A cost-effectiveness analysis of real-world treatment for elderly patients with multiple myeloma using a full disease model

The cost-effectiveness of using a prognosis-tailored strategy model to triage couples with idiopathic infertility for assisted reproduction technology

OBJECTIVES

To evaluate whether a prognosis-tailored triage of ART for couples with idiopathic infertility by using the Hunault prognostic model can decrease the cost of treatment without compromising the chance of live birth.

STUDY DESIGN

This is a retrospective study conducted in an Australian fertility clinic. Couples seeking infertility consultation who were subsequently found to have idiopathic infertility after evaluation were included. We compared the costs per conception leading to live birth of the prognosis-tailored strategy with the immediate ART strategy, which generally reflects the current practice in Australian fertility clinics, over a 24-month period. In the prognosis-tailored strategy, for each couple, the prognosis for natural conception was assessed using the well-established Hunault model. Total cost of treatments were calculated as the sum of typical out-of-pocket and Australian Medicare cost (Australian national insurance scheme).

RESULTS

We studied 261 couples. In the prognosis-tailored strategy, the total cost was $2,766,781 and the live birth rate was 63.9%. In contrast, the immediate ART strategy yielded a live birth rate of 64.4% with a total cost of $3,176,845. Implementing the prognosis-tailored strategy using the Hunault model saved $410,064 in total and $1,571 per couple. The incremental cost-effectiveness ratio (ICER) was $341,720 per live birth.

CONCLUSION

In couples with idiopathic infertility, assessment of prognosis for natural conception using the Hunault model and delaying ART for 12 months in couples with favourable prognoses can considerably reduce costs without significantly compromising live birth rates.

Assessing the treatment pattern, health care resource utilisation, and economic burden of multiple myeloma in France using the Système National des Données de Santé (SNDS) database: a retrospective cohort study

BACKGROUND

Real-world data on health care resource utilisation (HCRU) and costs for French patients with multiple myeloma (MM) are limited due to the quickly evolving MM treatment landscape. This retrospective, national-level study quantified the MM economic burden in France.

METHODS

The study included patients with newly diagnosed MM from the Système National des Données de Santé coverage claims database between 2013 and 2018 who received active treatment within 30 days of diagnosis. HCRU included hospitalisations, drugs, consultations, procedures, tests, devices, transport, and sick leave. Costs were annualized to 2019 prices. Drug treatments, reported by line of therapy (LOT), were algorithmically defined using drug regimen, duration of therapy, and gaps between treatments. Analyses were stratified by stem cell transplantation status and LOT.

RESULTS

Among 6413 eligible patients, 6229 (97.1%) received ≥ 1 identifiable LOT; most received 1 (39.8%) or 2 LOT (27.5%) during follow-up. Average annual hospitalisation was 6.3 episodes/patient/year (median duration: 11.6 days). The average annual cost/patient was €58.3 K. Key cost drivers were treatment (€28.2 K; 39.5% of total HCRU within one year of MM diagnosis) and hospitalisations (€22.2 K; 48.6% of total HCRU costs in first year). Monthly treatment-related costs increased from LOT1 (€2.447 K) and LOT5 + (€7.026 K); only 9% of patients received LOT5 + . At LOT4 + , 37 distinct regimens were identified. Hospitalisation costs were higher in patients with stem cell transplantation than total population, particularly in the first year.

CONCLUSIONS

This study showed a high economic burden of MM in France (€72.37 K/patient/year in the first year) and the diversity of regimens used in late-line treatments.

Systematic literature review of health economic models developed for multiple myeloma to support future analyses

AIMS

The goal of this study was to review the economic evaluations of health technologies in multiple myeloma (MM) and provide guidance and recommendations for future health economic analyses.

MATERIALS AND METHODS

A systemic literature review (SLR) was conducted on original economic assessment studies and structured review papers focusing on the studies in MM. The search was limited to English language papers published from 1 January 2000 onwards. Publications not applying any type of modelling methodology to describe disease progression and patient pathways over a specific time horizon were excluded.

RESULTS

A total of 2,643 publications were initially identified, of which 148 were eligible to be included in the full-text review phase. From these, 49 publications were included in the final analysis. Most published health economic analyses supported by models came from high-income countries. Evaluations from middle-income countries were rarely published. Diagnostic technologies were rarely modelled and integrated care had not been modelled. Very few models investigated MM treatments from a societal perspective and there was a relative lack of evaluations regarding minimal residual disease (MRD).

LIMITATIONS

Limitations of the publications included differences between trial populations and modelled populations, justification of methods, lack of confounder analyses, and small trial populations. Limitations of our study included the infeasibility of comparing MM economic evaluations due to the significant variance in modelled therapeutic lines and indications, and the relative scarcity of published economic evaluations from non-high-income countries.

CONCLUSIONS

As published economic models lacked many of the elements of the complex and heterogeneous patient pathways in MM and they focused on single decision problems, a thorough, open-source economic whole disease modelling framework is needed to assess the economic value of a wide range of technologies across countries with various income levels with a more detailed view on MM, by including patient-centric and societal aspects.

Being Transparent About Brilliant Failures: An Attempt to Use Real-World Data in a Disease Model for Patients with Castration-Resistant Prostate Cancer

BACKGROUND

Real-world disease models spanning multiple treatment lines can provide insight into the (cost) effectiveness of treatment sequences in clinical practice.

OBJECTIVE

Our objective was to explore whether a disease model based solely on real-world data (RWD) could be used to estimate the effectiveness of treatments for patients with castration-resistant prostate cancer (CRPC) that could then be suitably used in a cost-effectiveness analysis.

METHODS

We developed a patient-level simulation model using patient-level data from the Dutch CAPRI registry as input parameters. Time to event (TTE) and overall survival (OS) were estimated with multivariate regression models, and type of event (i.e., next treatment or death) was estimated with multivariate logistic regression models. To test internal validity, TTE and OS from the simulation model were compared with the observed outcomes in the registry.

