Payer System Research Articles

Cost-effectiveness of ribociclib plus endocrine therapy versus placebo plus endocrine therapy in HR-positive, HER2-negative breast cancer.

BACKGROUND: The 2015 American Society of Clinical Oncology guidelines recommend first-line treatment of hormone receptor (HR)-positive breast cancer with endocrine therapy plus or minus palbociclib, a selective cyclin-dependent kinase (CDK)4/6 inhibitor. In 2018, the U.S. Food and Drug Administration approved ribociclib, a new orally available selective CDK4/6 inhibitor. While gains in progression-free survival (PFS) and overall survival (OS) from ribociclib are important for clinical and treatment outcomes, trade-offs in adverse events (AEs) and additional costs necessitate cost-effectiveness analysis (CEA) to assist consideration by third-party payer systems, physicians, and patients. OBJECTIVES: To (a) develop a Markov model and (b) determine the cost-effectiveness of ribociclib plus endocrine therapy versus endocrine therapy alone as treatment for premenopausal and perimenopausal patients with HR-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer. METHODS: A lifetime 3-state Markov model ("stable," "progressed," and "dead" health states) was developed using a U.S. payer perspective. Transition probabilities were calculated based on OS and PFS outcomes from the randomized controlled phase 3 trial MONALEESA-7. These Kaplan-Meier curves were extended to lifetime by estimating best-fit distributions using loglogistic distribution for ribociclib curves and Weibull distribution for placebo curves. Costs were obtained from national data sources using 2019 U.S. dollars (USD) and discounted by 3%. Utilities were obtained via published breast cancer literature and were included for each health state and for time spent with each AE. Results were expressed as an incremental cost-effectiveness ratio (ICER) expressed as USD per quality-adjusted life-year (QALY) saved. Treatments were assumed to be cost-effective based on a willingness-to-pay (WTP) threshold of $150,000 per QALY gained. Base-case, 1-way sensitivity tornado diagrams and probabilistic sensitivity analyses demonstrated changes in the ICER and were driven by the cost of ribociclib and the utility of remaining in the stable health state. RESULTS: Ribociclib plus endocrine therapy was cost-effective at an ICER of $124,513 per QALY when compared with endocrine therapy alone at a WTP threshold of $150,000. The ribociclib plus endocrine therapy arm had an effectiveness of 5.28 QALYs and a total cost of $385,112, while placebo plus endocrine therapy provided only 2.46 QALYs at a lower total cost of $67.246. The model was sensitive to the cost of ribociclib and the utility of time spent in the stable health state. Probabilistic sensitivity analysis demonstrated that endocrine therapy alone was cost-effective until a WTP of $125,000 and was cost-effective 72% of the time at the WTP threshold. CONCLUSIONS: Ribociclib plus endocrine therapy is more cost-effective than endocrine therapy alone. Professionals in managed care settings should consider the pharmacoeconomic benefits of ribociclib for the treatment of HR-positive, HER2-negative breast cancer as they make value-based formulary decisions. Further CEAs should be considered as direct treatment comparison trials between CDK4/6 inhibitors are completed in the future. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose.

A Welfare Analysis of Competitive Insurance Markets with Vertical Differentiation and Adverse Selection

A feature of many insurance markets is that they combine vertical differentiation (all consumers prefer high to low-coverage policies) and adverse selection (high cost customers prefer high-coverage plans). Building on Novshek and Sonnenschein (1978) and Azevedo and Gottlieb (2017), this paper characterizes the competitive equilibria in a vertically differentiated market characterized by adverse selection. This provides a simple, dynamic model of the market, along with their welfare consequences over time in response to policy changes. The model makes predictions consistent with recent evidence on the ACA exchange in the US (Frean et al. (2017)). Moreover, it provides a complete characterization of the health insurance “death spiral”. The death spiral leads to an inefficient outcome, but does not lead to a complete breakdown of the market. Rather, it predicts a large number of plans, with coverage that falls with an individual’s willingness to pay. It is shown that introducing a minimum coverage standard combined with an insurance mandate cannot restore efficiency. The optimal system depends on both the valuation of public funds and the social value of insurance. Depending on these parameters, a number of different types of systems may be optimal, including a single payer system with mandatory participation for all, such as the Canadian system, a mixed private-public system, as one sees in many countries, or a pure, free market system.

