Per Member Per Year Research Articles

Budget impact analysis of introducing fruquintinib for metastatic colorectal cancer previously treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy and biologics in the United States from the payer perspective

Aims Fruquintinib is a selective small molecule tyrosine kinase inhibitor of vascular endothelial growth factor receptor (VEGFR)-1, -2, and -3 recently approved in the United States (US) for the treatment of adult patients with metastatic colorectal cancer (CRC) who have previously been treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF biological therapy, and if RAS wild-type and medically appropriate, anti-epidermal growth factor receptor therapy. This study aimed to estimate the 5-year budget impact of fruquintinib from a US payer perspective (commercial and Medicare). Materials and methods A budget impact model was developed to compare two scenarios: a reference scenario in which patients received regorafenib, trifluridine/tipiracil, or trifluridine/tipiracil with bevacizumab and an alternative scenario in which patients received reference scenario treatments or fruquintinib. Market shares were evenly divided across available options. A 5-year time horizon and a hypothetical health plan of 1 million members was assumed. The model included epidemiological inputs to estimate the eligible population; clinical inputs for treatment duration, progression-free survival, overall survival, and adverse event (AE) frequency; and cost inputs for treatment, AEs, disease management, subsequent therapy, and terminal care costs. Budget impact was reported as total, per member per year (PMPY), and per member per month (PMPM). Results The model estimated an eligible population of 194 patients (39 per year) over 5 years. In the base case, the estimated 5-year budget impact of fruquintinib was $4,077,073 ($0.82 PMPY and 0.07 PMPM) for a commercial health plan. During the first year, the estimated budget impact was $627,570 ($0.63 PMPY and 0.05 PMPM). Results were robust across sensitivity analyses. PMPM costs from the Medicare perspective were greater than the base-case (commercial) ($0.17 vs. $0.07) due to higher incidence of CRC in that population. Conclusions Fruquintinib is associated with a low budget impact for payers based on proposed thresholds in the US.

Expenditure mapping of pediatric imaging costs using a resource utilization band analysis of claims data

ObjectiveTo segregate imaging expenditures from claims data by resource utilization bands (RUBs) and underlying conditions to create an “expenditure map” of pediatric imaging costs. MethodsA Claims data for children enrolled in a commercial value-based plan were categorized by RUB 0 non-user, 1 healthy user, 2 low morbidity, 3 moderate morbidity, 4 high morbidity, & 5 very high morbidity. The per member per year (PMPY) expense, total imaging spend, and imaging modality with the highest spend were assessed for each RUB. Diagnosis categories associated with high imaging costs were also evaluated. ResultsThere were 40,022 pediatric plan members. 14% had imaging-related claims accounting for approximately $2.8 million in expenditures. Member distribution and mean PMPY expenditure RUB was respectively: RUB 0 (3,037, $0), RUB 1 (6,604, $7), RUB 2 – 13,698, $27), RUB 3 – 13,341, $87), RUB 4 (2,810, $268), RUB 5 (532, $841). RUB 3 had the largest total imaging costs at $1,159,523. The imaging modality with the greatest mean PMPY expense varied by RUB with radiography highest in lower RUBs and MRI highest in higher RUBs. The top 3 diagnoses associated with the highest total imaging costs were developmental disorders ($443,980), asthma ($388,797), and congenital heart disease ($294,977) and greatest mean PMPY imaging expenditures malignancy/leukemia ($3,100), transplant ($2,639), and tracheostomy ($1,661). DiscussionExpense mapping using claims data allows for a better understanding of the distribution of imaging costs across a covered pediatric population. This tool may assist organizations in planning effective cost-reduction initiatives and learning how imaging utilization varies by patient complexity in their system.

Health Care Utilization and Costs Associated With Empagliflozin in Older Adults With Type 2 Diabetes.

We compared health care resource utilization (HCRU) and costs for inpatient and outpatient services and dispensed medications in older adults with type 2 diabetes initiating empagliflozin versus dipeptidyl peptidase 4 inhibitors (DPP-4is). The study population included U.S. Medicare fee-for-service beneficiaries with diabetes (age ≥65 years) initiating empagliflozin or DPP-4is (August 2014 to September 2018). We estimated rate ratios (RRs) for HCRU outcomes using zero-inflated negative binomial regression and per-member per-year (PMPY) cost differences using generalized linear model with gamma distributions, overall and stratified by baseline cardiovascular disease (CVD), after adjusting for 143 baseline covariates using 1:1 propensity score matching. We identified 23,335 matched pairs (mean age 72 years, 51% with baseline CVD). HCRU rates were lower in empagliflozin versus DPP-4i initiators (number of inpatient days, RR 0.89 [95% CI 0.82, 0.97]; number of emergency department [ED] visits, 0.86 [0.82, 0.91]; number of hospitalizations, 0.86 [0.79, 0.93]; number of office visits, 0.96 [0.95, 0.98]). Inpatient cost (-$713 PMPY [95% CI -847, -579), outpatient cost (-$198 PMPY[-272, -124]), and total cost of care (-$1,109 PMPY [-1,478, -739]) were lower for empagliflozin versus DPP-4is, although diabetes medication cost was higher in empagliflozin initiators ($454 PMPY [95% CI 284, 567]). In the CVD subgroup, total cost was lower for empagliflozin initiators (-$2,005 PMPY [-2,451, -1,337]), while the difference was attenuated in the non-CVD subgroup (-$296 PMPY[-740, 148]). Among older adults with diabetes, empagliflozin was associated with a lower number of inpatient days, hospitalizations, ED visits, and office visits and with lower costs of care compared with DPP-4is, especially in those with history of CVD.