RESULTS

Although patient characteristics and survival outcomes of the simulated data were comparable to those in the observed data (median OS 20.6 vs. 19.8 months, respectively), the disease model was less accurate in estimating differences between treatments (median OS simulated vs. observed population: 18.6 vs. 17.9 [abiraterone acetate plus prednisone], 24.0 vs. 25.0 [enzalutamide], 20.2 vs. 18.7 [docetaxel], and 20.0 vs. 23.8 months [radium-223]).

CONCLUSIONS

Overall, the disease model accurately approximated the observed data in the total CRPC population. However, the disease model was unable to predict differences in survival between treatments due to unobserved differences. Therefore, the model is not suitable for cost-effectiveness analysis of CRPC treatment. Using a combination of RWD and data from randomised controlled trials to estimate treatment effectiveness may improve the model.

Conceptual Framework and Methodological Challenges for Modeling Effectiveness in Oncology Treatment Sequence Models

In this review, we summarize the challenges faced by existing oncology treatment sequence decision models and introduce a general framework to conceptualize such models. In the proposed framework, patients with cancer receive at least two lines of therapy (LOTs) followed by palliative care throughout their lifetime. Patients cycle through progression-free and progressive disease health states in each LOT before death. Under this framework, four broad aspects of modeling effectiveness of treatment sequences need exploration. First, disease progression, treatment discontinuation, and the relationship between the two events should be considered. Second, the effectiveness of each LOT depends on its placement in a treatment sequence as the effectiveness of later LOTs may be influenced by the earlier LOTs. Third, the treatment-free interval (TFI; time between discontinuation of earlier LOT and initiation of later LOT) may impact a therapy's effectiveness. Fourth, in the absence of head-to-head trials directly comparing LOTs, indirect treatment comparison (ITC) of outcomes for a specific LOT or even for the entire treatment sequence is important to consider. A search of decision models that estimated effectiveness of at least two lines of oncology therapy was conducted in PubMed (N = 20) and technology appraisals by the National Institute for Health and Care Excellence (N = 26) to assess four methodological aspects related to the model framework: (1) selection of outcomes for effectiveness in a treatment sequence, (2) approaches to adjust the efficacy of a treatment in consideration of its place in the sequence, (3) approaches to address TFIs between LOTs, and (4) incorporation of ITCs to estimate comparators' effectiveness in the absence of direct head-to-head evidence. Most models defined health states based on disease progression on different LOTs while estimating treatment duration outside of the main model framework (30/46) and used data from multiple data sources in different LOTs to model efficacy of a treatment sequence (41/46). No models adjusted efficacy for the characteristics of patients who switched from an earlier LOT to a later LOT or adjusted for the impact of prior therapies, and just six models considered TFIs. While 11 models applied ITC results to estimate efficacy in comparator treatment sequences, the majority limited the ITC to one LOT in the sequence. Thus, there is substantial room to improve the estimation of effectiveness for treatment sequences using existing data when comparing effectiveness of alternative treatment sequences.

The Cost-Effectiveness Analysis of Transplant-Ineligible Myeloma Patients with Bortezomib plus Thalidomide plus Dexamethasone (VTD) or Bortezomib plus Melphalan plus Prednisolone (VMP) Treatment in Southern Taiwan

Background: This study aimed to evaluate the cost-effectiveness of treating transplant-ineligible myeloma patients with either a bortezomib plus thalidomide plus dexamethasone (VTD) or a bortezomib plus melphalan plus prednisolone (VMP) treatment in Taiwan. Methods: Newly diagnosed, transplant-ineligible myeloma patients with VTD or VMP therapy were enrolled from two medical centers in southern Taiwan. Quality-adjusted life years (QALYs) were used as the measurement unit of the effectiveness evaluation, and the incremental cost-effectiveness ratio (ICER) was used for comparison between the two groups. A net monetary benefit approach and cost-effectiveness acceptability curve were also used for the cost-effectiveness assessment. A one-way sensitivity analysis was used to check the impact of different parameters. In total, 77 patients were enrolled in the study with 43 patients in the VTD group and 34 patients in the VMP group. Clinical presentations were similar without significant difference, except the VTD group had a higher survival rate (p = 0.029). Comparisons of the two groups over an eight-month time horizon revealed a significant lower mean of direct medical costs in the VTD group than in the VMP group (p < 0.001), and a significantly higher average QALY was gained (p < 0.001). Conclusions: The study demonstrated the greater clinical benefit and cost-effectiveness of VTD compared to VMP therapy in transplant-ineligible, newly diagnosed myeloma patients.

Treatment patterns and outcomes in real-world transplant-ineligible patients newly diagnosed with multiple myeloma

Despite the significant proportion of older patients with newly diagnosed multiple myeloma (MM), most clinical trials driving therapeutic decisions in routine practice include younger and presumably healthier patients than those in the real world. Furthermore, longitudinal studies suggest that elderly, transplant-ineligible patients with MM are not benefitting enough from new anti-MM agents. We retrospectively analyzed the profile of and treatment patterns and outcomes in 675 transplant-ineligible patients with MM who started frontline therapy in routine practice. The mean (SD) age was 75.6 (6.7) years; 152 (47.4%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 2-4, and 73 (25.1%) had high cytogenetic risk. The most frequent frontline therapy was non-VMP bortezomib-based regimens (n=207; 30.7%), which were more frequent among patients with ECOG PS 0/1 and higher risk (e.g., international staging system (ISS) stage III, severely impaired glomerular filtrate rate (GFR), high lactate dehydrogenase (LDH), and high-risk cytogenetics); 185 patients (27.4%) started an attenuated (lite) VMP regimen, and 159 (23.6%) a VMP (VISTA) regimen. Median progression-free survival and overall survival (OS) were 15.3 months (95%CI 14.0-16.9) and 33.5 months (95%CI 29.1-37.2), respectively; 405 patients (78.2%) achieved partial response or better. Age, ECOG PS, ISS stage, serum LDH, GFR, cytogenetic risk, and treatment regimen significantly influenced OS. In this study, a remarkable proportion of transplant-ineligible patients with MM were older, frontline regimens were highly heterogeneous, and patients at higher risk often received less efficacious combinations. These findings suggest that clinicians have limited objective criteria for therapeutic decisions for this patient group.

