden; and work absences from Försäkringskassan (Swedish Social Insurance Agency). We compared annual direct healthcare costs (inpatient, outpatient and drug costs) and indirect costs from lost productivity, and analysed risks of early retirement, stroke, myocardial infarction and mortality. Hazard ratios (HRs) were estimated using Cox proportional regression adjusted for baseline age, sex, comorbidities, education and marital status. Results Individuals with ASCVD (N=231,417) had similar ages, sex distribution and education to matched controls, but were more likely to have T2D or renal disease (Table). Over the 5-year study period, average annual total direct and indirect costs for people with ASCVD were 2.5 times higher than in controls; direct healthcare costs in the ASCVD group were three times those for controls (Figure). In both groups, indirect costs accounted for nearly two-thirds of total costs. In the ASCVD group, inpatient costs comprised 74% of total direct costs, whereas outpatient costs and drug costs contributed 15% and 11%. In controls, total direct costs were made up of 70% inpatient costs, 18% outpatient costs and 12% drug costs. All-cause mortality was 72% higher in people with ASCVD than in controls (HR: 1.72 [95% confidence interval: 1.69–1.75]). Individuals with ASCVD were also more likely than controls to experience stroke (HR: 1.89 [1.83–1.95]), myocardial infarction (HR: 2.33 [2.26–2.41]) and early retirement (HR: 3.04 [2.78–3.33]). Conclusions Individuals with ASCVD incurred more than 2.5 times the total costs of matched controls, and had a greater risk of death, CV events and early retirement. Effective measures to prevent ASCVD and to slow its progression could limit these substantial burdens for individuals, healthcare systems and society. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was supported by a grant from Novo Nordisk A/S to the Swedish Institute for Health Economics. Medical writing support was provided by Oxford PharmaGenesis, Oxford, UK, with funding from Novo Nordisk A/S.

Pediatric Concurrent Hospice Care: Cost Implications of a Hybrid Payment Model.

Implementation of concurrent hospice care led to a new hybrid payment model that combines hospice payments with payments for non-hospice medical care. Little is known about the cost implications of this new hybrid payment model. The purpose was to identify costs and compare concurrent care and standard hospice care costs by estimating the average incremental Medicaid cost of care over time. Using national Medicaid data of 18147 hospice children and a multilevel generalized linear model, we calculated the incremental costs of receiving concurrent vs standard hospice care. We used the total cost of care over the last year of life. Increments for the analysis were hospice length of stay, stratified to 1 day, 2-14 days, and 15 + days. Overall, compared to standard hospice care, enrollment in concurrent hospice care was significantly associated with an increase in outpatient care and prescription drug costs. For a stay of 1 day, concurrent hospice care decreased inpatient costs and increased costs of prescription drugs. For stays between 2 and 14 days, concurrent hospice decreased total costs and inpatient costs, but increased prescription drug costs. With a hospice stay of 15 + days, concurrent hospice had significantly higher costs across all measures, including total costs, inpatient costs, outpatient costs, and prescription drug costs. This study provides critical insight into incremental costs of receiving concurrent vs standard hospice care. More research is needed to understand how concurrent hospice lengthy hospice stays are associated with increases of costs.

DRUG COST OF OUTPATIENT TREATMENT FOR HYPERTENSION AT HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Background: Hypertension is a common disease in the world as well as in Vietnam, a great threat to human health. With the number of people suffering from hypertension constantly increasing, the cost of treatment for this chronic disease is a dilemma that not only affects patients directly, but also a burden to society. The study was conducted to contribute to the analysis of the current outpatient drug costs for hypertensive patients. Materials and method: Conducted restropective study. Data was collected outpatient drug payment information for hypertensive patients in 2018. There were 1805 outpatient treatment sessions from 1-6/2018 included in the analysis. Results: The average drug cost of an outpatient treatment course for hypertension is 339,088 ± 257,021 VND. Imported drugs accounted for 80.69% of the total cost and 90.48% of the outpatient treatment course. The cost of antihypertensive drugs accounted for 38.21% of the total drug cost, and the drugs with the highest cost were brand-name drugs. Conclusion: The average drug cost of the treatment course of hypertensive patients with complications/comorbidities was significantly higher than that of patients with hypertension alone. Imported drugs and brand-name drugs account for a large proportion of drug costs for hypertensive outpatients. Key words: drug cost, hypertension, outpatient, Hue University of Medicine and Pharmacy Hospital.

