Health care costs and resource use of managing hemophilia A: A targeted literature review

Efficacy and Cost-Effectiveness of Low-Dose vs Standard Dose Prophylaxis for Hemophilia in Indonesia: A Systematic Review

Studies on high-dose prophylaxis therapy using Factor VIII show promising decrease in the Annual Bleeding Rates (ABR) in hemophilia patients. However, the greater dose and frequency raise concerns on cost considerations and adherence of the patients, especially in several countries where resources are limited. Other data has proven that the low dose prophylaxis is also promising regarding the decrease of ABR. The purpose of this systematic review is to conduct a comprehensive analysis of the lower dosage formulation used for prophylaxis in hemophilia. A PubMed and Embase database search was performed based on articles that met the following criteria: written in English language and published within the last 10 years. Consequently, the following key terms were used in combination: 'high dose', 'low dose', 'recombinant', 'prophylaxis', and 'hemophilia' in different combinations. 19 articles were included for this review. 10 of the investigated papers demonstrated decrease in ABR, functional improvement of affected joints, alleviation of pain, and a better quality of life in hemophilia patients. Low dose prophylaxis has proven to significantly improve symptoms, lower ABR and preserve joint and bone health compared to episodic or on-demand treatment. Furthermore, low dose prophylaxis (LDP) was also observed to be cost-effective and more convenient in certain countries, especially in south-east Asia where resources are limited. Overall, low dose prophylaxis appears to be non-inferior in improving the overall Quality of Life in people with hemophilia, and therefore could be a beneficial alternative in countries of the south east Asian region.

Economic Burden of Haemophilia from a Societal Perspective: A Scoping Review

INTRODUCTION

Haemophilia is a rare genetic bleeding disorder that leads to musculoskeletal complications. The high cost of haemophilia treatment necessitates a thorough evaluation of its economic burden. However, due to the difficulty of estimating direct non-medical, indirect, and intangible costs, studies often underestimate the actual economic burden of haemophilia. This scoping review aims to summarise economic studies in haemophilia conducted from a societal perspective.

METHODS

A systematic search across eight scholarly databases, grey literature, and reference lists until the 5th of July 2023 was conducted to identify relevant studies. The inclusion criteria encompassed full-text, English-language publications of economic analyses in congenital haemophilia from a societal perspective. Model-based studies and those adopting a payer perspective were excluded. Costs were adjusted to international dollars (I$) and US dollars (US$) in 2022 for comparability.

RESULTS

Out of 2993 potential sources identified, 25 studies met the inclusion criteria, covering 7226 persons with haemophilia across 22 countries. All studies reported direct medical costs, with four excluding the cost of haemostatic therapy. Fifteen studies reported direct formal non-medical costs, while eight reported direct informal non-medical costs. All but one study reported the indirect costs. The average annual costs of haemophilia varied widely based on treatment modality, disease severity, geographical location, and included cost categories. When including the cost of clotting factor replacement therapy (CFRT), the total cost for severe haemophilia without inhibitors ranged from 1566 I$ to 700,070 I$ per person per year (lowest value reported in India and highest in the United States). CFRT represented up to 99.9% of the total cost for those receiving prophylaxis and up to 95.1% for episodic treatment. Haemostatic therapies accounted for 82% of the total cost in patients with inhibitors.

CONCLUSION

There is a significant heterogeneity in defining cost categories required for a comprehensive economic analysis from a societal perspective. While haemostatic therapies constitute a substantial portion of the overall cost, direct non-medical and indirect costs are crucial as they are often paid out-of-pocket and may impede access to treatment. It is essential for haematologists and economists to establish a standardised costing framework for future studies, particularly in the era of novel therapies.

The Impact of Emicizumab Prophylaxis on Hospitalizations and Emergency Department Visits Among Hemophilia A Patients Is Age Related

INTRODUCTION

Hemophilia A (HA) therapy poses a significant healthcare burden. In recent years, emicizumab has been approved for prophylaxis. The current study explores the impact of transitioning to emicizumab on emergency department (ED) visits and hospitalizations in pediatric and adult HA patients.

METHODS

Data of HA patients transitioned to emicizumab at the Israeli National Hemophilia Center was retrospectively analyzed. Demographic information, inhibitor status, treatment duration, number, and reasons of ED visits and hospitalizations were assessed.

RESULTS

Overall, transitioning to emicizumab significantly reduced ED visits and hospitalizations. While children experienced a significant reduction in both ED visits and hospitalizations, adults showed no statistically significant change. Post-emicizumab initiation, main reasons for ED visits among children shifted from prophylactic treatment and central line-associated complications to injury-related incidents.