Cost-effectiveness of Novel Treatment Sequences for Transplant-Ineligible Patients With Multiple Myeloma

IMPORTANCE

Although the number of treatments for elderly patients with non-transplant-eligible (NTE) multiple myeloma (MM) has increased substantially, evidence is lacking on the clinical effectiveness and cost-effectiveness of novel treatment sequences.

OBJECTIVE

To determine the optimal sequence of treatment for patients with NTE MM from the perspective of the patient, physician, and society.

DESIGN, SETTING, AND PARTICIPANTS

Using data from a Dutch observational registry, this economic evaluation combined evidence from network meta-analyses in a patient-level simulation model and modeled time-to-event and types of events from a hospital perspective with a lifetime horizon. Data analysis was performed from June 2019 to September 2020.

INTERVENTIONS

Thirty treatment sequences, including up to 3 lines of therapy, were compared with bortezomib-melphalan-prednisone (VMP)-lenalidomide-dexamethasone (LenDex)-pomalidomide-dexamethasone (PomDex).

MAIN OUTCOMES AND MEASURES

The primary outcomes of the model were overall survival (OS), quality-adjusted life-years (QALYs), costs, and cost-effectiveness.

RESULTS

Sequences starting with daratumumab-VMP (second line: carfilzomib-lenalidomide-dexamethasone or elotuzumab-lenalidomide-dexamethasone) or bortezomib-melphalan-prednisone-thalidomide-maintenance bortezomib-thalidomide (VMPT-VT) (second line: daratumumab-lenalidomide-dexamethasone) had the largest expected OS (7.5 years), which is 3.5 additional life-years compared with VMP-LenDex-PomDex. Total costs per patient for these sequences ranged between $786 024 and $1 085 794. The sequence VMPT-VT-carfilzomib-lenalidomide-dexamethasone-panobinostat-bortezomib-dexamethasone had the most favorable cost-effectiveness ratio ($98 585 per life-year gained and $132 707 per QALY gained vs VMP-LenDex-PomDex).

CONCLUSIONS AND RELEVANCE

These findings suggest that sequences including novel treatments were highly effective, but the cost-effectiveness ratios were above currently accepted willingness-to-pay thresholds. Treating MM with novel agents necessitates either a large increase in budget or a substantial reduction of drug costs by price negotiations, and these findings can support these reimbursement decisions and price negotiations.

Healthcare resource utilization and costs among patients with relapsed and/or refractory multiple myeloma treated with proteasome inhibitors in real-world clinical practice in Germany

AIMS

To assess the real-world healthcare resource utilization (HRU) and costs associated with different proteasome inhibitors (PIs) for the treatment of patients with relapsed and/or refractory multiple myeloma (RRMM) in Germany.

METHODS

We conducted a retrospective medical chart review of treatment patterns, outcomes, and HRU for patients with RRMM treated with bortezomib, carfilzomib, or ixazomib in second- or third-line (2L or 3L) therapy in Germany. Data were collected between 1 January 2017 and 30 June 2017. Costs were calculated based on drug prices and unit costs in Germany.

RESULTS

Physicians provided data on 302 patients. Mean monthly total direct costs per patient receiving PI-based therapy were €7,925 and €10,693 for 2L and 3L, respectively, of which approximately 90% was anti-myeloma drug costs. Overall, the highest costs were associated with patients receiving 3L therapy. Regardless of treatment line, costs were higher for patients who had received a stem cell transplant (SCT) in a previous treatment line than for those who had not; the data suggest that this reflects the use of triplet regimens following a SCT. Patients with a complete response (CR) experienced no unplanned hospitalizations during the study period, whereas patients with progressive disease experienced the highest number of unplanned and planned hospitalizations. In 2L therapy, the highest proportion of patients with a CR was observed in those receiving carfilzomib (12% carfilzomib; 4% bortezomib; 0% ixazomib).

LIMITATIONS

Patients with missing or incomplete follow-up data were included in the study and were accounted for using monthly cost estimates.

CONCLUSIONS

Anti-myeloma drugs were the main contributor to total HRU costs associated with RRMM in Germany. Improved treatment response was associated with lower costs and reduced hospitalizations.

Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Introduction

Evidence on long-term effectiveness and cost effectiveness of treatment sequences for multiple myeloma (MM) is sparse. We used published data and country-specific data to assess the cost effectiveness of four-line treatment sequences for elderly transplant-ineligible patients with MM in Serbia.

Method

We developed a Markov cohort model to compare long-term effectiveness and cost effectiveness of five sequential MM treatment alternatives from the perspective of the national healthcare provider. Effectiveness parameters on progression, mortality and adverse events were extracted from published clinical trials. Costs were based on price lists of the National Health Insurance Fund. We compared life expectancy, costs, and incremental cost-effectiveness ratios among alternative courses of action. The model was analyzed over a lifelong time horizon applying a 3% annual discount rate for effectiveness outcomes and costs. Robustness of the model was tested in multiple deterministic sensitivity analyses.