COST-DRIVERS OF HEALTHCARE EXPENDITURES IN INFLAMMATORY BOWEL DISEASE

Abstract INTRODUCTION Inflammatory bowel diseases (IBD) are gastrointestinal (GI) conditions associated with significant costs. Effective management of IBD should focus on improving patient symptoms and outcomes while containing healthcare costs. To develop high-value treatment strategies and influence policy on high-value care, we must first have a better understanding of the primary drivers of cost in this population. METHODS We conducted a real-world descriptive cohort study using data from IBM Watson, which is a nationwide insurance claims database covering millions of commercially insured individuals across the US. We identified adult patients aged 18 to 65 years with encounters associated with a diagnosis of IBD in the primary or secondary position from January 2019 to January 2020 based on ICD-10-CM codes for Crohn's disease (555.x) and ulcerative colitis (556.x). Analysis of IBD prevalence, costs, and service utilization was based on ICD, CPT, and NDC codes related to IBD conditions and services. All other codes without an associated GI diagnosis in the primary or secondary position were attributed to all-cause costs. Measures of cost and utilization were calculated as a per member per year (PMPY). RESULTS 105,496 patients with IBD were identified (Table 1). The mean PMPY total costs were $40,842 of which $31,051 (76%) were directly related to GI-related costs. Mean PMPY total costs in this population ranged from $1,178 to $144,945, with 15% of members experiencing costs > $76,346 PMPY. The main drives of GI-related costs can be divided into the following three categories: Inpatient costs ($8,206 [26%]), outpatient medical service costs ($11,306 [36%]), and drug costs ($11,539 [37%]) (Table 2). Per member utilization includes: 0.22 inpatient admissions, 0.10 surgeries, 1.02 GI visits, 2.87 non-gastroenterologist GI visit (which could include a visit to a primary medical doctor, rheumatologist, dietician, etc), 4.57 GI-testing, 0.48 GI imaging, 0.61 GI endoscopy, and 1.07 biologic medication prescriptions. CONCLUSIONS IBD care carries a significant financial burden on the US healthcare system. Unplanned emergency service and medication utilization continue to make up the majority of costs of IBD care and need to be the focus of value-based interventions. While appropriate high-cost pharmaceutical utilization should not be reduced, innovative strategies leveraging more cost-effective medication delivery may provide an important opportunity to curb costs. Furthermore, the high rate of non-gastroenterologist GI visits suggests that there is a potential for optimizing care pathways, by incorporating multidisciplinary care including, PCPs, mid-level providers, and other ancillary services into the IBD care model.

BUDGET IMPACT OF MIRIKIZUMAB-MRKZ IN THE TREATMENT OF ADULT PATIENTS WITH MODERATELY-TO-SEVERELY ACTIVE ULCERATIVE COLITIS IN THE UNITED STATES

Abstract BACKGROUND Mirikizumab (miri), an IL-23p19 antagonist, is undergoing US FDA review for treatment of moderately-to-severely active ulcerative colitis (UC) in adults. However, the budget impact of its addition to payer formularies is unknown. METHODS A de novo budget impact model was developed to estimate the cost of introducing miri to the formulary of a hypothetical one-million-member health insurance plan. Epidemiological inputs drew primarily from published sources, while market research informed the current and future market share of advanced therapies. The model accounted for drug acquisition, drug administration, treatment monitoring, and adverse event management, derived from US prescribing information, trial results, and published sources. Discontinuation and dose escalation rates were based on the literature, applying assumptions where data gaps existed. In the base case, the model assumed that half of miri’s market share would be accrued from ustekinumab (an IL-12/IL-23 antagonist). The base-case analysis adopted a US commercial payer perspective over a 3-year period. Deterministic sensitivity analyses (DSA) assessed the implications of uncertainty in model inputs, while scenario analyses estimated budget impact under alternative assumptions about the origin of miri’s market share, and about the patient population under consideration. RESULTS In the base-case, 445, 480, and 515 patients were predicted eligible for advanced therapies for UC in Year1, Year2, and Year3, respectively with total UC drug management expenditures of $137.4 million over three years. Introducing miri to formulary for moderately-to-severely active UC yielded cumulative incremental costs of $1.3 million (relative impact=0.93%), equivalent to $0.04 per member per month (PMPM) or $0.43 per member per year (PMPY). Among patients who had already failed an advanced therapy, miri yielded lower cumulative incremental costs of $0.8 million (relative impact=1.1%), equivalent to $0.02 PMPM/$0.28 PMPY, consistent with the more narrowly defined eligible patient population (219, 252, and 284 patients in Year1, Year2, and Year3, respectively). In the scenario in which miri’s market share derived only from ustekinumab, the model predicted total cost savings of $2.6 million over three years (relative impact=-1.9%), as well as PMPM savings of $0.07 and PMPY savings of $0.85, due to higher estimated average drug costs associated with ustekinumab. DSA results suggested that base-case results were robust to uncertainty in the value of key model parameters. CONCLUSION Introducing miri to formulary for moderately-to-severely active UC may offer patients and clinicians an additional therapeutic option to manage this challenging and debilitating condition at minimal added cost to payers. The addition of miri to formulary could be relatively budget neutral or cost saving in some contexts.

