Costs, resource utilization, and treatment patterns for patients with metastatic melanoma in a commercially insured setting.

OBJECTIVE: To estimate real-world healthcare costs, resource utilization, and treatment patterns among metastatic melanoma (MM) patients who received a therapy recommended in current treatment guidelines during 2011 and 2012, following approval in the US of novel therapies (ipilimumab and vemurafenib). RESEARCH DESIGN AND METHODS: Administrative claims data were used in a retrospective, longitudinal, open cohort study. Adult MM patients were identified using ICD-9 codes. Therapy-based patient cohorts and index dates were defined by the first receipt of a therapy of interest: ipilimumab, vemurafenib, paclitaxel (alone and in combination), interleukin-2, dacarbazine (alone and in combination), or temozolomide. The follow-up period extended until the end of eligibility or data availability. A multivariate regression model was used to compare outcomes of the ipilimumab and vemurafenib cohorts, controlling for baseline and demographic characteristics. MAIN OUTCOME MEASURES: Direct healthcare costs (2013 US dollars) and utilization (incidence rates) were measured on a per-patient-per-month (PPPM) basis for each treatment cohort. Treatment patterns were assessed, including the frequency of patients receiving a second therapy of interest. RESULTS: The study population included 834 patients (265 ipilimumab, 234 vemurafenib, 174 paclitaxel, 104 interleukin-2, 46 dacarbazine, and 11 temozolomide). Costs ranged from $10,879 PPPM (temozolomide) to $35,472 PPPM (ipilimumab). Adjusted total costs were $18,337 PPPM higher for the ipilimumab vs. the vemurafenib cohort (p < 0.001), primarily due to higher outpatient costs. Multivariate analysis did not find significant differences in resource utilization between ipilimumab and vemurafenib, except that ipilimumab patients had fewer outpatient visits (excluding treatment visits). Ipilimumab and vemurafenib patients received a second therapy of interest (12% and 11%, respectively) less frequently than interleukin-2 and dacarbazine patients. CONCLUSIONS: The cost and resource utilization burden of MM is high and varies substantially across treatment cohorts. The two novel therapies, ipilimumab and vemurafenib, have quickly been adopted and are the most frequently used therapies. The results observed during the approximately 6 month follow-up period may not be representative of the full clinical experience of patients with MM.

Treatment of COPD: relationships between daily dosing frequency, adherence, resource use, and costs.

BACKGROUND: Medication adherence is important in managing COPD. This study analyzed real-world use of inhaled medications for COPD to characterize relationships between daily dosing frequency, adherence, healthcare resource utilization, and cost. METHODS: This retrospective study used a large administrative claims database covering 8 million insured lives in the US from 1999 to 2006. Patients were stratified based on the recommended daily dosing frequency of their first COPD drug claim following COPD diagnosis. Adherence was measured using proportion of days covered (PDC) over 12 months following treatment initiation. Healthcare resource use included inpatient, outpatient, and emergency room visits. A multivariate regression model assessed the relationship between adherence and one-year healthcare resource use, controlling for demographics, comorbidities, and baseline resource use. Unit healthcare costs were obtained from the 2005 Medical Expenditure Panel Survey, adjusted to 2008 dollars. RESULTS: Based on a sample of 55,076 COPD patients, adherence was strongly correlated with dosing frequency. PDC was 43.3%, 37.0%, 30.2% and 23.0% for QD, BID, TID, and QID patient cohorts, respectively. Regression analysis showed that one-year adherence was correlated with healthcare resource utilization. For 1000 COPD patients, a 5% point increase in PDC reduced the annual number of inpatient visits (-2.5%) and emergency room visits (-1.8%) and slightly increased outpatient visits (+.2%); the net reduction in annual cost was approximately $300,000. CONCLUSION: COPD patients who initiated treatment with once-daily dosing had significantly higher adherence than other daily dosing frequencies. Better treatment adherence was found to yield reductions in healthcare resource utilization and cost.