Results

The sequences were defined by the frontline treatment: MPT (melphalan-prednisone-thalidomide), MPV (melphalanprednisone-bortezomib), CTD (cyclophosphamide-thalidomide-dexamethasone), VCD (bortezomib-cyclophosphamidedexamethasone) and BP (bendamustine-prednisone). MPV sequence resulted in the highest remaining life expectancy (4.76 life years). Cost-effectiveness analysis resulted in three non-dominated strategies: MPT, VCD, and MPV sequences, with an incremental cost-effectiveness ratio of EUR 35,300 per life-year gained (LYG) for VCD and EUR 47,200/LYG for MPV relative to MPT.

Conclusion

MPV sequence was the most effective in terms of life expectancy for elderly transplant-ineligible MM patients in Serbia. Bortezomib-based strategies would be recommended for the frontline treatment of patients with MM in Serbia if the willingness-to-pay threshold is around EUR 35,000-60,000/LYG.

Cost Effectiveness of Transplant, Conventional Chemotherapy, and Novel Agents in Multiple Myeloma: A Systematic Review

BACKGROUND

Treatments for multiple myeloma (MM) have been rapidly evolving. Newly developed treatment regimens are likely to be more effective but also cost more than conventional therapies.

OBJECTIVE

We conducted a systematic review to compare the cost effectiveness of different classes of MM treatment.

METHODS

We searched the PubMed, MEDLINE, Web of Science, and EMBASE databases for studies published during 1990-2018 comparing the cost effectiveness of transplant, chemotherapeutic and novel MM treatments. Titles and abstracts were independently reviewed for eligibility by two investigators. The quality of the included studies was evaluated using the 16-item, validated Quality of Health Economics Studies instrument.

RESULTS

Twenty-four publications were included in the systematic review and summarized according to treatment regimen and line. For first-line treatment, transplant was the most cost-effective option for transplant-eligible MM patients [the incremental cost-effectiveness ratio (ICER) was $4053-€45,460 per quality-adjusted life-year (QALY) gained, and $3848-$72,852 per life-year gained (LYG)], and the ICER for novel agents compared with conventional chemotherapy was $59,076 per QALY and $220,681 per LYG. For second-line treatment, in comparisons of novel agent-based regimens, ICERs were inconsistent. However, bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone (ICERs showed cost saving, £30,153 per QALY gained, and €39,911 per LYG, respectively).

CONCLUSIONS

For transplant-eligible MM patients, transplant is a cost-effective first-line treatment. More cost-effectiveness analyses comparing novel agents in the first-line treatment regimen are warranted to determine which agent or regimen is the most cost effective. In the second-line setting, it is unclear which novel agent-based regimen is most cost effective, but bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone.

Cost-effectiveness analysis of capecitabine plus bevacizumab versus capecitabine alone in elderly patients with previously untreated metastatic colorectal cancer from Chinese societal perspective

PURPOSE

The aim of the study was to evaluate the cost-effectiveness of capecitabine plus bevacizumab compared with capecitabine alone in elderly patients with metastatic colorectal cancer (CRC) from a Chinese societal perspective.

METHODS

A decision-analytic Markov model was conducted to simulate the process of metastatic CRC. Three distinct health states: progression-free survival (PFS), progressive disease and death were included. Clinical data were derived from the AVEX trial. Health effectiveness was denoted in quality-adjusted life years (QALYs) and health utilities were derived from previously published studies. Incremental cost-effectiveness ratio (ICER) was regarded as the primary endpoint and willingness-to-pay (WTP) threshold was set at $26,753.37/QALY (3 × per capita GDP of China, 2017). One-way sensitivity analyses and probabilistic sensitivity analysis were also performed to explore the parameters uncertainty in the study.

RESULTS

Over a 10-year life horizon, capecitabine plus bevacizumab gained 1.14 QALYs at an average cost of $21,609.48, while the effectiveness and cost of capecitabine group were 0.99 QALYs and $7274.83, respectively. The ICER between the two groups was $95,564.33/QALY. Parameters that mostly influenced the results of the model were utility of PFS state, duration of PFS state for capecitabine plus bevacizumab, total cost of PFS state for capecitabine plus bevacizumab and price of bevacizumab. The probabilities of capecitabine plus bevacizumab and capecitabine as the dominant option were 0% and 100% at the WTP threshold of $26,753.37/QALY.

CONCLUSIONS

The results of the study showed that capecitabine plus bevacizumab is unlikely to be a cost-effective treatment option for elderly patients with metastatic CRC.

Efficacy of first-line treatments for multiple myeloma patients not eligible for stem cell transplantation: a network meta-analysis

Decision making for patients with multiple myeloma (MM) not transplant eligible (NTE) is complicated by a lack of head-to-head comparisons of standards of care, the increase in the choice of treatment modalities, and the promising results that are rapidly evolving from studies with novel regimens. To support evidence-based decision making, we performed a network meta-analysis for NTE MM patients that synthesizes direct and indirect evidence and enables a comparison of all treatments. Relevant randomized clinical trials were identified by a systematic literature review in EMBASE®, MEDLINE®, MEDLINE®-in-Process and the Cochrane Central Register of Controlled Trials for January 1999 to March 2016. Efficacy outcomes [i.e. the hazard ratio (HR) and 95% confidence interval (95%CI) for progression-free survival] were extracted and synthesized in a random effects network-meta analysis. In total, 24 studies were identified including 21 treatments. According to the network-meta analysis, the HR for progression-free survival was favorable for all NTE MM treatments compared to dexamethasone (HR: 0.19-0.90). Daratumumab-bortezomib-melphalan-prednisone and bortezomib-melphalan-prednisone-thalidomide with bortezomib-thalidomide maintenance were identified as the most effective treatments (HR: 0.19, 95%CI: 0.08-0.45 and HR: 0.22, 95%CI: 0.10-0.51, respectively). HR and 95%CI for currently recommended treatments, bortezomib-lenalidomide-dexamethasone, bortezomib-melphalan-prednisone, and lenalidomide-dexamethasone compared to dexamethasone, were 0.31 (0.16-0.59), 0.39 (0.20-0.75), and 0.44 (0.29-0.65), respectively. In addition to identifying the most effective treatment options, we illustrate the additional value and evidence of network meta-analysis in clinical practice. In the current treatment landscape, the results of network meta-analysis may support evidence-based decisions and ultimately help to optimize treatment and outcomes of NTE MM patients.