Efficacy and Cost Effectiveness of Intravenous Ferric Carboxymaltose Versus Iron Sucrose in Adult Patients with Iron Deficiency Anemia

Abstract: Objectives: Iron deficiency anemia (IDA) is a major health issues and common type of nutritional deficiency worldwide. For IDA treatment, IV iron is a useful therapy. Many intravenous (IV) iron preparations are used for treatment of iron-deficiency anemia (IDA). The purpose of this study is to evaluate the efficacy of ferric carboxymaltose (FCM) in comparison to iron sucrose (IS) in treatment of IDA adult patients; considering cost-effectiveness (CE) for IDA patients from Qatar healthcare system perspective. We evaluated both treatments considering their response outcomes at 12 months period as well their respective acquisition costs. Methods: This was a cross sectional study with retrospective data performed on 764 IDA adult patients who were treated either with FCM or IS for IDA linking clinical efficacy (defined as improvement in hemoglobin (HB), ferritin and transferrin saturation levels) utility, and CE evaluation, including Incremental Cost-Effectiveness Ratio (ICER) over a 12-months period. The response to treatment was the primary outcomes. As the clinical laboratory data were collected before and after the first injection of the medications. The cost i.e. resources consumed were also the main outcome in our study. The cost effectiveness of FCM and IS was the secondary outcome. Direct healthcare costs were derived from the national healthcare payer system. Both descriptive and differential statistics were applied for data analysis. Alpha = 0.05. Results: Patients in the IS group used significantly higher number of injections, ampoules of medication, NS 0.9% bags and visits to the IV suite compared to FCM group. There were significant changes of laboratory tests between the FCM and IS groups. Further analysis in the change of effectiveness, indicated that the changes of hemoglobin and MCH levels in the IS group were significantly higher than the FCM group. The overall cost of IS therapy was significantly slightly higher than FCM. The medication cost for FCM was approximately 6.5 times higher than IS but cheaper in terms of bed cost and nursing cost. CE ratio illustrated that FCM and IS were significantly different in terms of HB, ferritin and MCH levels. Further, ICER indicated that further justifications and decisions need to be made for FCM when using HB, iron, transferrin saturation, MCH and MCV levels as the surrogate outcomes. Conclusions: The higher cost of FCM versus IS can be offset by savings in healthcare personnel time and bed space. ICER indicated that further justifications and decisions need to be made for FCM when using HB, iron, transferrin saturation, MCH and MCV levels as the surrogate outcomes. Limitations and strengths: Limited data is available with respect to comparison of safety and adverse effects of FCM and IS. The data is reliable as it was collected and documented before and after the treatment. Patients were monitored 30 min after the infusion to ensure keen observation and maximum safety. Disclosures No relevant conflicts of interest to declare.

Readiness of health care systems to generate RWE: Frequency of radiographic imaging of metastatic disease during first-line systemic therapy.

268 Background: Regulatory and Health Technology Assessment (HTA) agencies are increasingly using real world data (RWD) to support real world evidence (RWE), but the readiness of healthcare systems to reliably generate RWE is unknown. As a quality assurance measure we examined the preparedness of a single payer system to provide RWE by evaluating the frequency of CT imaging during standard first line metastatic systemic treatment of breast, colorectal (CRC) and lung cancer. Methods: A 1-year cohort of de novo metastatic breast, CRC, lung cancer patients treated with first line systemic therapy (excluding hormone therapy) referred to BC Cancer in 2016 was retrospectively reviewed. Duration of first line treatment was calculated from first to last dose of therapy. Baseline CT included imaging within 8 weeks prior to and 3 weeks after treatment initiation (first cycle). Last CT included imaging up to 8 weeks after the last dose of therapy. Results: A cohort of 675 patients was identified from the BC Cancer Registry. The distribution of de novo metastatic disease at diagnosis was lung (n = 379), CRC (n = 214) followed by breast cancer (n = 82). Conclusions: In our publicly funded health care system, baseline CT scans within 4 weeks prior to treatment ranged from 57-72%. The median CT imaging interval during first line metastatic treatment was ranged from 7.9-11.3 weeks. RWD from routine clinical practice differs significantly from clinical trials, the gold standard for regulatory and HTA assessments. Population-based data may contribute to RWE with caution due to limitations imposed by clinical practice. [Table: see text]