Out-of-Pocket Costs for Patients Undergoing Thyroid Surgery.

The aim of this study was to determine out-of-pocket costs (OOPC) in patients undergoing thyroidectomy for benign and malignant conditions in a commercially insured US population. Little is known about OOPC for thyroid surgery in the United States. Retrospective cohort study using claims of patients undergoing thyroidectomy from the IBM Watson Marketscan database from 2008 to 2017. OOPCs accrued from 90 days before surgery to 360 days after thyroid surgery were quantified. Costs were divided into expenditures for inpatient care, outpatient care and outpatient drug costs and over three time periods: from 90 days preoperatively to 30 days post operatively, from 30 days post operatively to 90 days postoperatively, and from 90 days to 1 year after surgery. A total of 45,971 commercially insured patients aged 18 to 95 years who underwent thyroidectomy were identified after excluding patients who changed coverage and patients on capitated plans. The median OOPC per patient in the study period of 90 days before surgery to 360 days after surgery was $2434 [interquartile range (IQR) $1273-$4226], the median insurance reimbursement was $15,520 (IQR $7653-$29,149). Patients undergoing thyroidectomy for malignant conditions had a median OOPC of $3019 (IQR $1596-$5021) compared to $2271 (IQR $1201-3954) for benign conditions ( P < 0.0001).Patients with preferred provider organization coverage had a median OOPC of $2624 (IQR $1458-$4358) compared to HMO patients with a median OOPC of $1529 (IQR $739 to 3058), and high deductible health plans with a median OOPC of $4265 (IQR $2788-$6210) ( P < 0.0001). Despite commercial insurance coverage, patients face substantial OOPCs in the surgical management of thyroid disease in the United States.

Evaluation of a package of risk-based pharmaceutical and lifestyle interventions in patients with hypertension and/or diabetes in rural China: A pragmatic cluster randomised controlled trial.

Primary prevention of cardiovascular disease (CVD) requires adequate control of hypertension and diabetes. We designed and implemented pharmaceutical and healthy lifestyle interventions for patients with diabetes and/or hypertension in rural primary care, and assessed their effectiveness at reducing severe CVD events. We used a pragmatic, parallel group, 2-arm, controlled, superiority, cluster trial design. We randomised 67 township hospitals in Zhejiang Province, China, to intervention (34) or control (33). A total of 31,326 participants were recruited, with 15,380 in the intervention arm and 15,946 in the control arm. Participants had no known CVD and were either patients with hypertension and a 10-year CVD risk of 20% or higher, or patients with type 2 diabetes regardless of their CVD risk. The intervention included prescription of a standardised package of medicines, individual advice on lifestyle change, and adherence support. Control was usual hypertension and diabetes care. In both arms, as usual in China, most outpatient drug costs were out of pocket. The primary outcome was severe CVD events, including coronary heart disease and stroke, during 36 months of follow-up, as recorded by the CVD surveillance system. The study was implemented between December 2013 and May 2017. A total of 13,385 (87%) and 14,745 (92%) participated in the intervention and control arms, respectively. Their mean age was 64 years, 51% were women, and 90% were farmers. Of all participants, 64% were diagnosed with hypertension with or without diabetes, and 36% were diagnosed with diabetes only. All township hospitals and participants completed the 36-month follow-up. At 36 months, there were 762 and 874 severe CVD events in the intervention and control arms, respectively, yielding a non-significant effect on CVD incidence rate (1.92 and 2.01 per 100 person-years, respectively; crude incidence rate ratio = 0.90 [95% CI: 0.74, 1.08; P = 0.259]). We observed significant, but small, differences in the change from baseline to follow-up for systolic blood pressure (-1.44 mm Hg [95% CI: -2.26, -0.62; P < 0.001]) and diastolic blood pressure (-1.29 mm Hg [95% CI: -1.77, -0.80; P < 0.001]) in the intervention arm compared to the control arm. Self-reported adherence to recommended medicines was significantly higher in the intervention arm compared with the control arm at 36 months. No safety concerns were identified. Main study limitations include all participants being informed about their high CVD risk at baseline, non-blinding of participants, and the relatively short follow-up period available for judging potential changes in rates of CVD events. The comprehensive package of pharmaceutical and healthy lifestyle interventions did not reduce severe CVD events over 36 months. Improving health system factors such as universal coverage for the cost of essential medicines is required for successful risk-based CVD prevention programmes. ISRCTN registry ISRCTN58988083.