The economic impact of exacerbations of chronic obstructive pulmonary disease and exacerbation definition: a review.

Chronic obstructive pulmonary disease (COPD) poses a significant economic burden on society, and a substantial portion is related to exacerbations of COPD. A literature review of the direct and indirect costs of COPD exacerbations was performed. A systematic search of the MEDLINE database from 1998-2008 was conducted and supplemented with searches of conference abstracts and article bibliographies. Articles that contained cost data related to COPD exacerbations were selected for in-depth review. Eleven studies examining healthcare costs associated with COPD exacerbations were identified. The estimated costs of exacerbations vary widely across studies: $88 to $7,757 per exacerbation (2007 US dollars). The largest component of the total costs of COPD exacerbations was typically hospitalization. Costs were highly correlated with exacerbation severity. Indirect costs have rarely been measured. The wide variability in the cost estimates reflected cross-study differences in geographic locations, treatment patterns, and patient populations. Important methodological differences also existed across studies. Researchers have used different definitions of exacerbation (e.g., symptom- versus event-based definitions), different tools to identify and measure exacerbations, and different classification systems to define exacerbation severity. Unreported exacerbations are common and may influence the long-term costs of exacerbations. Measurement of indirect costs will provide a more comprehensive picture of the burden of exacerbations. Evaluation of pharmacoeconomic analyses would be aided by the use of more consistent and comprehensive approaches to defining and measuring COPD exacerbations.

The impact of proton pump inhibitor compliance on health-care resource utilization and costs in patients with gastroesophageal reflux disease.

OBJECTIVE: Standard pharmacotherapy for patients with gastroesophageal reflux disease (GERD) includes treatment with proton pump inhibitors (PPIs). This study examined the effect of GERD patients' compliance with PPI therapy on health-care resource utilization and costs. METHODS: This was a retrospective study of more than 25 million managed care lives in the United States from January 2000 through February 2005. Administrative claims data were obtained from the National Managed Care Benchmarks database, developed by Integrated Health Care Information Solutions. GERD-diagnosed patients who had at least two PPI dispensings were extracted and grouped into two treatment categories based on their PPI medication possession ratio (MPR): compliant (MPR > 0.8) and noncompliant. A regression-based difference-in-differences approach was used to estimate the effect of compliance on the frequency and costs of inpatient and outpatient visits and pharmacy costs. Statistical controls included health plan type, patient age, baseline use of nonsteroidal antiinflammatory drugs, and comorbidities. RESULTS: Of the total 41,837 patients studied, 68% were compliant. On an annual, per-patient basis, PPI compliance resulted in 0.47 fewer outpatient visits (P = 0.040), 0.03 fewer inpatient visits (P = 0.015), and 0.47 fewer hospitalization days (P = 0.001) from the pre-PPI use period, compared to noncompliance. PPI therapy increased pharmacy costs for both groups, but the total annual health-care costs were reduced for both groups. Compliant patients experienced a greater decline in total cost from the pre-PPI period compared to noncompliant patients (declines of $3261 vs. $2406 per patient per year, P = 0.012). CONCLUSIONS: Both health-care resource use and costs were reduced after initiation of PPI therapy. Additional reductions from the pre-PPI period were further observed by compliance with PPI therapy.

Comparison of hospitalization risk and associated costs among patients receiving sargramostim, filgrastim, and pegfilgrastim for chemotherapy-induced neutropenia.