State and society relations from 1974 to 1991: a case of southwestern Ethiopia

ABSTRACT The need to study the relation between state and periphery in the past is one of the means to understand the socioeconomic and political history of the local people in Africa. Hence, this paper is principally geared to examine the issues of relation between the Ethiopian state (center) and peoples lived in southwestern Ethiopian from 1974 to 1991. Southwestern Ethiopia is a very broad region found in the Southern Nations, Nationalities and Peoples of Regional State of Ethiopia consisting of many cultural groups. Thus, the study mainly focuses on the relation between the central government and the peoples in southwestern Ethiopia such as Surma, Dizi, Me’en, Bench, Zilmamo and Sheko. The area was incorporated into the central government in 1898. From that time onwards, the gebar (tax payer) system, labor exploitation and slave trade instituted in most parts of the region. During the Derg regime (1974–1991) the relation between the aforementioned peoples and the center (state) has relatively changed. The gebar system, labor exploitation, and the slave trade were abandoned from the region. The central government instituted different national reforms which included distributing land to the landless, providing basic education, establishing peasant associations, clustering people through villegazation and resettlements, and organizing the people through cooperatives. However, the Surma people who shared border with Sudan resisted the government reforms. Thus, the government did not successfully implement the reforms in Surma and in some parts of the Me’en and Dizi area.

Impact Of A Dedicated Purpose Built Small Footprint Cardiac CT On Operational Efficiency And Cost Effectiveness

Introduction: With growing guideline support and clinical evidence, the demand for CCTA is increasing at a significant rate globally. With modest reimbursement in the US and limited resources in single payer systems, access to cardiac CT remains an issue. We aimed to assess the impact of a small footprint purpose built cardiac CT on access and the cost of CCTA.

Implementing Lifestyle Change Interventions to Prevent Type 2 Diabetes in US Medicaid Programs: Cost Effectiveness, and Cost, Health, and Health Equity Impact.

BackgroundLifestyle change interventions (LCI) for prevention of type 2 diabetes are covered by Medicare, but rarely by US Medicaid programs that constitute the largest public payer system in the USA. We estimate the long-term health and economic implications of implementing LCIs in state Medicaid programs.MethodsWe compared LCIs modeled after the intervention of the Diabetes Prevention Program versus routine care advice using a decision analytic simulation model and best available data from representative surveys, cohort studies, Medicaid claims data, and the published literature. Target population were non-disability-based adult Medicaid beneficiaries aged 19–64 years at high risk for type 2 diabetes (BMI ≥25 kg/m2 and HbA1c ≥ 5.7% or fasting plasma glucose ≥ 110 mg/dl) from eight study states (Alabama, California, Connecticut, Florida, Iowa, Illinois, New York, Oklahoma) that represent around 50% of the US Medicaid population. Incremental cost-effectiveness ratios (ICERs) measured in cost per quality-adjusted life years (QALYs) gained, and population cost and health impact were modeled from a healthcare system perspective and a narrow Medicaid perspective.ResultsIn the eight selected study states, 1.9 million or 18% of non-disability-based adult Medicaid beneficiaries would belong to the eligible high-risk target population – 66% of them Hispanics or non-Hispanic black. In the base-case analysis, the aggregated 5- and 10-year ICERs are US$226 k/QALY and US$34 k/QALY; over 25 years, the intervention dominates routine care. The 5-, 10-, and 25-year probabilities that the ICERs are below US$50 k (US$100 k)/QALY are 6% (15%), 59% (82%) and 96% (100%). From a healthcare system perspective, initial program investments of US$800 per person would be offset after 13 years and translate to US$548 of savings after 25 years. With a 20% LCI uptake in eligible beneficiaries, this would translate to upfront costs of US$300 million, prevent 260 thousand years of diabetes and save US$205 million over a 25-year time horizon. Cost savings from a narrow Medicaid perspective would be much smaller. Minorities and low-income groups would over-proportionally benefit from LCIs in Medicaid, but the impact on population health and health equity would be marginal.ConclusionsIn the long-term, investments in LCIs for Medicaid beneficiaries are likely to improve health and to decrease healthcare expenditures. However, population health and health equity impact would be low and healthcare expenditure savings from a narrow Medicaid perspective would be much smaller than from a healthcare system perspective.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00565-w) contains supplementary material, which is available to authorized users.