Evaluation of claims data from a commercial value-based insurance product shows pediatric imaging is not a major driver of overall or pediatric healthcare expenditures.

Initiatives to reduce healthcare expenditures often focus on imaging, suggesting that imaging is a major driver of cost. To evaluate medical expenditures and determine if imaging was a major driver in pediatric as compared to adult populations. We reviewed all claims data for members in a value-based contract between a commercial insurer and a healthcare system for calendar years 2021 and 2022. For both pediatric (<18 years of age) and adult populations, we analyzed average per member per year (PMPY) medical expenditures related to imaging as well as other categories of large medical expenses. Average PMPY expenditures were compared between adult and pediatric patients. Children made up approximately 20% of members and 21% of member months but only 8-9% of expenditures. Imaging expenditures in pediatric members were 0.2% of the total healthcare spend and 2.9% of total pediatric expenditures. Imaging expenditures per member were seven times greater in adults than children. The rank order of imaging expenditures and imaging modalities was also different in pediatric as compared to adult members. Evaluation of claims data from a commercial value-based insurance product shows that pediatric imaging is not a major driver of overall, nor pediatric only, healthcare expenditures.

Assessing the impact of recovery housing on healthcare utilization in Portland, Oregon

IntroductionCentral City Concern (CCC) operates several recovery housing sites in the Portland, Oregon metropolitan region, including the Blackburn Center (Blackburn) and the Richard L. Harris Building (Harris). This retrospective, observational study was designed to assess recovery housing's impact on inpatient detoxification readmission rates and healthcare utilization patterns. MethodsOur study population consisted of individuals discharged from CCC's Hooper Detox Stabilization Center from June 2019 to September 2020. A total of 75 clients housed at Blackburn, 63 clients housed at Harris, and 57 clients discharged as unhoused were included in the study sample. Using logistic regression for each of the two recovery housing groups relative to the unhoused group, we examined differences in readmissions to inpatient detoxification after their qualifying discharge. We then used Difference-In-Difference model to compare the per member per year (PMPY) use of different domains of health care before and after their qualifying discharge. ResultsCompared to clients discharged as unhoused, Blackburn and Harris residents had lower risk of readmissions to inpatient detoxification treatment at 90- and 180-days post-discharge. Additionally, while the mean number of PMPY emergency department visits increased for clients discharged as unhoused in the post period, the average number of emergency department visits decreased for clients who obtained recovery housing at Blackburn (DiD=-3.65 PMPY, p-value=0.02) and at Harris (DiD=-3.87 PMPY, p-value=0.01). ConclusionFindings highlight the impact and importance of recovery housing for individuals managing a substance use disorder and the value of healthcare system and public sector investment housing like Blackburn and Harris.

270-OR: Health Care Utilization and Cost Associated with Empagliflozin in Older Adults with Type 2 Diabetes—Results from the EMPRISE study

Within the EMPRISE study program, we compared the cost and healthcare utilization of empagliflozin (EMPA) vs. dipeptidyl peptidase-4 inhibitors (DPP-4i) using Medicare data (2014-18). We identified 23,335 pairs of 1:1 propensity score-matched patients aged ≥65 years with type 2 diabetes (T2D) initiating EMPA or a DPP-4i, overall and stratified by baseline cardiovascular disease (CVD). We estimated ratios and differences in rates of healthcare utilization per 1,000 person-years, and costs per member per year (PMPY) for EMPA vs. DPP-4i using zero-inflated negative binomial or gamma models. Compared to DPP-4i, EMPA was associated with lower rates of hospital days [rate ratio (RR) (95% CI) 0.89 (0.82, 0.97); rate difference (RD) -557 (-587, -528)], number of hospitalizations [RR 0.86 (0.79, 0.93); RD -73 (-84, -61)], and number of emergency visits [RR 0.86 (0.82, 0.91); RD -128 (-145, -111)]. Estimates were similar when stratified by baseline CVD. Relative to DPP-4i, EMPA was associated with lower total costs in USD [RR 0.94 (0.92, 0.96); PMPY -1109 (-1478, -739)], and inpatient costs [RR 0.84 (0.81, 0.87); PMPY -713 (-847, -579)], and nearly-similar pharmacy costs [RR 1.04 (1.02, 1.06); PMPY 355 (177, 532)]. RRs in baseline CVD subgroups were similar, but absolute RDs were larger in those with CVD. Relative to DPP-4i, EMPA reduced healthcare utilization and costs in routine care. Disclosure P.T.Htoo: Employee; Johnson &amp; Johnson. E.Patorno: Research Support; Boehringer Ingelheim Inc., National Institutes of Health, Patient-Centered Outcomes Research Institute, US Food and Drug Administration. H.Tesfaye: None. S.Schneeweiss: Consultant; Aetion, Inc., Research Support; UCB, Inc., Boehringer Ingelheim International GmbH, Stock/Shareholder; Aetion, Inc. D.J.Wexler: Other Relationship; Novo Nordisk A/S. R.Glynn: Research Support; Amarin Corporation, AstraZeneca, Kowa Pharmaceuticals America, Inc., Novartis, Pfizer Inc. N.Schmedt: Employee; Boehringer Ingelheim International GmbH. A.Deruaz-luyet: Employee; Boehringer Ingelheim International GmbH. L.Koeneman: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. J.M.Paik: None. Funding Boehringer Ingelheim (116283)

EE78 Budget Impact Analysis of Proactive Therapeutic Drug Monitoring for Inflammatory Bowel Disease Patients in the United States on Infliximab Therapy

Therapeutic Drug Monitoring (TDM), to measure drug and anti-drug antibodies and guide therapeutic adjustments, has been associated with positive clinical outcomes when using biologics such as infliximab (IFX) to treat inflammatory bowel disease (IBD). TDM may be ordered reactively or proactively as the preferred standard of care versus empiric dosing. This study aims to estimate the 2021 incremental budgetary change in per member per year (PMPY) in the US when a proactive TDM approach is implemented for IBD patients treated with IFX.