CONCLUSIONS

This real-world analysis demonstrates a substantial decrease in ED visits and hospitalizations, following emicizumab prophylaxis in HA patients. However, this improvement was age dependent as it was observed only among children. Further prospective studies evaluating this aspect may shed light on these findings.

Cost of hemophilia A in Brazil: a microcosting study

BACKGROUND

Patients with Hemophilia are continually monitored at treatment centers to avoid and control bleeding episodes. This study estimated the direct and indirect costs per patient with hemophilia A in Brazil and evaluated the cost variability across different age groups.

METHODS

A prospective observational research was conducted with retrospective data collection of patients assisted at three referral blood centers in Brazil. Time-driven Activity-based Costing method was used to analyze direct costs, while indirect costs were estimated based on interviews with family and caregivers. Cost per patient was analyzed according to age categories, stratified into 3 groups (0-11;12-18 or older than 19 years old). The non-parametric Mann-Whitney test was used to confirm the differences in costs across groups.

RESULTS

Data from 140 hemophilia A patients were analyzed; 53 were 0-11 years, 29 were 12-18 years, and the remaining were older than 19 years. The median cost per patient per year was R$450,831 (IQR R$219,842; R$785,149; $174,566), being possible to confirm age as a cost driver: older patients had higher costs than younger's (p = 0.001; median cost: 0-11 yrs R$299,320; 12-18 yrs R$521,936; ≥19 yrs R$718,969).

CONCLUSION

This study is innovative in providing cost information for hemophilia A using a microcosting technique. The variation in costs across patient age groups can sustain more accurate health policies driven to increase access to cutting-edge technologies and reduce the burden of the disease.

Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project

Objectives

This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED).

Methods

The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact.

Results

A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15 hours. There was no significant increase (27% vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease.

Conclusions

The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.

Exploring Female Relatives of Patients with Hemophilia' Awareness, Attitudes, and Understanding Towards Genetic Testing

Purpose

A better understanding of the factors that influence engagement is needed to provide a reference for conducting genetic testing in female relatives of patients with hemophilia (PWH). We therefore determined the perceptions and understanding of genetic testing among female relatives of PWH in China.

Methods

We carried out a qualitative study using in-depth, semi-structured interviews with 11 female relatives of PWH in Shanxi Province, China. The resulting data were analyzed using thematic analyses.

Results

This study extracted four topics: uncertainty about carrier genetic status; limited understanding of genetic testing; coexistence of positive and negative coping; and multi-aspect demands.

Conclusion

Healthcare professionals should provide personalized and multidimensional health education and comprehensive decision-making support to female relatives of PWH, to enhance their motivation and willingness to undergo genetic testing. It is also important to actively improve relevant policies, strengthen the genetic testing service system, and promote the popularization of genetic testing in female relatives of PWH.

Efficacy/effectiveness and safety of emicizumab prophylaxis of people with hemophilia A: a systematic review and meta-analysis

BACKGROUND

Emicizumab is a monoclonal antibody approved for prophylaxis against bleeds for people with hemophilia A (PwHA). A systematic review was conducted evaluating the efficacy/effectiveness and the safety of emicizumab as prophylaxis for PwHA compared to prophylaxis with factor VIII (FVIII) or bypassing agents (BPA), respectively in patients without and with inhibitors.

RESEARCH DESIGN AND METHODS

Database-directed search strategies were performed in Aug/26/2022 and updated in Mar/16/2023. Studies evaluating the prophylaxis with emicizumab versus prophylaxis with FVIII or BPA in PwHA without or with inhibitors, respectively, were selected by two independent reviewers. Data were extracted by two independent reviewers. Annualized bleeding rates for total treated bleeding events (ABR-all) were evaluated by meta-analysis. The quality of studies and certainty of evidence were assessed.

RESULTS

A total of 11 studies were included. The standard mean differences for ABR-all were -0.6 (95%CI -1.0 to -0.2, p-value = 0.0002), among PwHA without inhibitors, and -1.7 (95%CI -2.4 to -0.9, p-value <0.00001), among PwHA with inhibitors. However, there was moderate heterogeneity in both meta-analyses. The most frequent adverse event was injection site reaction.

CONCLUSIONS

Emicizumab prophylaxis was superior in reducing the ABR-all when compared with prophylaxis with FVIII or BPA.