PNS76 A PAN-EUROPEAN HTA, A SINGLE US PAYER?

Pressure to cut drug prices in the US is mounting on both sides of the political spectrum. With an election looming and multiple challengers promoting Medicare for All, a route towards consolidating the diverse US payer landscape into a single-payer system is emerging. Across the Atlantic, European national HTA bodies have spent 20 years developing divergent methods of assessment; however, moves towards consolidating divergent national HTAs into a pan-European HTA are ongoing. EUnetHTA was established in 2005 to create an effective and sustainable network for Health Technology Assessment (HTA) across Europe. EUnetHTA Joint Assessments (JAs) are HTAs produced together by at least four different national European HTA bodies. This research aims to evaluate whether the joint production of EUnetHTA JAs resulted in an alignment of national reimbursement decisions and what lessons this may hold for the US. Publicly available information on EUnetHTA JAs for individual drugs were identified along with the associated national appraisal by NICE, SMC,G-BA, TLV, HAS, AIFA, SMC, NCPE, ZIN, Medicinradet, AOTM and NOMA (to 31/12/2019). Twelve EUnetHTA JAs were identified, of these 8 were single technology appraisals, 5/8 for oncology indications and 2/8 were orphan drugs. Forty-seven corresponding national HTA appraisals were identified. Despite the presence of a EUnetHTA JA, national HTA decisions were non-uniform across all products Alecensa (7 positive/3 negative), Stivarga (3 positive/4 negative), Rydapt (6 positive/1 negative), Invokana (6 positive/3 negative), Nexavar (2 positive/3 negative), Cyramza (2 positive/6 negative), Zontivity (0 positive/1 negative), Zynquista (0 positive/0 negative). Drugs appraised under EUnetHTA JAs are not associated with unanimous reimbursement decisions at the national level. Despite political pressure at the European level there seems little appetite to harmonize HTA nationally. The lack of historical HTA across the US payer landscape is one less hurdle for proponents of a single payer system in the US.

Cardiovascular disease burden in adult patients with cancer: An 11-year nationwide population-based cohort study

BackgroundCardiovascular disease (CVD) is an important cause of morbidity and mortality in patients with cancer. However, the real-world CVD burden of adult cancer patients has not been well established. This study aimed to evaluate the prevalence and mortality of pre-existing and new-onset CVD in patients with cancers. MethodsWe analysed the prevalence and mortality of pre-existing and new-onset CVD in 41,034 adult patients with ten common solid cancers in a single payer system using data from the Korean National Health Insurance Service-National Sample Cohort from 2002 to 2013. ResultsWhen all types of cancer were included, 11.3% (n = 4647) of patients had pre-existing CVD when they were diagnosed with cancer. After excluding patients with pre-existing CVD, 15.7% of cancer patients (n = 5703) were newly diagnosed with CVD during the follow-up period (median 68 months). Both pre-existing and new-onset CVD were associated with increased risk of overall mortality and 5-year mortality. Multivariate analysis to predict all-cause mortality indicated both pre-existing and new-onset CVD, male sex, old age, prior history of diabetes or chronic kidney disease, suburban residential area, and low-income status as significant factors. ConclusionsEleven percent of cancer patients had pre-existing CVD at the time of cancer diagnosis, and about 16% of cancer patients without pre-existing CVD were newly diagnosed with CVD, mostly within 5 years after the cancer diagnosis. Proper management of pre-existing CVD is necessary and pre-emptive prevention of new-onset CVD may alter treatment options and outcomes.

Pharma Collaboration for Transparent Medical Information (phactMI™) Benchmark Study: Results of Organizational Structure and Resourcing of Medical Information Services in Support of Building Departmental Strategies.