A Generic Model for Follicular Lymphoma: Predicting Cost, Life Expectancy, and Quality-Adjusted-Life-Year Using UK Population-Based Observational Data

OBJECTIVES

To use real-world data to develop a flexible generic decision model to predict cost, life expectancy, and quality-adjusted life-years (QALYs) for follicular lymphoma (FL) in the general patient population.

METHODS

All patients newly diagnosed with FL in the UK's population-based Haematological Malignancy Research Network (www.hmrn.org) between 2004 and 2011 were followed until 2015 (N = 740). Treatment pathways, QALYs, and costs were incorporated into a discrete event simulation to reflect patient heterogeneity, including age and disease management. Two scenario analyses, based on the latest National Institute for Health and Clinical Excellence (NICE) guidelines (rituximab induction therapy for newly diagnosed asymptomatic patients and rituximab maintenance therapy for patients between treatments), were conducted and their economic impacts were compared to current practice.

RESULTS

Incidence-based analysis revealed expected average lifetime costs ranging from £6,165 [US$7,709] to £63,864 [US$79,862] per patient, and average life expectancy from 75 days to 17.56 years. Prevalence-based analysis estimated average annual treatment costs of £60-65 million [US$75-80 million], accounting for approximately 10% of the United Kingdom's annual National Health Service budget for hematological cancers as a whole. Assuming that treatment effects reported in trials are applicable to all patient groups, scenario analyses for two recent NICE guidelines demonstrated potential annual cost savings for the United Kingdom that ranged with uptake frequency from £0.6 million to £11 million [US$0.75-2.75 million].

CONCLUSIONS

Costs, survival, and QALYs associated with FL vary markedly with patient characteristics and disease management. Allowing the production of more realistic outcomes across the patient population as a whole, our model addresses this heterogeneity and is a useful tool with which to evaluate new technologies/treatments to support healthcare decision makers.

Cost-effectiveness analysis of treating transplant-eligible multiple myeloma patients in Macedonia

Purpose

A decision-analytic model was developed to study the impact of induction regimens vincristine, adriamycin, dexamethasone (VAD); thalidomide, dexamethasone (TD); and bortezomib, dexamethasone (BorD), followed by autologous stem cell transplantation (ASCT) for treating multiple myeloma (MM) patients in Macedonia. Additionally, a cost-effectiveness analysis (CEA) of treatment sequences to predict health effects and costs of different treatment sequences was performed.

Methods

Model strategies were based on a previously published study for treating patients with MM in Macedonia. The data on disease progression and treatment effectiveness were obtained from the published reports of randomized clinical trials (GIMEMA M-B02005, IFM 2005-01). Utility parameters were extracted from the literature. To compare treatment combinations, a decision tree model was developed. Additionally, a cost analysis for one-time per-protocol costs was performed from a Macedonian national health care perspective. The incremental cost-effectiveness ratios (ICERs)/quality-adjusted life years (QALYs) gained for 1-, 10-, and 20-year time horizons were determined. Costs and health outcomes were discounted to evaluate the effects of time in the model.

Results

The one-time costs of BorD (EUR 5,656) were higher compared to VAD (EUR 303) and TD (EUR 329), increasing the overall costs for BorD. Thus, the BorD combination dominated in the baseline results (1 and 10 years) and the ICER for TD vs. VAD was EUR 7,564/QALY (20 years, undiscounted model). However, in the discounted 20-year model, BorD showed an ICER of EUR 138,747/QALY gained for BorD vs. TD.

Conclusion

The CEA performed indicated that considering 1-year time horizon costs, VAD may be a cost-effective alternative vs. TD or BorD. However, for the longer period (10 or 20 years) including the discounting of future costs and outcomes, the TD and BorD combinations showed higher health benefits in terms of QALYs and more cost-effective vs. VAD. These results should be considered as supportive evidence by decision-makers and providers when deciding on the most cost-effective induction treatment strategy prior to ASCT in MM patients.

Value and Cost of Myeloma Therapy-We Can Afford It

A national conversation regarding the price and affordability of drugs exists, where concern for value and benefits of medications is challenged by the increasing price of both injectable and oral medications, including the cost of care of myeloma. At the same time, we have seen unprecedented improvements in the overall survival of patients with myeloma, mostly because of the availability of these new drugs. Here, we present data to assert that these medications and associated expenses are of direct benefit to patients and society. The entrepreneurial reward for drug development in the United States has fueled vigorous drug development efforts that have culminated in the approval of 11 new drugs for the treatment of myeloma by the U.S. Food and Drug Administration (FDA) since 1999. These patented drugs are available to patients in the United States usually at a higher price than in the rest of the world. Nevertheless, the majority of patients, via direct copay assistance or through indirect support via third parties, have access to these drugs irrespective of their socioeconomic status. One of the major regulatory hurdles that prevents access to these drugs is the legal impossibility that pharmaceutical companies have in directly supporting copay assistance for patients with government-funded health care. Moreover, assessments of value should include formal pharmacoeconomic analyses performed by experts. Interference with market forces and coercive action, such as price controls, or exercising eminent domain in the quest for cheaper medications will stymie innovation and rob us of the cures of the future.