Effect of a Package of Risk-Based Pharmaceutical and Lifestyle Interventions on Patients with Hypertension and/or Diabetes in Rural China: A Pragmatic Cluster Randomised Controlled Trial

Background: Primary prevention of cardiovascular disease (CVD) requires adequate control of hypertension and diabetes. We designed and implemented pharmaceutical and healthy lifestyle interventions for patients with diabetes and/or hypertension in rural primary care, and assessed their effectiveness at reducing the rate of severe CVD events. Methods: We used a pragmatic, parallel group, two-arm, controlled, superiority, cluster trial design. We randomised 67 township hospitals from rural Zhejiang province, China, to intervention (34) or control (33) arms. Using health records, we recruited patients with hypertension and a 10-year CVD risk of 20% or higher and all patients with type 2 diabetes. The intervention included prescription of a standardised package of medicines, individual advice on lifestyle change and adherence support. Control was usual hypertension and diabetes care. In both arms, as usual in China, most outpatient drug costs were out-of-pocket. The primary outcome was severe CVD events after 36 months of intervention, as recorded by the CVD surveillance system. Findings: We conducted the trial from December 2013 until May 2017. We randomly allocated 13,385 and 14,745 participants to the intervention and control arms respectively. At 36 months there were 762 and 874 severe CVD events in the intervention and control arms respectively (incidence rate = 1.92 and 2.01 per 100 person-years respectively; crude incidence rate ratio = 0.90 [95% CI: 0.74, 1.08; P = 0.259]). Self-reported adherence to recommended medicines was significantly higher in the intervention arm, but adherence was low. Differences in mean blood pressure were significant but small. No safety concerns were identified. Interpretation: The comprehensive package of pharmaceutical and healthy lifestyle interventions did not significantly reduce severe CVD events over 36 months. Improving health system factors such as universal coverage for the cost of essential medicines are required for successful risk-based CVD prevention programmes. Trial Registration: Current Controlled Trials (ISRCTN58988083). Funding: UK DFID (COMDIS-HSD) and Zhejiang Health Bureau. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethics approval was obtained from the University of Leeds School of Medicine Research Ethics Committee (reference HSLTLM/12/010) and the Ethics Committee of Zhejiang Provincial Centre for Disease Control and Prevention, China (reference 18/06/2012). Written informed consent was obtained from both hospital directors and all participating individuals.

Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis

BackgroundSocioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. However, the extent to which they exist at end-of-life (EOL) remains unclear.MethodsStudies in MEDLINE, EMBASE, CINAHL, ProQuest, Web of Science, Web of Knowledge, and OpenGrey databases were searched through December 2019 with hand-searching of in-text citations. No publication date or language limitations were set. Studies assessing SES (e.g. income) in adults, correlated to EOL costs in last year(s) or month(s) of life were selected. Two independent reviewers performed data abstraction and quality assessment, with inconsistencies resolved by consensus.ResultsA total of twenty articles met eligibility criteria. Two meta-analyses were performed on studies that examined total costs in last year of life – the first examined costs without adjustments for confounders (n = 4), the second examined costs that adjusted for confounders, including comorbidities (n = 2). Among studies which did not adjust for comorbidities, SES was positively correlated with EOL costs (standardized mean difference, 0.13 [95% confidence interval, 0.03 to 0.24]). However, among studies adjusting for comorbidities, SES was inversely correlated with EOL expenditures (regression coefficient, −$150.94 [95% confidence interval, −$177.69 to -$124.19], 2015 United States Dollars (USD)). Higher ambulatory care and drug expenditure were consistently found among higher SES patients irrespective of whether or not comorbidity adjustment was employed.ConclusionOverall, an inequality leading to higher end-of-life expenditure for higher SES patients existed to varying extents, even within countries providing universal health care, with greatest differences seen for outpatient and prescription drug costs. The magnitude and directionality of the relationship in part depended on whether comorbidity risk-adjustment methodology was employed.

HER2-Positive Metastatic Breast Cancer: A Retrospective Cohort Study of Healthcare Costs in the Targeted-Therapy Age.

Claims data (IBM MarketScan Commercial and MarketScan Medicare Supplemental databases) from June 30, 2011 to September 30, 2017 were used to evaluate the cost impact of human epidermal growth factor receptor2 (HER2)-positive metastatic breast cancer (MBC) in this retrospective cohort study. The primary analysis compared short-term costs for patients diagnosed with HER2+ MBC at least 180days after the end of first HER2-targeted treatment (MBC+ cohort) versus a propensity score matched cohort of patients with breast cancer who did not develop MBC (MBC- cohort). A pseudo-post period for patients in the HER2+ MBC- cohort was defined by indexing to the HER2+ treatment completion-MBC diagnosis time interval of the matched pair in the HER2+ MBC+ cohort; we then compared average monthly cost differences between these groups for the year preceding and following MBC diagnosis. In secondary analyses, we estimated medium-term aggregate and categorical healthcare costs for patients with HER2+ MBC up to 3years post-diagnosis. In the short-term primary analysis, costs for the HER2+ MBC+ and HER2+ MBC- cohorts were largely comparable in the year preceding MBC diagnosis. Monthly direct costs were significantly higher for the HER2+ MBC+ cohort in the months immediately preceding MBC diagnosis, with differences in the range of $500-5000. Following diagnosis, total monthly costs were $13,000-34,000 higher for patients in the HER2+ MBC+ cohort vs. the HER2+ MBC- cohort. In the medium-term secondary analysis, mean per patient total costs were $218,171 [standard error (SE) $5450] in the first year following MBC diagnosis and $412,903 (SE $13,034) cumulatively over 3years following diagnosis (among patients with complete follow-up). Primary cost contributors were outpatient visits ($195,162; SE $8043) and HER2-targeted therapy drug costs ($177,489; SE $8120). HER2+ MBC is associated with high short-term and medium-term direct healthcare costs. These could be alleviated with early diagnosis and optimal standard-of-care treatment for early breast cancer, which can significantly reduce the risk of recurrence.

Descriptive analysis of prevalence and medical expenses of cancer, cardio-cerebrovascular disease, psychiatric disease, and musculoskeletal disease in Korean firefighters.