An opportunity exists to leverage the collective insights and experiences of phactMI™ member companies on current medical information (MI) services across the pharmaceutical industry. The collective insights provide considerations for refined MI strategies and enhanced MI services. The trend of organizational structure and challenge of resourcing for MI services are key areas to support efficiency and bring value to the overall organization. Between December 2017 and February 2018, all 27 phactMI™ member companies were electronically sent a 300-question survey to support the development of MI services across the pharmaceutical industry. The survey had 9 key areas of focus, including organizational structure and resourcing. All 27 companies responded to the survey. Although the 27 companies survey differed in structure and size, the MI responsibilities performed both by in-house and outsourced groups were similar with each organization. Half of the groups outsourced various responsibilities which supported the non-product roles, such as quality assurance, compliance reporting, vendor operations management, reporting/analytics, technology and digital support, content-related process work, presentation specialists, and payer and health system support. Despite the ever-changing nature of the pharmaceutical industry, most responsibilities and outsourced work by MI groups remain the same over time. These findings provide MI teams various options for organizational structuring and resource strategies for MI services. These results highlight the services and focus areas that MI departments can explore and support the development of additional MI services across the pharmaceutical industry.

Cost effectiveness of in vitro fertilisation and preimplantation genetic testing to prevent transmission of BRCA1/2 mutations.

Is it cost-effective to use in vitro fertilisation and preimplantation genetic testing of monogenic defects (IVT/PGT-M) to prevent transmission of BRCA1/2 mutations to second-generation new births in comparison with naturally conceived births? In this cost-effectiveness analysis, we found that IVF/PGT-M is cost-effective for BRCA1 and BRCA2 mutation carriers if using a willingness to pay of $50 000 per quality-adjusted life-year (QALY). Carriers of a BRCA1 or BRCA2 mutation have a significantly increased risk of several types of cancer throughout their lifetime. The cost of risk reduction, screening and treatment of cancer in this population is high. In addition, there is a 50% chance of passing on this genetic mutation to each child. One option to avoid transmission of an inherited deleterious gene to one's offspring involves in vitro fertilisation with preimplantation genetic testing. We implemented a state transition model comparing the healthcare impact of a cohort of healthy children born after IVF/PGT-M, who have a population risk of developing cancer, to a cohort of naturally conceived live-births, half of whom are carriers of the BRCA mutation. Transition probabilities are based on published sources, a lifetime horizon and a perspective of a provincial Ministry of Health in Canada. The target population is the second-generation new births who have at least one parent with a known BRCA1 or BRCA2 mutation. At a willingness-to-pay threshold of $50 000 per QALY, IVF/PGT-M is a cost-effective intervention for carriers of either BRCA mutation. For BRCA1, the incremental cost-effectiveness ratio (ICER) for IVF/PGT-M is $14 242/QALY. For BRCA2, the ICER of intervention is $12 893/QALY. Probabilistic sensitivity analysis results show that IVF/PGT-M has a 98.4 and 97.3% chance of being cost-effective for BRCA1 and BRCA2 mutation carriers, respectively, at the $50 000/QALY threshold. Our model did not include the short-term negative effect of IVF/PGT-M on the woman's quality of life; in addition, our model did not consider any ethical issues related to post-implantation genetic testing. In countries in which the healthcare of a large segment of the population is covered by a single payer system such as the government, it would be cost-effective for that payer to cover the cost of IVF/PGT-M for couples in which one member has a BRCA mutation, in order to avoid the future costs and disutility of managing offspring with an inherited BRCA mutation. Dr Wong's research program was supported by the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council (NSERC), the Canadian Liver Foundation and an Ontario Ministry of Research, Innovation and Science Early Researcher Award. All authors declared no conflict of interests.

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians.

Visual Abstract.Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Visual Abstract. Envisioning a Better U.S. Health Care System for All: A...

