The Impact of Biosimilar Use on Total Cost of Care and Provider Financial Performance in the Medicare Oncology Care Model: A Population-Based Simulation Study

INTRODUCTION

Payment for oncology care is increasingly moving from fee-for-service to value-based payment (VBP). VBPs are agreements in which providers are held accountable for total cost of care (TCOC) through risk-sharing arrangements with payers that tie reimbursement levels to TCOC benchmarks. Oncology biosimilars may play an important role in managing financial risk in the VBPs like Medicare's Oncology Care Model (OCM), but there has been limited research in this area. The objective of this study is to estimate the impact of biosimilar adoption on TCOC and oncology provider financial performance under the terms of the Medicare OCM.

METHODS

We conducted a population-based simulation study using the Medicare Limited Data Set (LDS) and the methodology of Medicare's OCM. The primary outcome was the simulated average change in TCOC per 6-month episode of care attributable to use of biosimilars as an alternative to reference products. The study population consisted of episodes of care in 2020 and using the reference product or corresponding biosimilar for bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, or pegfilgrastim. TCOC was calculated for each episode of care with use of reference products only and compared with TCOC with corresponding biosimilars. The simulation calculated TCOC outcomes in cohorts of 100 episodes sampled from the Medicare LDS study population using a Monte Carlo simulation with 10,000 iterations.

RESULTS

Among the total of 8281 6-month oncology care episodes identified in the study period (initiating January 2020 to July 2020) in Medicare claims, 1586 (19.2%) episodes met OCM and study criteria and were included. Applying the simulation methods to these observed episodes, biosimilar substitution reduced mean TCOC per episode by $1193 (95% CI $583-1840). The cost reduction from biosimilars represented 2.4% of the average TCOC benchmark and led to a 15% reduction in the risk of providers needing to pay recoupments to Medicare for exceeding TCOC benchmarks.

CONCLUSIONS

On the basis of our simulation study using observed Medicare claims and OCM criteria, we found that biosimilar substitution for reference products can significantly lower episode TCOC and improve provider financial performance under the terms of the largest value-based payment model implemented to date.

Projected impact of oncology biosimilar substitution from the perspective of provider risk in value-based oncology payment models

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Background: Oncology biosimilars may play an important role in managing risk for providers participating in value-based payment (VBP) models. The impact of biosimilar substitution on risk to providers remains unclear, as prior researchers have adopted a generic budget impact approach. Methods: We estimated the impact of biosimilar substitution on financial risk to providers in oncology VBPs by applying simulation approaches to model the quantitative methodology (e.g. episode framing, pricing, risk adjustment) of Medicare’s Oncology Care Model (OCM). Patient demographic and utilization data to fit the models were drawn from the Medicare Limited Data Set (LDS). Risk was defined as total cost of care (TCOC) relative to target price for an episode per the OCM methodology. Target prices were estimated using the most recently available OCM risk adjustment coefficients (2020). Biosimilars for six oncology agents were examined: bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, and pegfilgrastim (hereafter biosimilar investigation agents – BIAs). Episode TCOC was computed under the assumption of the use of reference BIAs and was then recomputed after biosimilar substitution. The study population consisted of 1620 episodes framed per the OCM methodology using the most recently available LDS data (2019-2020) that had use of a BIA. The impact to provider groups was estimated by computing the change in OCM risk bands (incentive payment earned/ neutral/ payment owed back to Medicare) associated with biosimilar substitution in panels of 100 randomly selected episodes from the study population over 10000 simulation runs. In our base model, we assumed that substitution for antineoplastics would occur only in treatment naïve patients and that substitution for supportive therapies would occur for all eligible patients. Treatment naïve status was assessed by examining longitudinal LDS data from 2016-2020 for beneficiaries from the study population. Results: Biosimilar substitution resulted in a mean reduction in cost relative to target of approximately $1,200 per eligible episode and reduced the proportion of practices that were above benchmark for eligible episodes by 33% and increased the number of practices below target for eligible episodes by 42%. Additional scenario analyses suggested that adoption strategy was a major determinant of potential impact. If assumptions of antineoplastic substitution requiring treatment naïve status were relaxed, costs savings relative to target would go from $1200 per eligible episode to $2700. Conclusions: Biosimilar substitution significantly reduces aggregate provider risk in OCM, representing a significant potential intervention for providers to mitigate risk in oncology VBPs both in terms of absolute costs saved relative to target and reduction in risk band relative to payer projections.