BackgroundFirefighters are exposed to many dangerous working conditions. Many studies have identified the risk of disease for firefighters, but only a few studies have addressed the medical expenses of firefighters, which represents a concrete scale of disease. Our purpose in this study was to determine the medical expenditures of firefighters to assess the overall scale of disease in Korea. We focused on cancer, mental disorders, cardio-cerebrovascular disease, and musculoskeletal disease, the prevalence of which was expected to be high in firefighters.MethodsThis study utilized National Health Insurance Service data. We targeted firefighters, police officers, and government officials. We classified disease based on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. We compared prevalence by the age-standardized prevalence rate, considering standard distribution of the population. Medical expenditure of disease was defined as outpatient fees, hospitalization fees, and drug costs. Total medical expenditures were calculated by the sum of those 3 categories.ResultsThe age-standardized prevalence of cancer, mental disorders, and cardiovascular disease in firefighters was slightly higher than or similar to that of government officials and police officers (no significant difference). However, medical expenditures for stomach cancer, mental disorders, and most cardio-cerebrovascular diseases were higher in firefighters than in others. In particular, firefighters spent 12 times more money for ischemic heart disease than did government officials. Of musculoskeletal diseases, lumbar disc disorder had the highest expenditures among firefighters.ConclusionsThe age-standardized prevalence of most of diseases of firefighters was not as high as in the other groups, but the medical expenses of firefighters were much higher than those of government officials and police officers.

Economic Burden of Bronchiolitis Obliterans Syndrome (BOS) Following Allogeneic Hematopoietic Stem Cell Transplant (alloHSCT) in Patients with Commercial Insurance in the United States

Background Bronchiolitis obliterans syndrome (BOS), also known as respiratory chronic Graft versus Host Disease (cGvHD), is an obstructive airway disease of the lungs following alloHSCT that has significant morbidity and mortality. BOS is characterized by T-cell mediated inflammation and fibrosis of bronchiolar walls that reduces the diameter of the bronchioles resulting in progressive and irreversible airflow obstruction. BOS is a well described complication following lung transplant and can also be a complication following alloHSCT, with similar histopathology and clinical symptoms. There is currently no approved therapy for the treatment of BOS. While data on alloHSCT costs are available (Milliman 2017; Broder et al., 2017), little is known about the impact of BOS on healthcare resource use (HRU) and costs in alloHSCT. The aim of this study is to quantify the economic burden of BOS in alloHSCT patients. Methods We performed a retrospective analysis of commercial claims data from the IQVIA PharMetrics Plus™ database for patients aged 0-64 who were treated with alloHSCT from 1/1/2007 to 9/30/2017. Patients were observable 12 months before and after index alloHSCT. Those who developed BOS were identified using International Classification of Disease (ICD) diagnosis codes (ICD-9: 491.8, 491.9, 515, 516.34, 561.8; ICD-10: J41.8, J42, J84.09, J84.89, J84.115) and propensity score matched to identify patients who did not develop BOS after alloHSCT. We calculated mean annual per patient rates of hospitalizations, tests and treatments for BOS, as well as costs in the follow-up year for inpatient admissions, Emergency Department (ED) and non-ED outpatient visits, and prescription medications. Costs for the index HSCT were included in the first follow-up year costs. All analyses were repeated for the subset of patients observable in the second post-alloHSCT year. The effect of BOS was estimated as the difference in HRU and costs between the matched BOS and non-BOS alloHSCT patients. Results We identified 161 alloHSCT patients with commercial insurance coverage who developed BOS. A majority were male (60%). Mean age was 51.0 yrs (+/- SD: 12.13); a small proportion (2%) were under age 18. We also identified 161 matched alloHSCT patients who did not develop BOS. More BOS patients were diagnosed with leukemias or lymphomas compared with non-BOS patients (94% vs. 84%) in the pre-alloHSCT year, and more had pulmonary disease (asthma or COPD; 24% vs. 16%). No other differences were statistically significant at p&amp;gt;0.05. In the year following alloHSCT, BOS patients had higher mean per patient annual numbers of inpatient admissions (3.9 [+/- SD: 3.3] vs. 2.6 [+/- SD: 2.5]). More BOS patients received lung function testing, including spirometry (60% vs. 42%), and more were treated with ventilation, oxygen therapy or pulmonary rehabilitation (61% vs. 39%). Costs were higher for BOS patients ($560,048 vs. $408,764), with inpatient costs responsible for most of this difference ($446,622 vs. $300,146). Lung function test costs were over 3 times as high for BOS patients ($35,744 vs. $10,192) and lung function treatment costs 2.5 times as high ($31,761 vs. $7,994). Costs for patients observable in the second post-alloHSCT year were considerably lower, as the costs for the initial alloHSCT costs were reflected in the first year expenditures. Nonetheless, costs remained higher for BOS patients ($72,829 vs. $43,665), with higher inpatient, outpatient and prescription drug costs and HRU (Table, Figure). Conclusion AlloHSCT patients who develop BOS in the U.S. have higher rates of hospitalization and have more lung function tests and treatments, compared with alloHSCT patients with no diagnosis of BOS in the first 1-2 years post-alloHSCT. These higher rates of healthcare service use are accompanied by mean annual per patient costs that are $151,000 higher in the first post-alloHSCT year. Disclosures Sacks: Breath Therapeutics Inc.: Other: Employee of Precision Health Economics (PHE). PHE received funding from Breath Therapeutics for this research. . Healey:Breath Therapeutics Inc.: Other: Employee of Precision Health Economics (PHE). PHE received funding from Breath Therapeutics for this research. . Cyr:Breath Therapeutics Inc.: Other: Employee of Precision Health Economics (PHE). PHE received funding from Breath Therapeutics for this research. . Batt:Breath Therapeutics Inc.: Other: Scientific Adviser to Precision Health Economics (PHE). PHE receieved funding from Breath Therapeutics for this research.. Henig:Breath Therapeutics Inc.: Employment.