Long-term Outcomes in Patients With Multiple Myeloma: A Retrospective Analysis of the Dutch Population-based HAematological Registry for Observational Studies (PHAROS)

Supplemental Digital Content is available in the text

Registry data are important for monitoring the impact of new therapies on treatment algorithms and outcomes, and for guiding clinical decision making in multiple myeloma (MM). This observational study analyzed real-world data from patients in the Population-based HAematological Registry for Observational Studies who were treated for symptomatic MM from 2008 to 2013 in the Netherlands. The primary endpoint was overall survival (OS) from initiation of first-line treatment. Secondary endpoints included OS and progression-free survival per treatment line, treatment patterns, and treatment response. Between 2008 and 2013, 917, 583, 283, and 139 patients had initiated first, second, third, and fourth treatment lines, respectively. Thalidomide-based regimens were the most frequently used first-line treatment (66%); bortezomib- and lenalidomide-based regimens were most often used in the second line (41% and 27%, respectively). The median OS (95% confidence interval) ranged from 37.5 months (34.8–41.8 months) in the first line to 9.2 months (6.2–12.3 months) in the fourth line. Univariate analyses showed that survival benefits were most apparent in younger patients (≤65 vs >65 years). These analyses provide important real-world information on treatment patterns and outcomes in patients with MM.

Healthcare resource utilization among patients with relapsed multiple myeloma in the UK, France, and Italy

AIMS

To assess the real-world healthcare resource utilization (HRU) and costs associated with different treatment regimens used in the management of patients with relapsed multiple myeloma in the UK, France, and Italy.

METHODS

Retrospective medical chart review of characteristics, time to progression, level of response, HRU during treatment, and adverse events (AEs). Data collection started on June 1, 2015 and was completed on July 15, 2015. In the 3 months before record abstraction, eligible patients had either disease progression after receiving one of their country's most commonly prescribed regimens or had received the best supportive care and died. Costs were calculated based on HRU and country-specific diagnosis-related group and/or unit reference costs, amongst other standard resources.

RESULTS

Physicians provided data for 1,282 patients (387 in the UK, 502 in France, 393 in Italy) who met the inclusion criteria. Mean [median] total healthcare costs associated with a single line of treatment were €51,717 [35,951] in the UK, €37,009 [32,538] for France, and €34,496 [42,342] for Italy, driven largely by anti-myeloma medications costs (contributing 95.0%, 90.0%, and 94.2% of total cost, respectively). During active treatment, the highest costs were associated with lenalidomide- and pomalidomide-based regimens. Mean cost per month was lowest for patients achieving a very good partial response or better. Unscheduled events (i.e. not considered part of routine management, whether or not related to multiple myeloma, such as unscheduled hospitalization, AEs, fractures) accounted for 1-9% of total costs and were highest for bendamustine.

LIMITATIONS

The use of retrospective data means that clinical practice (e.g. use of medical procedures, evaluation of treatment response) is not standardized across participating countries/centers, and some data (e.g. low-grade AEs) may be incomplete or differently adjudicated/reported. The centers involved may not be fully representative of national practice.

CONCLUSIONS

Drug costs are the main contributor to total HRU costs associated with multiple myeloma. The duration of active treatment may influence the average total costs, as well as response, associated with a single line of therapy. Improved treatment outcomes, and reductions in unscheduled events and concomitant medication use may, therefore, reduce the overall HRU and related costs of care in multiple myeloma.

Challenges in Research and Health Technology Assessment of Rare Disease Technologies: Report of the ISPOR Rare Disease Special Interest Group

BACKGROUND

Successful development of new treatments for rare diseases (RDs) and their sustainable patient access require overcoming a series of challenges related to research and health technology assessment (HTA). These impediments, which may be unique to RDs or also apply to common diseases but are particularly pertinent in RDs, are diverse and interrelated.

OBJECTIVE

To develop for the first time a catalog of primary impediments to RD research and HTA, and to describe the cause and effect of individual challenges.

METHODS

Challenges were identified by an international 22-person expert working group and qualitative outreach to colleagues with relevant expertise. A broad range of stakeholder perspectives is represented. Draft results were presented at annual European and North American International Society for Pharmacoeconomics and Outcomes Research (ISPOR) congresses, and written comments were received by the 385-strong ISPOR Rare Disease Review Group from two rounds of review. Findings were refined and confirmed via targeted literature search.

RESULTS

Research-related challenges linked to the low prevalence of RDs were categorized into those pertaining to disease recognition and diagnosis, evaluation of treatment effect, and patient recruitment for clinical research. HTA-related challenges were classified into issues relating to the lack of a tailored HTA method for RD treatments and uncertainty for HTA agencies and health care payers.

CONCLUSIONS

Identifying and highlighting diverse, but interrelated, key challenges in RD research and HTA is an essential first step toward developing implementable and sustainable solutions. A collaborative multistakeholder effort is required to enable faster and less costly development of safe, efficacious, and appropriate new RD therapies that offer value for money.

Real life management of patients hospitalized with multiple myeloma in France

Background

Patients with multiple myeloma included in prospective clinical trials are highly selected and therefore are expected not to be representative of the entire patient population. Additionally recommendations based on literature data and randomized trials are not systematically implemented in all patients. We sought to determine how patients hospitalized with a diagnosis of multiple myeloma are currently treated in France.

Methods and findings

We performed a nation-wide search using the Programme de Médicalisation des Systèmes d’Information (PMSI) database which includes anonymous data for all patients hospitalized in France. We identified newly diagnosed cases in 2012 and analyzed the number and duration of hospital stays, coexisting conditions and treatment modalities with data available until the end of 2015. A diagnosis of multiple myeloma was determined for the first time during a hospitalization in France in 2012 in 6,282 patients (3,234 males and 3,048 females). The median age at diagnosis was 74 years (72 in males and 76 in females). A majority (55.3%) of patients were diagnosed and treated in a single heath center, including 37% in a university hospital and 52% in a non-university public hospital. Comorbidities potentially impacting on myeloma treatment were present in 57.5% of patients at diagnosis, and 15% had an associated diagnosis of another neoplasia. Intensive therapies with stem cell transplants were performed in 1033 patients (16% of total), the majority of which were aged less than 65 (881 patients, 85.3%). Stem cell transplants were performed more frequently in males while the distance between the site of residence and the transplant center had no impact on likelihood of receiving a transplant. Only 60% of patients less than 65 years old who were treated for their disease underwent intensification with stem cell transplant within the 4-year follow-up period.