Impact of Infliximab-dyyb (Infliximab Biosimilar) on Clinical and Patient-Reported Outcomes: 1-Year Follow-up Results from an Observational Real-World Study Among Patients with Inflammatory Bowel Disease in the US and Canada (the ONWARD Study)

Introduction

To date, there are limited real-world studies published on the use of infliximab-dyyb, a biosimilar to reference product (RP) infliximab approved for the treatment of moderate to severe inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC) in North America. This study examined utilization patterns and the effects of infliximab-dyyb on clinical outcomes, patient-reported outcomes (PROs), and healthcare resource use (HCRU) in IBD patients in a real-world setting.

Methods

In this prospective, observational study, adult IBD patients in the US and Canada were recruited to initiate treatment with infliximab-dyyb and followed for 12 months. Patients included biologic-naïve users of infliximab-dyyb and patients switching from RP infliximab or other biologics to infliximab-dyyb. Partial Mayo (pMAYO) and Harvey Bradshaw Index (HBI) scores measured clinical outcomes for the UC and CD cohorts, respectively. Key PRO measures included the SIBDQ, EQ-VAS, and psychological outcomes. In addition, work productivity, HCRU, and adverse events (AEs) were assessed.

Results

A total of 67 CD and 48 UC patients were enrolled (51% female; mean age 44 years; 87% Caucasian; mean BMI 27.9). Thirty-nine patients were biologic-naïve, 57 switched from RP infliximab, and 19 switched from other biologics. Among UC biologic-naïve users, pMAYO decreased from 5.67 to 1.09 (p < 0.0001) and the remission rate increased from 5.6 to 90.9% (p = 0.0015). For UC patients switching from RP infliximab, pMAYO decreased from 1.38 to 0.29 (p = 0.0103). For CD biologic-naïve users, HBI scores and remission rates did not significantly change. The scores on all the PROs significantly improved from baseline to 12 months. A total of 22 AEs occurred consistent with the known AE profile for infliximab.

Conclusions

Clinical outcomes among biologic-naïve users of infliximab-dyyb improved for UC and were maintained for CD patients. Biologic-naïve users of infliximab-dyyb showed significant improvements in PROs. Patients switching from RP infliximab to infliximab-dyyb maintained their clinical outcomes and PROs.

Trial Registration

ClinicalTrials.gov Registration Number: NCT03801928 (February 23, 2018).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02104-6.

Real-world usage of bevacizumab-bvzr biosimilar in US oncology practice

OBJECTIVES

Bevacizumab is commonly used to treat solid tumors. However, little is known about the manner and the extent to which bevacizumab biosimilars are utilized in real-world oncology practice in the United States. The objective of this study was to describe patient and provider characteristics and treatment patterns associated with the recently introduced bevacizumab-bvzr biosimilar.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective analysis of medical and pharmacy claims between January 24, 2019, and July 31, 2020, was performed. Adult patients with at least 1 claim indicating usage of bevacizumab-bvzr were included. Patients who could not be assigned to an applicable diagnosis group were excluded. Index treatment date was defined as the date of the first claim for bevacizumab-bvzr. Descriptive analysis was conducted for all study variables.

RESULTS

A total of 206 patients were included; patients most often were 65 years or older (49.5%), were female (62.6%), and resided in the West (45.1%). The most common indications observed for bevacizumab-bvzr were metastatic colorectal cancer (mCRC; 51.0%), cancer of the female genital organs (CFGO; 27.2%), glioblastoma (11.2%), and non-small cell lung cancer (8.7%). Overall, 72.4% and 48.2% of patients with mCRC and CFGO, respectively, had switched to bevacizumab-bvzr from the reference drug or another bevacizumab biosimilar. Bevacizumab-bvzr was used in chemotherapy combination regimens for patients with mCRC and CFGO.

CONCLUSIONS

Utilization was observed in extrapolated indications. Findings suggest that both switching between reference product and bevacizumab biosimilars and using bevacizumab-bvzr as part of chemotherapy combination regimens have been adopted in US oncology practice.