Budget Impact of the Vest™ High Frequency Chest Wall Oscillation System for Managing Airway Clearance in Patients with Complex Neurological Disorders: A US Healthcare Payers' Perspective Analysis.

ObjectiveAs a recognized therapy to improve airway clearance, high-frequency chest wall oscillation (HFCWO) is used to manage reduced vital capacity in patients with complex neuromuscular disorders (cNMD). This study aimed to investigate the budget impact of HFCWO versus chest wall physical therapy (CWPT) from a US-commercial payer perspective.MethodsIn combination with a previously developed cost-effectiveness model, a budget impact model was developed to evaluate the incremental budgetary impact associated with introducing a HFCWO device over a 5-year time horizon. The model compared the cost implications associated with the commonly used CWPT procedure, as the current scenario, with a new scenario consisting of 80% of market share for HFCWO. The resource use and costs included in the analyses were costs associated with the HFCWO device (Vest™ System) and its consumables, patient training, and medical services such as hospitalization, medications, emergency room, and outpatient visits. The primary outcome measures included total and incremental budgetary impact per member per year (PMPY).ResultsIn a hypothetical plan of 1,000,000 members (men: 49.2%), 2099 patients with cNMD were estimated to be eligible to receive airway clearance services over 5 years. The new scenario (HFCWO and CWPT [US$24 PMPY]) was cost-saving compared with the current scenario (CWPT only [$34 PMPY]) with a cost reduction of US$9.46 PMPY. The model estimated a net cost-saving of US$1,594,131 and US$9,591,343 over 1 and 5 years, respectively.ConclusionThis study suggests the HFCWO technique to manage the reduction in vital capacity in patients with cNMD would lead to favorable budget impact results.

Budget Impact of Belantamab Mafodotin (Belamaf) Adoption in the Treatment of Patients with Relapsed or Refractory Multiple Myeloma in the United States

PurposeEstimate the budget impact of belantamab mafodotin (belamaf) for patients with relapsed/refractory multiple myeloma (RRMM) who have received ≥4 prior therapies, including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent.MethodsA budget impact analysis (BIA) was developed to estimate the cost difference between current (no belamaf) and projected (with belamaf) market scenarios over 3 years. Comparators were identified from a systematic literature review and included selinexor + dexamethasone or best supportive care. The number of treatment-eligible patients were estimated using an epidemiology model. Base-case analyses were conducted from a US commercial payer perspective (cost year: 2019). Model inputs included market share estimates, treatment duration, and costs of drug acquisition/administration, concomitant medications, adverse event (AE) management, treatment monitoring, and subsequent treatments based on published literature/cost databases. Budget impact, calculated as the difference in costs between current and projected scenarios over 3 years, was reported as cost per member per month (PMPM) and per member per year (PMPY). One-way sensitivity analysis assessed which key parameters most affected model outcomes. Alternative scenarios were tested (1- or 5-year time horizon; Medicare perspective; negligible cost of mental status change AE).ResultsIn a hypothetical commercial payer health plan with 1 million members, 33 patients were identified as treatment-eligible over 3 years. Introducing belamaf for patients with RRMM resulted in an estimated budget-neutral PMPM cost of −$0.0003 and PMPY of −$0.004, based on n=9/33 patients receiving treatment. Sensitivity analyses showed that budget impact in the base case was most sensitive to changes in treatment duration and drug acquisition costs. Base-case results were consistent across all scenarios assessed.ConclusionBIA indicates that adoption of belamaf in this patient population would be budget neutral for a US health plan.

Budget Impact Analysis of Switching Chemotherapy Patients Using Granulocyte Colony-Stimulating Factors (G-CSFs) from Pegfilgrastim to Short-Acting G-CSFs in the United States