Conclusions

A large majority of patients hospitalized with a diagnosis of multiple myeloma are elderly, in particular females, and not eligible for transplants. Among the patients aged less than 65 and receiving therapy for their disease, 40% do not undergo transplants. These data emphasize the need for alternative therapies.

Cost-Effectiveness of Novel Agents in Medicare Patients with Multiple Myeloma: Findings from a U.S. Payer's Perspective

BACKGROUND

Since multiple myeloma (MM) incurs a substantial economic burden in care management, more and more discussion has been generated in recent years about the costs of novel antimyeloma drugs and their associated value. Because of these costs, economic assessment that quantifies value of care over the long-term is essential.

OBJECTIVE

To determine the cost-effectiveness (measured as cost per life-year saved) of front-line novel agent-based therapy use among a cohort of elderly patients with MM in a real-world setting.

METHODS

We identified 2,551 elderly patients with advanced MM from 2000 to 2009 who initiated novel agent-based therapy (bortezomib, lenalidomide, or thalidomide) or chemotherapy from the Surveillance, Epidemiology, and End Results-Medicare linked data. Patients were characterized according to age at diagnosis, sex, race, geographic region, marital status, socioeconomic status, comorbidities, and receipt of novel agents. Twenty-month cost of care and overall survival related to MM were compared between patients treated with novel agent-based therapy and patients treated with chemotherapy. A net monetary benefit approach and corresponding cost-effectiveness acceptability curves were used to evaluate the cost-effectiveness of novel agent-based therapy.

RESULTS

Overall, average 12-month MM total costs were 2.03 times higher for novel agent-based therapy ($144,665) than for chemotherapy ($47,750). Antimyeloma pharmacy costs represented about 31% ($45,095) of total MM costs for patients treated with novel agents but represented about 19% ($8,921) of total MM costs for patients treated with chemotherapy. Twelve-month survival rates increased significantly among patients receiving novel agents compared with patients receiving chemotherapy. In the incremental net monetary benefit analysis, after adjusting for potential covariates, patient use of novel agents was only cost-effective compared with chemotherapy when the willingness-to-pay thresholds were high, at about $230,000.

CONCLUSIONS

Given the most common treatment practices in the United States, the use of novel agent-based therapy is not cost-effective at its current level of cost and effectiveness. Future studies should evaluate the generalizability of these results by evaluating cost-effectiveness of novel agent-based therapy use in different patient populations.

DISCLOSURES

Funding for this study was contributed by the Agency for Healthcare Research and Quality (R01-H5018956). The authors have nothing to disclose. Study concept and design were contributed by Chen, Lairson, and Du, along with Chan. Chen and Du took the lead in data collection, along with Lairson and Huo. Data interpretation was performed by Chen, Chan, and Du, along with Lairson and Huo. The manuscript was written by Chen, along with Du, Lairson, Chan, and Huo, and revised by primarily by Du, along with Lairson, Huo, Chen, and Chan.

Balancing the Optimal and the Feasible: A Practical Guide for Setting Up Patient Registries for the Collection of Real-World Data for Health Care Decision Making Based on Dutch Experiences

OBJECTIVES

The aim of this article was to provide practical guidance in setting up patient registries to facilitate real-world data collection for health care decision making.

METHODS

This guidance was based on our experiences and involvement in setting up patient registries in oncology in the Netherlands. All aspects were structured according to 1) mission and goals ("the Why"), 2) stakeholders and funding ("the Who"), 3) type and content ("the What"), and 4) identification and recruitment of patients, data handling, and pharmacovigilance ("the How").

RESULTS

The mission of most patient registries is improving patient health by improving the quality of patient care; monitoring and evaluating patient care is often the primary goal ("the Why"). It is important to align the objectives of the registry and agree on a clear and functional governance structure with all stakeholders ("the Who"). There is often a trade off between reliability, validity, and specificity of data elements and feasibility of data collection ("the What"). Patient privacy should be carefully protected, and address (inter-)national and local regulations. Patient registries can reveal unique safety information, but it can be challenging to comply with pharmacovigilance guidelines ("the How").

CONCLUSIONS

It is crucial to set up an efficient patient registry that serves its aims by collecting the right data of the right patient in the right way. It can be expected that patient registries will become the new standard alongside randomized controlled trials due to their unique value.

Myeloma in the Real World: What Is Really Happening?

Multiple myeloma (MM) is the second most common hematologic malignancy and is predominantly a disease of the elderly. In the past 2 decades, a range of new therapeutic options have become available, leading to improvements in patient outcomes, including both attainment of remission and overall survival. These improved outcomes have heralded a paradigm shift from a palliative approach toward more active management, including the use of sequential therapies, with the goal of prolonging progression-free and overall survival and preserving organ function to enable delivery of further therapy at relapse. Until now, most outcome data for MM have come from clinical trials, with few reports available on patients treated outside the clinical trial setting-in the "real world." Clinical trials are routinely undertaken in specialist centers, and extrapolation of these trial data to broader clinical practice might not accurately reflect "real-world" patient outcomes. Optimal management of MM is of key importance for positive patient outcomes, and further scrutiny of the efficacy and safety of the various reported therapies and how clinical trial findings are being translated or applied in the real-world management of MM is required. In the present review, we have described the minimal published evidence available through a comprehensive published data search of MEDLINE using the OvidSP interface on the management and outcomes of MM outside the setting of clinical trials, including evidence on the uptake of new therapies and their efficacy and tolerability in standard practice. Clinical registries might be able to help provide these data in the future.