Evolving Perceptions, Utilization, and Real-World Implementation Experiences of Oncology Monoclonal Antibody Biosimilars in the USA: Perspectives from Both Payers and Physicians

BACKGROUND

The adoption of oncology biosimilars has been slow in the USA, which may be attributed in part to stakeholder perceptions and lack of operational guidance that supports favorable access to biosimilars.

OBJECTIVE

Our objective was to understand the real-world implementation experiences with oncology biosimilars of US payers and healthcare professionals (HCPs) as their experience with biosimilars has evolved.

METHODS

In-depth qualitative interviews with payers (n = 20) and HCPs (n = 17 physicians, n = 3 practice managers) were conducted. Payers included managed care organizations (MCOs), integrated delivery networks, and pharmacy benefit managers (PBMs). Physicians were affiliated with a healthcare network or were community based, specialized in hematology/oncology, and had prescribed oncology biosimilars. Audio transcripts of the interviews were coded using MaxQDA software to enable descriptive analysis of the qualitative data.

RESULTS

Over 80.0% of physicians perceived the efficacy and safety of biosimilars to be highly comparable to that of originators. Up to 87.5% of physicians reported using biosimilars in > 50% of their treatment-naïve patients and were comfortable using biosimilars in all approved indications. To encourage utilization, 75.0% of MCOs/PBMs preferred biosimilars over originators in treatment-naïve patients and implementation via step therapy. Physician involvement in choosing biosimilars was minimal, which was largely dependent on practice protocols or insurance preferences. The major factor influencing payers' coverage decisions and biosimilar adoption was potential cost savings.

CONCLUSIONS

US payers and physicians who have experience with biosimilars have favorable views of oncology biosimilars, particularly for treatment-naïve patients. A framework for integrating biosimilars into oncology practice is developing, primarily driven by insurance coverage, contracting, and cost benefits.

Greater uptake, an alternative reimbursement methodology needed to realize cost-saving potential of oncology biosimilars in the United States

BACKGROUND: Biologics are an important treatment option for solid tumors and hematological malignancies but are a primary driver of health care spending growth. The United States has yet to realize the promise of reduced costs via biosimilars because of slow uptake, partially resulting from commercial payer reimbursement models that create economic incentives favoring the prescribing of reference biologics. OBJECTIVE: To examine the economic feasibility of an alternative reimbursement methodology that prospectively shares savings across commercial payers and providers to shift economic incentives in favor of lower-cost oncology biosimilars. METHODS: Using 3 oncology monoclonal antibody drugs (trastuzumab, bevacizumab, and rituximab) as examples, we developed an alternative reimbursement model that would offer an additional per unit payment (or "extra consideration") such that providers' net income per unit for biosimilars and reference biologics become equal. Provider-negotiated rates (or payer-allowable amounts) and average sales prices were obtained from claims data and projected to develop prices/costs from 2021 through 2025. Scenario analyses by varying key model assumptions were performed. RESULTS: The alternative reimbursement model achieved 1-year and 5-year payer savings in the commercial market for all 3 drugs in the sites of service analyzed. The base analysis showed first-year cost savings to payers, net of cost sharing, of up to 9% in physician offices (POs) and up to 1% in non-340B hospital outpatient departments (HOPDs) for patients using the drugs analyzed. Five-year cumulative savings per patient ranged from about $12,600-$16,100 in PO and $2,200-$4,100 in HOPD. Payer savings varied depending on the characteristics of the provider with which the payer was negotiating (eg, lower- vs highermarkup providers, POs vs HOPDs). CONCLUSIONS: Positive payer savings shown in our modeling suggest that an alternative reimbursement arrangement could facilitate an economic compromise wherein commercial payers can save on biosimilars while providers' incomes are preserved. DISCLOSURES: Research funding was provided by Pfizer Inc. Yang and Shelbaya are employees of Pfizer Inc. and own Pfizer stock. Carioto, Pyenson, Smith, Jacobson, and Pittinger are employees of Milliman Inc., which received research funding from Pfizer Inc., for work on this study. Milliman, Inc., provides actuarial and other professional services to organizations throughout the healthcare industry. None of these are contingent, equity or investment relationships.