Introduction: Neutropenia is a common complication in patients receiving myelosuppressive chemotherapy for nonmyeloid malignancies. Severe and febrile neutropenia (FN) are associated with prolonged hospitalization, serious infections and broad-spectrum antibiotic use, decreased quality of life, and increased medical costs and mortality. G-CSFs are often administered to reduce incidence, severity, and duration of FN in chemotherapy patients. While pegfilgrastim is dosed once per chemotherapy cycle (14-day efficacy), data suggest the average duration of short-acting G-CSF use is considerably shorter than 14 days. This analysis estimated the budget impact of increasing utilization of short-acting G-CSFs (filgrastim [Neupogen®], tbo-filgrastim [Granix®, a filgrastim follow-on biologic], and filgrastim-sndz [Zarxio®, a filgrastim biosimilar]) while decreasing utilization of long-acting pegfilgrastim (Neulasta®) products for patients with nonmyeloid malignancies treated with myelosuppressive chemotherapy from a US payer perspective.Methods: An interactive budget impact model was developed to estimate changes in drug and administration costs associated with a projected 10% reduction in pegfilgrastim market share (an estimated 7.6% of the total G-CSF market) and an equal increase split evenly across short-acting product lines (approximately 1/3 allocated to 300-mcg products and 2/3 allocated to 480-mg products within product lines) for patients with nonmyeloid malignancies treated with myelosuppressive chemotherapy within a 1-million-member health plan. Patient self-administration at home was assumed for 40% of patients receiving short-acting G-CSFs and 10% of patients receiving long-acting agents, with the remaining administered by health care provider (HCP) in an office or other outpatient setting. Patients receiving short-acting G-CSFs were assumed to require 10 doses per chemotherapy cycle, with long-acting agents given once per cycle. Self-administered products were purchased via the patient's pharmacy benefit at an assumed Tier 3 formulary status with a patient copay of $57 per prescription. HCP-administered products were assumed to be primarily (85%) purchased through the patient's medical benefit and provided on site, while a small proportion of patients (15%) were assumed to purchase G-CSFs through their pharmacy benefit to be HCP administered; in both cases, administration costs for injections were included, and with pharmacy benefit adjudication, a patient drug cost-share was applied ($57 per prescription). Base-case data were derived from publicly available resources. The budget impact was calculated using a 1-year time horizon, along with the difference in effective per-member per-year (PMPY) cost between current and proposed scenarios; univariate sensitivity analyses were conducted.Results: The effective annual per-patient plan drug costs ranged from $12,288 to $30,772 for short-acting G-CSFs and from $27,013 to $33,698 for pegfilgrastim (depending on dose and adjudication channel per product). The estimated total effective annual plan cost prior to the utilization shift was $425,518,352 (PMPY = $425.53) and was $419,985,093 (PMPY = $419.99) following the shift. The home administration budget increased by $5,793,056, while the HCP administration budget decreased by $11,326,314, for an overall annual cost savings of $5,533,259 (PMPY = $5.54). Per-patient savings for tbo-filgrastim and filgrastim-sndz ranged from 16.1% to 54.5%, depending on dose and adjudication channel. The model was most sensitive to changes in pegfilgrastim acquisition cost and the patient's medical benefit cost-share.Conclusions: Budget impact analyses examine the financial impact associated with the introduction of new treatments or shifting existing treatment patterns to help decision makers determine how best to allocate resources. Without considering additional impacts of health plan contracted rates and manufacturer rebates, the annual plan per-patient drug cost for tbo-filgrastim and filgrastim-sndz formulations were substantially less expensive than pegfilgrastim for an average treatment cycle. This analysis estimated an annual US health plan cost savings of over $5.5 million or more than $5.50 PMPY following an overall 7.6% utilization shift from long-acting to short-acting G-CSFs. DisclosuresJames:Teva Pharmaceuticals: Consultancy. Trautman:Teva Pharmaceuticals: Consultancy. Szabo:Teva Pharmaceuticals: Employment. Tang:Teva Pharmaceuticals: Employment.

PP459 Healthcare Resource Utilisation Of Anti-Neutrophil Cytoplasmic Antibody Associated Vasculitis Patients: Real-World Data From English Clinical Practice Research Datalink

IntroductionAnti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a rare, serious and often life-threatening disease. The use of available treatments options (immunosuppressants and glucocorticoids (GCs)) improves the prognosis of AAV greatly; however, GC use is associated with significant toxicity related morbidities and the management of AAV is costly. However, information of the costs associated with AAV in the United Kingdom is limited. This study aimed to quantify the burden of AAV using a large England and Wales source of real-world data, the Clinical Practice Research Datalink (CPRD) Hospital Episode Statistics (HES) linked database, to identify healthcare resource utilization and generate estimates of costs.MethodsIncident patients (n = 220) were included if ≥ eighteen years, with diagnosis read codes G754.00/G75A.00; ICD codes M31.3/M31.7 from January 1997 to December 2017. Costs were taken from Unit Costs of Social and Health Care, National Health Service reference costs and electronic drug tariff. Distinction was made between type of consultations, outpatient visits and inpatient admission based on Healthcare Resource Grouping. Costs were summarised as mean per member per year (PMPY) in 2016 prices and presented before and after diagnosis.ResultsIn the year preceding AAV diagnosis, mean costs PMPY were GBP12,012 [USD15,400], (GBP5,339 [USD6,845] inpatient, GBP766 [USD982] outpatient, GBP314 [USD403] GP, GBP5,594 [USD7,172] GP prescribing). In the year of AAV diagnosis (Y0) costs PMPY were GBP28,252 [USD36,220], GBP15,436 [USD19,790] inpatient, GBP1,863 [USD2,388] outpatient, GBP2,407 [USD3,086] GBP8,545 [USD10,956] GP prescribing). Costs in the years post-diagnosis remained higher than pre-diagnosis with a low of GBP22,839 [USD29,281] in Y4. The prescribing costs (GC, methotrexate and azathioprine) were the largest contributor in Y0-Y4 (GBP15,047 [USD19,291] Y1; GBP12,325 [USD15,801] Y4).ConclusionsDiagnosis of AAV is associated with increased healthcare costs, including higher inpatients costs in the year of diagnosis and subsequently higher prescribing costs in the community. Given the incidence (17.2 cases per million) and considering only costs in the year of diagnosis, an additional GBP15.6 million [USD24.6 million] of healthcare resource utilization occurs every year from new diagnoses of AAV. However, this will likely be underestimated due to the lack of secondary care prescribing data in CPRD-HES and prescribing of immunosuppressant treatments in this setting.