Impact of marital status, insurance status, income, and race/ethnicity on the survival of younger patients diagnosed with multiple myeloma in the United States

BACKGROUND

Recent advances in the treatment of multiple myeloma (MM) have been associated with improved survival, predominantly among young and white patients. The authors hypothesized that sociodemographic factors, adjusted for race/ethnicity, influence the survival of younger patients with MM.

METHODS

Overall survival (OS) data were obtained for individuals included in the Surveillance, Epidemiology, and End Results (SEER-18) program who were diagnosed with MM before the age of 65 years between 2007 and 2012. The sociodemographic variables addressed were marital status, insurance status, median household income, and educational achievement in the county of residence. Race/ethnicity was defined as a self-reported construct including Hispanic (regardless of race), non-Hispanic black, non-Hispanic white, and other.

RESULTS

There were 10,161 cases of MM included with a median follow-up of 27 months (range, 0-71 months; 22,179 person-years). Using multivariable Cox proportional hazards analysis, SEER registry; age; male sex; and 3 sociodemographic factors including marital status (other than married), insurance status (uninsured or Medicaid), and county-level income (lowest 2 quartiles), but not race/ethnicity, were found to be associated with an increased risk of death. The 4-year estimated OS rate was 71.1%, 63.2%, 53.4%, and 46.5% (P<.001), respectively, for patients with 0, 1, 2, or 3 adverse sociodemographic factors. Hispanic and non-Hispanic black individuals were found to have more adverse sociodemographic factors and worse OS. However, when the population was stratified by the cumulative number of sociodemographic factors, no consistent association between race/ethnicity and OS was observed after adjustment for confounders.

CONCLUSIONS

Sociodemographic factors that potentially affect care, but not race/ethnicity, were found to influence the survival of younger patients with MM. Cancer 2016;122:3183-90. © 2016 American Cancer Society.

Cost-effectiveness of bortezomib for multiple myeloma: a systematic review

OBJECTIVES

To review published cost-effectiveness analyses (CEA) assessing bortezomib (BTZ) for multiple myeloma (MM) and explore possible bias affecting the cost-effectiveness of BTZ.

METHODS

Literature was searched for published CEAs assessing BTZ or BTZ-containing regimens for MM from 2003 to 2015. The reported incremental cost-effectiveness ratios (ICER) were adjusted by 2014 country-specific gross domestic product per capita (GDPPC) to compare the cost-effectiveness threshold of the World Health Organization (3 GDPPC per gained quality-adjusted life year [QALY]).

RESULTS

A total of 17 published CEAs were included in this review. When compared to non-BTZ treatments, BTZ-containing regimens were cost-effective for induction treatment prior to stem cell transplantation (SCT) in Canada, Poland, and Germany (ICER per QALY: 0.9299-2.254 GDPPC). BTZ/melphalan/prednisolone (VMP) was cost-effective for previously untreated and SCT-ineligible MM patients when compared to melphalan plus prednisolone (MP), melphalan/prednisone/lenalidomide with lenalidomide maintenance, and cyclophosphamide/thalidomide/dexamethasone (CTD) (ICER per QALY: dominant to 2.374 GDPPC) in Canada, UK, and USA. BTZ was cost-effective for relapsed/refractory MM when compared to best supportive care (ICER per life year: 0.9317-1.8210 GDPPC) in the UK and the USA, thalidomide in USA (0.5178 GDPPC/LY), and dexamethasone (DEX) in four Nordic countries (€54,451-€81,560/QALY). However, the cost-effectiveness for VMP versus MP plus thalidomide (MPT) and continuous lenalidomide (LEN) plus low-dose DEX (RD) for previously untreated and SCT-ineligible MM patients and BTZ versus LEN/DEX for relapsed/refractory MM patients could be unreliable because of the bias associated with model design and the indirect comparisons of treatment effects.

CONCLUSION

Published CEAs suggested that BTZ or BTZ-containing regimens were cost-effective when compared to most non-BTZ treatments for MM. However, the conflicting cost-effectiveness for VMP versus MPT for previously untreated and SCT-ineligible MM and BTZ versus LEN/DEX for relapsed/refractory MM needs more robust evidence for further clarification.

Overview of cost-effectiveness analysis and health state utilities in multiple myeloma and estimations of health state utilities from real-world macedonian data

Multiple myeloma (MM) is a hematological neoplastic plasma-cell disorder in the bone marrow. Nowadays, the survival of MM patients has improved by using novel therapies (e.g., bortezomib, thalidomide). Decision-analytic models (DAM) are known to be very useful in guiding clinical and health policy decisions by systematically evaluating expected outcomes of alternative treatments. When conducting DAM, it is recommended by National Institute for Clinical Excellence (NICE) as the preferred framework to use qualityadjusted life years as the main measure for health outcomes derived from generic preference-based instruments. The objective of our study was to identify and analyze the structural and methodological approaches of published studies that evaluated: (1) DAM for various treatment strategies in MM and (2) published health utility values (HUVs) after MM treatment. The searches were developed in the electronic literature database PubMed/MEDLINE. Additionally, we aimed to derive real-world data for HUVs from the current patients’ treatment landscape in the Hematology Clinical Center in Skopje. The survey collecting national HUVs was conducted during the period January-November 2016, using the generic preference-based instrument EQ-5D-5L, administered at one-time point in 20 MM patients. Only five studies reported on using a DAM. Seven studies were included in the extraction of already published HUVs. The calculated national health utility score of 0.723 was comparable to the published data in the previously identified studies reporting on similar MM treatment protocols. Several modeling approaches and HUVs, developed for different treatment strategies and target groups in MM were identified. Those data could be used to parameterize a DAM for MM treatment.