Real-world use and acceptance of biosimilar monoclonal antibodies of rituximab in oncology practice in the USA

Aim: To describe treatment patterns and patient and provider characteristics associated with the recently introduced biosimilar rituximab-pvvr. Methods: This retrospective analysis included adult patients with one or more claims for rituximab-pvvr, with an index date of 23 January 2020 and a study period covering 1 January 2019-31 July 2020. Results: Of 249 patients included, the most common rituximab-pvvr indications were non-Hodgkin's lymphoma (77.5%) and chronic lymphocytic leukemia (11.2%). Some patients with non-Hodgkin's lymphoma (42.5%) and chronic lymphocytic leukemia (39.3%) switched to rituximab-pvvr from the reference product or another rituximab biosimilar. Most patients were aged ≥65 years (63.5%) and were male (54.6%). Most (59.0%) rituximab-pvvr prescribers practiced in the south of the USA. Conclusion: Utilization occurred in approved and extrapolated indications. These preliminary findings suggest switching between reference product and rituximab biosimilars; rituximab-pvvr combination regimens are being adopted in real-world oncology practice.

Does Biosimilar Bevacizumab Offer Affordable Treatment Options for Cancer Patients in the USA? A Budget Impact Analysis from US Commercial and Medicare Payer Perspectives

BACKGROUND

Bevacizumab remains the most widely used and most thoroughly characterized angiogenesis inhibitor for a range of advanced cancers. Bevacizumab-bvzr (Zirabev®), a biosimilar of bevacizumab, was recently approved by the US Food and Drug Administration (FDA), which provides a less costly option. This study aimed to evaluate the financial impact of introducing bevacizumab-bvzr from US commercial and Medicare payer perspectives.

METHODS

A Microsoft Excel-based budget impact model was developed over a 5-year time horizon. Target population was patients to be treated with bevacizumab for FDA-approved indications. Drug costs (2020 US$) were based on average sales price and wholesale acquisition cost, accounting for payer-specific reimbursement models and provider settings. Drug dosing and duration were based on prescribing information and pivotal trial publications.

RESULTS

In a hypothetical 10-million-member health plan, 503 and 723 patients were estimated to be treated with bevacizumab in year 1 and year 5, respectively. Assuming an annual market shift of 1.7%, 3.6%, 6.7%, 9.4%, and 11.9% to bevacizumab-bvzr, an annual cost saving of $313,363 ($0.003 per member per month [PMPM]) was estimated for a commercial payer and $92,880 ($0.001 PMPM) for Medicare in year 1. Cumulative 5-year cost savings were $7,030,924 ($0.012 PMPM) for a commercial payer and $4,059,257 ($0.007 PMPM) for Medicare. More than half of the cost savings was attributed to patients with metastatic colorectal cancer.

CONCLUSIONS

The introduction of biosimilar bevacizumab-bvzr was estimated to provide substantial cost savings for US payers, which would allow additional patients access to bevacizumab treatment.

Effects of dose titration on adherence and treatment duration of pregabalin among patients with neuropathic pain: A MarketScan database study

OBJECTIVE

To examine pregabalin dose titration and its impact on treatment adherence and duration in patients with neuropathic pain (NeP).

METHODS

MarketScan database (2009-2014) was used to extract a cohort of incident adult pregabalin users with NeP who had at least 12 months of follow-up data. Any dose augmentation within 45 days following the first pregabalin claim was defined as dose titration. Adherence (measured by medication possession ratio/MPR) and persistence (measured as the duration of continuous treatment) were compared between the cohorts with and without dose titration. Logistic regressions and Cox proportional hazards models were used to identify the factors associated with adherence (MPR ≥ 0.8) and predictors of time to discontinuation.

RESULTS

Among the 5,186 patients in the analysis, only 18% of patients had dose titration. Patients who had dose titration were approximately 2.6 times as likely to be adherent (MPR ≥ 0.8) (odds ratio = 2.59, P < 0.001) than those who did not have dose titration. Kaplan-Meier analysis shows that the time to discontinuation or switch was significantly longer among patients who had dose titration (4.99 vs. 4.04 months, P = 0.009).

CONCLUSIONS

Dose titration was associated with improved treatment adherence and persistence among NeP patients receiving pregabalin. The findings will provide valuable evidence to increase physician awareness of dose recommendations in the prescribing information and to educate patients on the importance of titration and adherence.