Costs associated with renal and cardiovascular events among patients with type 2 diabetes mellitus and nephropathy: a cost model based on the CREDENCE clinical trial

Objective To estimate the avoided costs associated with reductions in end-stage kidney disease (ESKD), certain CV events (non-fatal myocardial infarction [MI], non-fatal stroke, hospitalization for heart failure [HHF]), and renal and CV death for patients treated with canagliflozin versus placebo, based on CREDENCE trial results. Methods Renal (including ESKD) and CV events averted, based on the differences in adjusted rates of events between the canagliflozin and placebo arms in CREDENCE, were projected to the proportion of the members of a managed care organization (MCO) fitting the inclusion criteria in CREDENCE (i.e. diabetic nephropathy, at least 30 years old). The number of events averted for the population was multiplied by the unit-cost of the event, extracted from a targeted literature review, to obtain costs avoided per member per year (PMPY). One-way sensitivity analysis provided a range for the cost avoided PMPY, based on variations in the events averted, unit cost and size of the projected population. Results Costs avoided PMPY were $2.92 for ESKD with a range of $1.28–$4.20. Costs avoided PMPY were $0.54 (-$0.28–$1.16) for non-fatal MI, $0.30 (-$0.22–$0.65) for non-fatal stroke, $1.56 ($0.80–$2.11) for HHF, $0.06 ($0.05–$0.07) for renal death, and $0.51 ($0.00–$0.91) for CV death. For non-fatal MI and non-fatal stroke, the lower bound of the range is interpreted as an incremental cost. Conclusions Positive costs avoided for each of the outcomes considered were predicted in the main analysis, with ESKD as the outcome predicted to have the greatest costs avoided at $2.92 PMPY.

Anticoagulation Therapy in Patients with Non-valvular Atrial Fibrillation in a Private Setting in Brazil: A Real-World Study.

ResumoFundamento:A segurança e a eficácia da varfarina dependem da qualidade do controle da anticoagulação. Estudos observacionais associam controle deficiente com aumento de morbidade, mortalidade e custos com saúde.Objetivos:Desenvolver um perfil de pacientes com fibrilação atrial não valvar (FANV) tratados com varfarina em ambiente ambulatorial e hospitalar privado brasileiro, avaliar a qualidade do controle da anticoagulação e sua associação com resultados clínicos e econômicos.Métodos:Este estudo retrospectivo, por meio de um conjunto de dados de seguros privados de saúde no Brasil, identificou pacientes com FANV tratados com varfarina entre 01 de maio de 2014 a 30 de abril de 2016, descreveu seu manejo da anticoagulação e quantificou os custos relacionados à doença. Foram recuperados dados demográficos, histórico clínico, medicação concomitante e tempo na faixa terapêutica (TTR) dos valores da razão normalizada internacional (RNI). Os pacientes foram agrupados em quartis de TTR, com um bom controle sendo definido como TTR ≥65% (método de Rosendaal). Sangramentos maiores e custos médicos diretos por todas as causas foram calculados e comparados entre subgrupos de controle bons e ruins. Valores de p < 0,05 foram considerados estatisticamente significantes.Resultados:A análise incluiu 1220 pacientes (mediana de seguimento: 1,5 anos; IIQ: 0,5–2,0). Em média, cada paciente recebeu 0,95 medidas mensais de RNI (RNI média: 2,60 ± 0,88, com 26,1% dos valores < 2 e 24,8% > 3), (mediana de TTR: 58%; IIQ: 47-68%), (TTR médio: 56,6% ± 18,9%). Apenas 31% dos pacientes estavam bem controlados (TTR médio: 78% ± 10%), com 1,6% apresentando grandes sangramentos na mediana do seguimento e custos médicos diretos por membro por ano (PMPY) de R$25.352 (± R$37.762). Pacientes com controle abaixo do ideal (69%) foram associados a 3,3 vezes mais sangramentos graves (5,3% vs. 1,6%; p <0,01) e custos 40% maiores (R$35.384 vs. R$25.352; p < 0,01).Conclusões:Mais de 60% dos pacientes estavam abaixo da meta desejada e os custos associados foram significativamente maiores nesta população.

Economic Outcomes Following Combinatorial Pharmacogenomic Testing for Elderly Psychiatric Patients.

We compared economic outcomes when elderly patients with neuropsychiatric disorders received psychotropic medications guided by a combinatorial pharmacogenomic (PGx) test. This is a subanalysis of a 1-year prospective assessment of medication cost for patients with neuropsychiatric disorders receiving combinatorial PGx testing. Pharmacy claims were used to compare per member per year (PMPY) medication cost for patients ≥65 and <65 years old when medications were congruent or incongruent with the PGx test. Polypharmacy was also assessed. Congruent prescribing was associated with savings of US$3497 PMPY (P < .001) for patients ≥65 years and US$2467 PMPY (P < .001) for patients <65, compared to incongruent prescribing. Congruent prescribing in patients ≥65 treated by primary care providers was associated with US$4113 PMPY (P = .026) in savings, while congruent prescribing by psychiatrists was associated with US$120 PMPY (P = .719). Congruent prescribing was also associated with one fewer neuropsychiatric medication for patients ≥65 (P = .070). Congruence with PGx testing was associated with medication cost savings in elderly patients.