The Impact of Diagnostic Assessment Programs on the Diagnosis and Treatment of Colon and Rectal cancers in a Single Payer System

Introduction: To streamline the diagnostic and pre-treatment assessments for patients with colorectal cancer, specialised Diagnostic Assessment Programs (DAPs) were developed across the province of Ontario, Canada. We compared the performance of DAPs with usual care (non-DAPs). Methods: Patients with colorectal cancer diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we compared wait times, healthcare utilization, and overall survival between DAP and non-DAP patients. Results: A total 2,606/18,046 (14%) colorectal cancer patients attended a DAP for part of their diagnostic assessment. DAP patients were younger, lived closer to a DAP, had higher income, were more likely to have stage 2-3 disease (versus stage 1), had tumors in the rectum or rectosigmoid junction, and were less likely to have been an inpatient at the time of diagnosis [odds ratio 3.39 (2.68-4.29)]. DAP patients were more likely to receive diagnostic imaging before treatment, consultation with a medical oncologist or radiation oncologist, and chemotherapy or radiation compared with non-DAP patients. After adjusting for case mix, DAP patients had a time until treatment that was longer by 9.5 (7.4, 11.5) days, but better overall survival than non-DAP patients [hazard ratio 0.84 (0.75-0.94)]. A longer time from diagnosis until treatment was not associated with worse overall survival [hazard ratio 0.96 (0.93-1.00)]. Conclusion: Colorectal DAPs provide more comprehensive healthcare and are associated with better overall survival. Wait-times as efficiency metrics should be interpreted carefully, as this is affected by triaging or enhanced treatment planning that may promote improved outcomes.

Budget impact analysis of multiple varicella vaccination strategies: a Mexico perspective

ABSTRACT A number of live-attenuated varicella vaccines are produced globally that provide protection against the varicella zoster virus. In Mexico, varicella vaccination is not included in the national immunization program and is recommended for use only in high-risk subgroups. We developed a budget impact model to estimate the impact of universal childhood immunization against varicella on the national payer system in Mexico. A scenario of no varicella vaccination was compared to scenarios with vaccination with a single dose at 13 months of age, in alignment with the existing program of immunization with the measles-mumps-rubella vaccine. Nine different vaccination scenarios were envisioned, differing by vaccine type and by coverage. Varicella cases and treatment costs of each scenario were computed in a dynamic transmission model of varicella epidemiology, calibrated to the population of Mexico. Unit costs were based on Mexico sources or were from the literature. The results indicated that each of the three vaccine types increased vaccine acquisition and administration expenditures but produced overall cost savings in each of the first 10 years of the program, due to fewer cases and reduced varicella treatment costs. A highly effective vaccine at 95% coverage produced the greatest cost savings.

“Formulating a New Healthcare System with Old Ideals: America’s Next Step”

The American healthcare system is in chaos. It is in shambles because of what American’s value and how they have changed over time. American values have changed with their healthcare system. To help adopt a single-payer system, Americans and their government need to see how their values can coexist with that system. Americans can become open to the idea by making a new system that appeals to what they value. The current healthcare system does not cover everyone, costs more than, and produces lower health outcomes compared to the rest of the developed world. If the American healthcare system is to adopt a single payer system, they would need to shape it around what they value as a nation.

Dasatinib and Nilotinib As Upfront Therapy for Chronic-Phase Chronic Myeloid Leukemia (CML-CP) in Qatar: A Cost Effectiveness Analysis (CEA)

Objectives: Many tyrosine kinase inhibitors (TKIs) are approved for treating the chronic phase of chronic myeloid leukemia (CML-CP). This study aims at identifying the optimal upfront TKI treatment strategy; considering cost-effectiveness for CML patients from Qatar healthcare system perspective. Evaluated strategies included the newer generation TKIs; dasatinib 100 mg once daily and nilotinib 300mg twice daily. We evaluated both treatments considering their molecular and cytogenetic response outcomes at 12 months follow up as well their respective acquisition costs. Methods: A decision tree model was developed linking clinical effectiveness (defined as major molecular response MMR and/or complete cytogenetic response CCyR), utility, and cost data over a 12-months period. The choice of 12 months period is due to the evidence that the degree of short-term molecular and cytogenetic responses at certain follow- up times is correlated with CML prognosis. Patients who achieve a CCyR are shown to have high remission rates as well overall survival (OS) rates. Patients with newly diagnosed CML are adopted from Qatar Cancer Registry.The probability of primary clinical outcome is calculated from DASISON (dasatinib) and ENESTnd (nilotinib) trials. Direct healthcare costs were derived from the national healthcare payer system, whereas ADR data were derived from local incident reporting system. Results: In the first-line treatments of CML patients, with greater MMR (39% nilotinib vs 12% dasatinib) and CCyR (24% nilotinib vs 16% dastinib) response outcomes, and more adverse drug reactions (ADR) than dasatinib (13.3% vs 4%), nilotinib use is more cost effective with annual costs (QAR 232,102) and after 12 months follow up. Despite the lower acquisition annual cost of dasatinib (QAR 217,125), the incremental cost effectiveness ratio (ICER) of nilotinib versus dasatinib per MMR/CCyR achieved was 56,506 QAR per year. There were no cases in both arms that progressed to accelerated or blast phase. At a threshold of 3 times GDP per capita of Qatar and according to WHO recommendation, the nilotinib use is still cost-effective. Limitations: For the surrogate outcome, we only consider the percentage of patients with or without MMR / CCyR response at 12 months. Nevertheless, we do not consider the depth and the duration of the MMR or CCyR. Conclusions: Upfront therapy of CML-CP patients by nilotinib plan appears to be more cost-effective than dasatinib. Although local real-life data for the effectiveness of these drugs are still warranted. The results of this study implying that nilotinib would be advantageous as first-line treatment for CML-CP patients from Qatar healthcare system perspective. Disclosures No relevant conflicts of interest to declare.