Quantifying the Economic Burden of Myelodysplastic Syndromes Among Elderly US Patients

Introduction: Myelodysplastic syndromes (MDS) include a diverse group of bone marrow disorders associated with high mortality and morbidity. In individuals with MDS, the bone marrow produces dysfunctional blood cells with about one-third of patients progressing to acute myeloid leukemia (AML). Previous estimates of the economic burden of MDS are highly variable, with the existing clinical literature deficient of detailed economic data and existing economic studies lacking accurate information on MDS diagnostics. To address the issue, this study uses registry-linked claims data from SEER-Medicare to estimate the economic burden of MDS among elderly individuals in the US. Methods: We conducted a retrospective case-control study using SEER-Medicare data from January 1, 2010 to December 31, 2016. The study included two cohorts, both aged ≥66 years: (i) patients diagnosed with MDS between January 1, 2011 and December 31, 2015, and (ii) cancer-free controls from a 5% random sample of Medicare beneficiaries. Patients with MDS were followed from index date, defined as the date of initial MDS diagnosis, to death, study end date, or 24 months post-index, whichever occurred first. A 1-year pre-index lookback period was used to identify comorbidities. Except in the instance of death, all individuals had a minimum of 1-year post-index follow-up. We propensity score-matched MDS cases and controls using demographic factors and comorbidities. After examining standardized differences between the MDS and control groups under various caliper widths and allowed numbers of matches, a caliper width of 0.05 of the standard deviation of the propensity score with 25 matched neighbors with replacement was chosen, as this minimized standardized differences across covariates. We calculated average 30-day cost burden for each matched patient based on costs incurred over the number of days in their individual follow-up period. We then estimated incremental healthcare cost burden for patients with MDS relative to the matched controls, including inpatient, outpatient, and pharmaceutical drug costs. We used a generalized linear model (GLM) with a log link and adjusted for demographics and comorbidities. Results: Of the 18,780 patients diagnosed with MDS during the study period, 9,524 met the inclusion criteria. Prior to matching, the control group of 288,877 cancer-free patients was 40% male with a mean age of 75.8 years (SD=8.3), while the MDS group was 57% male with a mean age of 80.1 years (SD=7.4). In addition, standardized differences between the groups were &gt;0.2 for 50% (8/16) of comorbidities considered. After matching, the number of matched controls fell to 109,075 individuals that were 57% male with a mean age of 80.6 (SD=8.4), and standardized differences were &lt;0.04 for all 16 comorbidities. Unadjusted analyses revealed that, in the first two years following diagnosis, patients with MDS had a $6,599/month total cost, $4,005 of which was MDS-related, compared with $2,122/month for matched controls, a difference of $4,478 in total monthly cost (nominal P&lt;.001). After adjusting for patient characteristics using GLM, estimated monthly cost was $7,400/month for patients with MDS and $2,005/month for controls, a difference of $5,395/month (nominal P&lt;.001). This translates to an estimated two-year cost of $177,601 for patients with MDS compared to $48,125 for cancer-free controls, a difference of $129,476. Approximately 58% of this difference was due to higher medical costs, with the remaining 42% due to higher pharmaceutical costs. Higher inpatient hospitalization costs ($2,319/month for patients with MDS; $851/month for controls; $1,468 cost difference, nominal P&lt;.001) and Part B drug costs ($1,434/month for patients with MDS; $71/month for controls; $1,363 cost difference, nominal P&lt;.001) were key drivers of the incremental cost burden. Conclusion: The economic burden of MDS is higher than that of the cancer-free Medicare population, with an estimated incremental adjusted cost burden of nearly $130,000 in the two years following MDS diagnosis. Medical costs make up the majority of this cost difference. Our results provide an updated estimate of the economic burden of MDS using the most recent data and MDS coding methodology, with detailed estimates of cost by component. Our results fall within the range of estimates of previous studies using SEER-Medicare data. Figure Disclosures Shafrin: Precision Medicine Group: Employment, Equity Ownership. Green:Precision Health Economics: Employment, Other: Employee of Precision Health Economics (PHE). PHE received funding from Breath Therapeutics for this research. . Murphy:Precision Medicine Group: Employment. Everson:Precision Medicine Group: Employment. Dennen:Precision Medicine Group: Employment. Price:Jazz Pharmaceuticals: Employment, Equity Ownership. Batt:Precision Medicine Group: Consultancy.