Actionable Real-World Evidence to Improve Health Outcomes and Reduce Medical Spending Among Risk-Stratified Patients with Diabetes.

Type 2 diabetes mellitus (T2DM) is a chronic condition with a high economic burden as well as drug treatments that have not all demonstrated effects on longevity. Managed care organizations want to improve health outcomes in these complex patients but lack actionable evidence to make informed decisions on which therapies are most effective among their members and may also control total health care spending. To produce actionable evidence by identifying antidiabetic treatments that are effective and may reduce total cost of care in various risk groups of patients with T2DM, using insurance claims data that includes medical claims and pharmacy dispensing data among members of Horizon Blue Cross Blue Shield of New Jersey with T2DM. We identified patients with T2DM in longitudinal claims data from Horizon between 2014 and 2017 with demographic and enrollment information, inpatient and outpatient diagnoses and procedures, and pharmacy dispensing. Outcomes included myocardial infarction, heart failure (HF), stroke, percutaneous revascularization, health care services utilization, and plan costs (i.e., medical, pharmacy, and total cost of care). After propensity score decile adjustment on over 20 covariates, we evaluated the effectiveness and safety of second-line antidiabetic treatment that included sodium-glucose co-transporter-2 (SGLT-2) inhibitors, sulfonylureas (SUs), dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Among 115,308 members with T2DM, the most common comorbidities were cardiovascular risk factors, including hyperlipidemia (56%), hypertension (50%), and existing cardiovascular disease (CVD; 55%). Among members receiving dual antidiabetic treatment (n = 20,204), the most prevalent treatments were metformin plus the following second-line medications: SUs (42%), DPP-4 inhibitors (29%), SGLT-2 inhibitors (10%), or GLP-1 receptor agonists (3%). Approximately 20% of members accounted for 79% of total cost of care, with an average of $9,605 per member per year (PMPY). Compared with SU initiation and after propensity score decile adjustment, new users of SGLT-2 inhibitors had a reduced risk for HF hospitalization (HR = 0.35, 95% CI = 0.13-0.89), hypoglycemia, albuminuria, microvascular disease, and metabolic failure. Among SGLT-2 inhibitor initiators with established CVD, the savings in total cost of care compared with SU initiators was $5,520 per member over an average treatment duration of 6 months and an approximate savings of $11,000 PMPY if patients persisted on treatment for 12 months. In the Horizon membership, we confirmed that SGLT-2 inhibitors reduce HF hospitalizations, resulting in reduced medical spending and savings in total cost of care. Regulatory-grade analytics of local data provided the confidence to encourage increased SGLT-2 inhibitor use to produce better outcomes and save total cost of care despite higher pharmacy spending. This research did not receive outside funding; however, Aetion has since begun a contractual relationship with Horizon Blue Cross Blue Shield of New Jersey. Garry, Petruski-Ivleva, Cheever, and Rajan are employees of and have stock options in Aetion, a company that makes software for the analysis of real-world data. Eapen was an employee of Aetion during the implementation of this study. Rassen is an employee of and has ownership interest in Aetion. Murk is a consultant to Aetion of which he owns equity. Schneeweiss is a consultant to WHISCON and to Aetion, of which he also owns equity. He is the principal investigator of investigator-initiated grants to the Brigham and Women's Hospital from Bayer, Genentech, Boehringer Ingelheim, and Vertex. Gambino is an employee and officer at Horizon Blue Cross and Blue Shield of New Jersey. He was recently appointed to a board observer position at Aetion, as Horizon has small equity interest in Aetion. Jan is an employee of Rutgers State University and Horizon Blue Cross Blue Shield of New Jersey and has no conflict of interest or association with Aetion or any pharmaceutical company. Jang and Rubin are employees of Horizon Blue Cross and Blue Shield of New Jersey and have no conflict of interest or association with Aetion. This work was presented as a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL; as part of a continuing education session at the AMCP Managed Care & Specialty Pharmacy 2019 Annual Meeting in San Diego, CA, March 25-28, 2019; as invited podium presenter at the Blue Cross Blue Shield 2019 National Summit conference in Grapevine, TX, April 29-May 2, 2019; and was accepted for a podium presentation at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2019 annual conference in New Orleans, LA, May 18-22, 2019, where it won an award for Best Podium Presentation.

Canadian Medication Cost Savings Associated with Combinatorial Pharmacogenomic Guidance for Psychiatric Medications.

ObjectiveTo estimate Canadian pharmacy cost savings associated with psychiatric medication prescribing that is guided by combinatorial pharmacogenomic testing in patients switching or augmenting their psychiatric medication.MethodsPharmacy claims data from a United States (US) pharmacy benefit manager were analyzed for 1662 patients who recently augmented or switched to a different antidepressant or antipsychotic medication and underwent combinatorial pharmacogenomic testing. Costs of prescription medications were translated to the Canadian healthcare system by matching drug names and doses using the Ontario Drug Benefit Formulary. One-year costs (2017 CAD) were compared between patients whose clinician prescribed antidepressants or antipsychotics that were consistent (congruent) or inconsistent (incongruent) with the combinatorial pharmacogenomic test recommendations.ResultsPatients whose psychiatric medication treatment was congruent with the combinatorial pharmacogenomic test report saved $1061 CAD per member per year (PMPY) on prescription medication costs relative to patients whose medications were incongruent with their test report (p<0.0001). For patients ages <65 and ≥65, prescription medication costs were $979 and $1178 CAD PMPY lower, respectively, for patients who followed the report recommendations (p=0.0004 and p=0.13). Prescription drug fills from the US pharmacy claims were concordant with the Canadian Formulary; 62% of fills matched at both the drug name and dose strength, 81% matched at drug name, and >99% matched at the therapeutic chapter.ConclusionsAntidepressant and antipsychotic prescribing that was congruent with combinatorial pharmacogenomic test guidance was associated with significant cost savings on Canadian prescription medications according to the Ontario Drug Benefit Formulary.