Outcome Among Adolescents and Young Adults with Acute Myeloid Leukemia at Pediatric Versus Adult Centers: A Population-Based Study Using the IMPACT Cohort

Background: Survival outcomes among adolescents and young adults (AYA) with acute myeloid leukemia (AML) remain poor. In AYA with acute lymphoblastic leukemia, outcomes differ between patients treated in pediatric vs. adult centers. This has not been well evaluated in AML. We therefore compared outcomes between AYA with AML treated at pediatric vs. adult centers using a population-based clinical database. In addition, we determined other predictors of outcome within this population. Methods: The IMPACT Cohort comprises all Ontario, Canada AYA aged 15-21 years diagnosed with one of six common cancers (including AML) between 1992-2012. Detailed demographic, disease, treatment, and outcome data were collected through chart abstraction and validated by content experts. Locus of cancer care (LOC - pediatric vs. adult center) was determined based on where the majority of therapy was delivered in the first three months after diagnosis. Linkage to population-based health administrative data identified additional cancer events (second cancers, relapse, death). Event-free (EFS) and overall survival (OS) were determined using Kaplan-Meier methods. The impact of LOC on EFS and OS was determined using multivariable Cox proportional hazard models, adjusting for demographic, disease, and treatment variables. Events included disease progression, relapse, death, and second malignancies. Results: Among 140 AYA with AML, 89 (63.6%) received therapy at an adult center. AYA treated in pediatric centers were younger than those treated at adult centers (median 16 years vs. 19 years; p<0.001) and were more likely to live in higher-income neighborhoods [37/51 (72.5%) vs. 47/89 (52.8%); p=0.02]. Disease markers such as presenting white blood cell count and AML subtype did not differ by LOC. The 5-year EFS and OS for the whole cohort were 35.0%±4.0% and 53.6%±4.2%. Neither EFS nor OS differed by LOC (Table 1). In multivariable analyses adjusting for disease characteristics, LOC was not predictive of either EFS [adult vs. pediatric center hazard ratio (HR) 1.3, 95thconfidence interval (CI) 0.8-2.2, p=0.27] or OS (HR 1.0, CI 0.6-1.6, p=0.97). AYA with AML living in rural areas however experienced significantly inferior outcomes as compared to their urban counterparts (EFS: HR 2.5, CI 1.3-4.7, p=0.005; OS: HR 2.0, CI 1.1-3.8, p=0.04). Conclusions: In this population-based cohort, outcomes did not differ between AYA with AML treated at pediatric vs. adult centers, unlike what has been previously shown in AYA with acute lymphoblastic leukemia. However, rural AYA experienced substantially inferior outcomes than urban AYA, suggesting that even within a universal single payer system of healthcare, socioeconomic disparities persist in this population. Disclosures No relevant conflicts of interest to declare.