BACKGROUND: Sargramostim is a granulocyte-macrophage-colony-stimulating factor (GM-CSF). Unlike filgrastim and pegfilgrastim, which are granulocyte-colony-stimulating factors (G-CSFs), sargramostim activates a broader range of myeloid lineage-derived cells. Therefore, GM-CSF might reduce infection risk more than the G-CSFs. This study compared real-world infection-related hospitalization rates and costs in patients using G/GM-CSF for chemotherapy-induced neutropenia. METHODS: This retrospective matched-cohort study analyzed nationally representative health insurance claims in the United States from 2000 through 2007. The sample population included patients who received chemotherapy and G/GM-CSF. G/GM-CSF treatment episodes began with the first administration of G/GM-CSF and ended when a subsequent administration was >28 days after a prior administration. Sargramostim patients were matched 1:1 with filgrastim and pegfilgrastim patients based on gender and birth year. Outcomes included infection-related hospitalization rates and the associated costs. Hospitalization rates were analyzed using univariate and multivariate Poisson methods; covariates included myelosuppressive agents received, tumor type, anemia, and comorbidities. RESULTS: A total of 990 sargramostim-filgrastim and 982 sargramostim-pegfilgrastim matched pairs were analyzed. Cohorts were similar with regard to age, gender, and comorbid conditions. Several differences were observed with regard to tumor type, anemia, and chemotherapy, but no systematic trends were apparent. Sargramostim patients experienced a 56% lower risk of infection-related hospitalizations compared with filgrastim and pegfilgrastim patients. Infection-related hospitalization costs were 84% and 62% lower for sargramostim patients compared with patients treated with filgrastim and pegfilgrastim, respectively. CONCLUSIONS: Among patients with or at risk for chemotherapy-induced neutropenia, these data indicated that use of sargramostim was associated with a reduced risk of infection-related hospitalization and lower associated costs compared with filgrastim or pegfilgrastim.

Costs, quality of life and treatment compliance associated with antibiotic therapies in patients with cystic fibrosis: a review of the literature.

BACKGROUND: Cystic fibrosis is the most common incurable hereditary disease in the US. Persistent respiratory infection is the leading cause of morbidity and mortality in cystic fibrosis patients. OBJECTIVE: This study aimed to review the literature on economic and quality of life outcomes and treatment compliance associated with antibiotic therapies for cystic fibrosis patients. METHODS: A systematic literature review was conducted using keyword searches of the MEDLINE database and selected conference abstracts. The review covered studies published between January 1990 and May 2007. RESULTS/CONCLUSIONS: Evidence suggests that inhaled tobramycin, a key chronic suppressive therapy, can reduce other healthcare costs. The main determinants of the cost of care include disease severity and respiratory infection. Costs vary widely by country. There is evidence that inhaled tobramycin and oral azithromycin improve quality of life and that treatment setting and patient convenience may also impact on quality of life. Antibiotic treatment compliance varied significantly and depended on the method of measurement, with more subjective measures tending to be higher. This review concludes by offering directions for future research.

Safety impacts of SUVs, vans, and pickup trucks in two-vehicle crashes.

Policy makers, vehicle manufacturers, and consumers have shown growing concern about the relative safety of sport utility vehicles (SUVs), vans, pickups, and cars. Empirical analysis of real-world crashes is complicated by the possibility that apparent relationships between vehicle type and safety may be confounded by other factors, such as driver behavior and crash circumstances. This study compares different vehicle types with respect to their crashworthiness (self-protection) and aggressivity (risk to others) in crashes between two passenger vehicles. The U.S. Crashworthiness Data System is used to analyze detailed information on 6,481 drivers involved in crashes during 1993-1999. Logistic regression analysis is used to model the risk of serious injury or death to a driver, conditional on a crash occurring. Covariates include the body type of each vehicle in the crash; the driver's age, gender, and restraint use; and the configuration of the crash. A unique feature of this study is the use of "delta-v" to represent the joint effects of vehicle mass and crash severity. While estimated effects are somewhat sensitive to the injury severity level used as the outcome variable, SUVs, vans, and pickups appear to be more aggressive and may be more crashworthy than cars. Effects of pickups are most pronounced. Drivers in pickups face less risk of serious injury than car drivers (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.20-0.60), and drivers who collide with pickups experience more than twice the risk than those who collide with a car (OR, 2.18; 95% CI, 1.03-4.62). While vehicle mass and crash severity contribute to the apparent crashworthiness and aggressivity of passenger vehicles, other vehicle characteristics associated with body type (e.g., the stiffness and height of the underlying structure of the vehicle) also influence safety risks.