Morbidity related controlling of pharmaceutical expenditures using prescription data

The controlling of outpatient drug costs in Germany is implemented almost entirely on the federal state level. Each year the regional representatives of the Statutory Health Insurances (SHI) and the Association of SHI Physicians in all federal states have to define an upper limit for pharmaceutical expenditures. In the most northern federal state (Schleswig-Holstein) the regional parties agreed on a morbidity related approach solely based on prescription data to meet with the spending target. The underlying patient-related classification system is called Morbidity Related Groups (MRG). Introductory the underlying data, the present model for controlling measures and the hard-/software used today will be discussed. Subsequently improvements and extensions to the MRG classification system leading to a generalized model of drug resourcing are suggested.

Cost of Care for the Initial Management of Ovarian Cancer.

To examine the cost of care during the first year after a diagnosis of ovarian cancer, estimate the sources of cost, and explore the out-of-pocket costs. We performed a retrospective cohort study of women with ovarian cancer diagnosed from 2009 to 2012 who underwent both surgery and adjuvant chemotherapy using the Truven Health MarketScan database. This database is comprised of patients covered by commercial insurance sponsored by more than 100 employers in the United States. Medical expenditures, including physician reimbursement, for a 12-month period beginning on the date of surgery were estimated. All payments were examined, including out-of-pocket costs for patients. Payments were divided into expenditures for inpatient care, outpatient care (including chemotherapy), and outpatient drug costs. The 12-month treatment period was divided into three phases: surgery to 30 days (operative period), 1-6 months (adjuvant therapy), and 6-12 months after surgery. The primary outcome was the overall cost of care within the first year of diagnosis of ovarian cancer; secondary outcomes included assessment of factors associated with cost. A total of 26,548 women with ovarian cancer who underwent surgery were identified. After exclusion of patients with incomplete insurance enrollment or coverage, those who did not undergo chemotherapy, and those with capitated plans, our cohort consisted of 5,031 women. The median total medical expenditures per patient during the first year after the index procedure were $93,632 (interquartile range $62,319-140,140). Inpatient services accounted for $30,708 (interquartile range $20,102-51,107; 37.8%) in expenditures, outpatient services $52,700 (interquartile range $31,210-83,206; 58.3%), and outpatient drug costs $1,814 (interquartile range $603-4,402; 3.8%). The median out-of-pocket expense was $2,988 (interquartile range $1,649-5,088). This included $1,509 (interquartile range $705-2,878) for outpatient services, $589 (interquartile range $3-1,715) for inpatient services, and $351 (interquartile range $149-656) for outpatient drug costs. The average cost of care for women with ovarian cancer in the first year after surgery is approximately $100,000. Patients bear approximately 3% of these costs in the form of out-of-pocket expenses.