P5003Reduced healthcare utilization in routine care initiators of empagliflozin with and without heart failure: interim analysis from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study

Abstract Background Empagliflozin (EMPA) reduced the risk of hospitalization for heart failure (HHF) (HR 0.65; 95% CI 0.50- 0.85) as demonstrated in the EMPA-REG OUTCOME trial in adults with type 2 diabetes (T2D) and established CV disease. However, the impact of EMPA treatment initiation on healthcare resource utilization (HCRU) in routine care in patients with history of heart failure (HF) or without history of HF remains unexplored. Purpose To compare HCRU among EMPA and dipeptidyl peptidase-4 inhibitor (DPP4i) initiators with and without HF history at time of treatment initiation. Methods We analyzed HCRU in the first two years after marketing of EMPA as part of EMPRISE, a non-interventional study on the comparative effectiveness, safety and HCRU of EMPA for T2D patients in routine care in two US commercial and Medicare claims datasets (08/2014–09/2016). We identified a 1:1 propensity-score-matched cohort of T2D patients ≥18 years initiating either EMPA or a DPP4i with and without baseline HF, and assessed the balance at baseline (period of 365 days) on ≥140 covariates including clinical, HCRU, and cost-related covariates using absolute standardized differences. We compared the risk of first all-cause hospitalization, risk of first HHF, risk of first emergency department (ED) visit, hospital length of stay (LOS), HF-related LOS, number of hospital admissions, HF-related hospital admissions, office visits, and ED visits in EMPA and DDP4i initiators. Results After propensity score matching, we identified 2,050 pairs with HF and 15,428 pairs without HF in the three datasets with mean follow-up of 5.2 and 5.4 months, respectively. All baseline characteristics were well balanced (with aSD&lt;0.1). Compared to patients without HF history, patients with HF were older (65 vs 58), more commonly female (51% vs 46%), and had CV history (64% vs 19%) (Table 1). Compared to DPP4i, the hazard ratio (HR) for first hospitalization was 0.68 (95% CI: 0.56, 0.83) for EMPA initiators with HF, and 0.89 (95% CI: 0.80, 1.00) for initiators without HF. Risk of HF-related hospitalization and ED visit was lower in EMPA initiators with prior HF [HR=0.53 (0.38, 0.74) and HR=0.73 (0.58, 0.93), respectively] and without prior HF [HR=0.45 (0.27, 0.73) and HR=0.82 (0.70, 0.95), respectively]. Compared to DPP4i initiators, EMPA initiators with and without baseline HF had lower number of all hospital admissions [Incidence rate ratio (IRR)= 0.59 (0.50, 0.70) and IRR= 0.78 (0.71, 0.85), respectively] and HF-related hospital admissions [IRR=0.49 (0.37, 0.65) and IRR=0.34 (0.22, 0.53), respectively]. In-hospital days and HF-related in-hospital days per member per year (PMPY) in patients with and without HF history initiating EMPA were lower than DDP4i (Table 1). Conclusions Results observed in this interim analysis of EMPRISE showed reduction in overall HCRU as well as HF-related HCRU in both patients with and without heart failure (HF) initiating EMPA compared to DDP4i initiators. Acknowledgement/Funding This study was supported by a research grant to the Brigham and Women's Hospital from Boehringer-Ingelheim.

Evaluation of the economic and clinical impact of community pharmacist-driven pharmacy benefit management services

ObjectiveTo evaluate the economic and clinical impact of community pharmacist–led pharmacy benefit management (PBM) services. SettingIndependent community pharmacy in western North Carolina. Practice descriptionSona Benefits is a PBM partner to self-funded plans in western North Carolina. The services provided by Sona Benefits are led by pharmacists at its affiliate company, Sona Pharmacy + Clinic. Practice innovationIn October 2016, Sona Benefits began providing PBM services to members employed by a local continuing care retirement community. EvaluationEconomic outcome measures included change in total medical and prescription costs per member per year (PMPY) and change in cost per prescription from baseline. Change in clinical outcome measures (hemoglobin A1C, weight, blood pressure) was assessed for members who participated in 2 or more quarterly health coaching sessions. ResultsPrescription costs were reduced from $1219.72 to $858.57 PMPY and medical health care costs were reduced from $5910.76 to $4290.30 PMPY from baseline. This represented a total decrease of $1981.61 PMPY in health care costs. A reduction in the average cost per prescription from $95.10 to $61.88 was observed. For patients enrolled and active in health coaching, we observed reductions in weight, hemoglobin A1C, and blood pressure. Between the initial and final health coaching visits, average weight decreased from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg), the percentage of patients at hemoglobin A1C goal increased from 47% to 53%, and percentage of patients at goal for blood pressure increased from 58% to 78%. ConclusionInclusion of community pharmacists in PBM service delivery produced economic benefits for plan sponsors. Preliminary clinical data suggested benefits of pharmacist-led health coaching services, but further evaluation is needed to determine the long-term impact.