PDG70 KNOWLEDGE, ATTITUDES AND PRACTICES OF MOROCCAN COMMUNITY PHARMACISTS TOWARDS THE THIRD-PARTY PAYER SYSTEM

The third-party payer system (TPPS) in pharmacy is officially launched in Morocco in July 2012. The main objective of the study is to evaluate the knowledge, attitudes and practices of the TPPS, to have an idea about its feasibility, acceptability by community pharmacists as well as its advantages and disadvantages. It’s an observational study conducted between January and June 2017 in several cities in Morocco. A questionnaire survey of 28 items was used. A convenience sampling was done. Data collection was made in electronic form and on paper. A total of 108 pharmacists were interviewed. 97% of pharmacists were aware of TPPS. However, only a third using it, the pharmacists interested are those who have a long experience (more than 10 years). Among those who are using it, more than the half process less than one prescription per trimester, About a quarter process more than 6 prescriptions per month. Only two-thirds have their National Professional ID (INP). Less than 5% have left the convention. Repayment is usually done in less than 2 months. The procedures are cumbersome and time consuming, they are more complicated when it comes to the CNOPS (national fund of social security organizations). 85% refuse to dispense the T4 bracket beyond 832 USD (public selling price), because it is below the break-even point. As benefits, community pharmacists say this system serves patients (61.5%), and contribute to recovering the pharmaceutical monopoly (24.6%). As disadvantages, pharmacists believe that their profit margin on these products is poor and not proportional to taxation. In addition, these drugs are too expensive and few pharmacies can acquire them. The TPPS is known but not widely used nor accepted by pharmacists. Improvements to the convention could certainly encourage their accession.

Transaksi Jual Beli Dengan Sistem Member Card Dalam Perspektif Ekonomi Islam (Penelitian Pada Toko Sophie Paris Hibrida Bengkulu)

The purpose of this study was to determine the legal system of member cards in buying and selling transactions in Sophie Paris Hybrid city of Bengkulu in the perspective of Islamic economics. This study used descriptive qualitative method. Data collection techniques carried out by observation, interviews and documentation. The research informants were determined by purposive sampling, namely the Business Center owner, Business Center assistant and member card user members. Data analysis was performed using data reduction techniques, data presentation and conclusion drawing. The results of this study conclude that: The member card system in buying and selling transactions at Sophie Paris who want to join as a member member pays Rp.70,000 registration fee, gets a bag, guidebook, and ID card, 30% discount on Sophie Paris catalog 20% Sunday catalog, bonuses and rewards for each rank up. The member card system in buying and selling transactions in the perspective of Islamic economics that is given free or paid at the beginning of registration is legitimate and permissible, if not contrary to Islamic economic principles. From the explanation of the fatwa institutions it can be understood that the member card system is not allowed to collect money for take advantage of consumers who want to become members, but the collection of money is permitted if the money withdrawn from the member card holder is only limited to the cost of making the card and the issuer does not take advantage of the card issuance at all. The member card system at Sophie Paris Hybrid with a paid system at the beginning of the registration must not be because the registration or administration money is not a substitute for making member card financing but registration money if you want to join as a member member.

Values-Based Interventions in Patient Engagement for Those with Complex Needs.

The objective was to evaluate a novel intervention that integrates a psychological, values-based approach with coordinated care management. This paper describes an integrated comprehensive health record system to enhance engagement with a subset of those with complex needs; those who are high-needs, high-cost (HNHC). Patients are selected after conducting data analysis on the most costly and complex patients of a payer system that works with HNHC patients. Specifically, the Patient Care Intervention Center in Houston TX, applies the values-based intervention to HNHC patients. This pilot study reports data from 18 HNHC patients over 6 months; specifically, outcomes related to daily functioning, depression, working alliance, stages of change, and overall well-being. Additionally, this paper reports preliminary findings from qualitative monitoring of provider experiences implementing the values-based approach and integrated evaluation. HNHC patients improved their daily functioning over 4 months but no other significant changes were found over time. Patients self-reported mild depression, strong working alliances with their provider, being in the contemplation phase of change, and moderate well-being. There also was variation when patients completed the assessments and data points were collected. Although this is a small sample and short time frame, preliminary results suggest that the intervention has a positive impact on HNHC patient daily functioning. Provider accounts of the implementation describe using the evaluation items to inform their interactions with patients, and also suggest that patient literacy level impacts when data can be collected. Other changes to the approach are suggested.