Medical costs in patients with heart failure after acute heart failure events: one-year follow-up study

Aims: This study investigated annual medical costs using real-world data focusing on acute heart failure.Methods: The data were retrospectively collected from six tertiary hospitals in South Korea. Overall, 330 patients who were hospitalized for acute heart failure between January 2011 and July 2012 were selected. Data were collected on their follow-up medical visits for 1 year, including medical costs incurred toward treatment. Those who died within the observational period or who had no records of follow-up visits were excluded. Annual per patient medical costs were estimated according to the type of medical services, and factors contributing to the costs using Gamma Generalized Linear Models (GLM) with log link were analyzed.Results: On average, total annual medical costs for each patient were USD 6,199 (±9,675), with hospitalization accounting for 95% of the total expenses. Hospitalization cost USD 5,904 (±9,666) per patient. Those who are re-admitted have 88.5% higher medical expenditure than those who have not been re-admitted in 1 year, and patients using intensive care units have 19.6% higher expenditure than those who do not. When the number of hospital days increased by 1 day, medical expenses increased by 6.7%.Limitations: Outpatient drug costs were not included. There is a possibility that medical expenses for AHF may have been under-estimated.Conclusion: It was found that hospitalization resulted in substantial costs for treatment of heart failure in South Korea, especially in patients with an acute heart failure event. Prevention strategies and appropriate management programs that would reduce both frequency of hospitalization and length of stay for patients with the underlying risk of heart failure are needed.

A Transparent and Consistent Approach to Assess US Outpatient Drug Costs for Use in Cost-Effectiveness Analyses

BackgroundAssessment of drug costs for cost-effectiveness analyses (CEAs) in the United States is not straightforward because the prices paid for drugs are not publicly available and differ between payers. CEAs have relied on list prices that do not reflect the rebates and discounts known to be associated with these purchases. ObjectivesTo review available cost measures and propose a novel strategy that is transparent, consistent, and applicable to all CEAs taking a US health care sector perspective or a societal payer’s perspective. MethodsWe propose using the National Average Drug Acquisition Cost (NADAC), the Veterans Affairs Federal Supply Schedule (VAFSS), and their midpoint as the upper bound, lower bound, and base case, respectively, to estimate net drug prices for various payers. We compare this approach with wholesale acquisition cost (WAC), the most common measure observed in our literature review. The minimum WAC is used to provide the most conservative comparison. ResultsOur sample consists of 1436 brand drugs and 1599 generic drugs. On average, the upper bound (NADAC) is 1% and 9.8% lower than the WAC for brand and generic drugs respectively, whereas the lower bound (VAFSS) is 48.3% and 54.2% lower than the WAC. The NADAC is less than the WAC in 89.6% of drug groups. The distributions of these relationships do not show a clear mode and have wide variation. ConclusionsOur study suggests that the WAC may be an overestimate for the base case because the minimum WAC is higher than the NADAC for most drugs. Our approach balances uncertainty and lack of data for the cost of pharmaceuticals with the need for a transparent and consistent approach for valid CEAs.