Rituximab biosimilars in hematologic malignancies: the need for a real-world approach

The introduction of rituximab biosimilars into healthcare systems can potentially help to control healthcare costs for the treatment of hematologic malignancies. However, there are currently several barriers to the uptake of biosimilars. This review discusses barriers to the adoption of rituximab biosimilars by stakeholders including patients and healthcare providers. We outline the importance of utilizing real-world evidence in providing additional clinical experience on rituximab biosimilars in hematologic malignancies to improve stakeholder confidence regarding their efficacy and safety. We conclude by offering recommendations for designing and conducting effective real-world studies. Such studies can provide evidence to help achieve lower-priced biologics and improved patient access to help sustain the treatment of hematologic malignancies with biologics, including rituximab biosimilars.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

Economic Outcomes Related to Persistence and Dosing of Celecoxib in Patients with Osteoarthritis (OA) Using a Retrospective Claims Database Analysis

Objective

This study describes treatment patterns, healthcare resource utilization (HCRU), and costs associated with persistence, switching, and dosing of branded celecoxib in osteoarthritis (OA) patients.

Methods

This retrospective claims database analysis used MarketScan^® Commercial Claims and Encounters (MarketScan) data from 2009 to 2013. Included patients were adult (≥ 18 years), incident celecoxib users with ≥ 1 OA claim. The treatment switch analysis analyzed outcomes in patients persistent on celecoxib versus switched to a generic nonsteroidal anti-inflammatory drug (NSAID). The dosing analysis stratified patients as under-dose (<200 mg per day) and standard dose (≥200 mg per day). HCRU, costs, and treatment duration were compared in persistent versus switched and standard dose versus under-dose patients using descriptive, multivariate logistic regression, and Kaplan–Meier analysis.

Results

A total of 65,530 patients met the inclusion criteria. During follow-up, 83% discontinued celecoxib without switching, 10% were persistent, and 5% switched to a generic NSAID. Ninety percent received a standard dose of celecoxib. Switched (versus persistent) patients had significantly higher all-cause hospital admissions, length of stay, emergency room (ER) visits, and office visits per person year (PPY), all P <0.001; and under-dosed (versus standard dose) patients had significantly higher hospital admissions (P<0.001), length of stay (P<0.001), and ER visits (P= 0.021) PPY. Persistent versus switched patients had lower mean total all-cause costs PPY ($20,378 vs $23,949, P<0.001). Standard dose versus under-dose patients had lower mean total all-cause costs ($23,680 vs $26,955 PPY, P<0.001), and not statistically significant higher mean total OA-related costs ($5698 vs $5524 PPY, P=0.441).

Conclusion

Patients that switched from branded celecoxib to a generic NSAID or received an under-dose of branded celecoxib had higher average overall HCRU and costs. OA-related inpatient and outpatient cost savings may offset the higher drug cost of celecoxib for persistent patients.

Healthcare resource use and cost associated with timing of pharmacological treatment for major depressive disorder in the United States: a real-world study

Background: Guidelines recommend selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI) as first-line treatments for major depressive disorder (MDD) and emphasize the importance of early pharmacological treatment as key factors to treatment success.Objectives: To compare the MDD-related healthcare resource utilization (HCRU) and cost among patients (1) with early vs late pharmacological treatment initiation and (2) achieving minimum therapeutic dose (MTD) early vs late.Methods: The MarketScan database (2010-2015) was used. Adults who were newly-treated with SSRI/SNRI within 12 months after the initial MDD diagnosis (index) were included. Patients who initiated SSRI/SNRI within 2 weeks of the index date were defined as early initiators; those who reached MTD within 4 weeks of index date were defined as early MTD achievers. MDD-related HCRU and costs per year after the index date were compared between early and late initiators and between early and late achievers using propensity score matching and generalized linear models.Results: Of the 55,539 patients, 60% were early initiators and 61% were early MTD achievers. The mean number of MDD-related outpatient visits per year were significantly higher for late initiator (6.7 vs 4.2, p < .001) and late MTD achievers (6.5 vs 4.5, p < .001) vs their early counterparts. Mean annual MDD-related outpatient, drug, and total cost were significantly higher for late initiators and MTD achievers vs the early groups.Conclusions: There is an opportunity to improve outcomes by treating MDD patients with SSRI/SNRI within 2 weeks and at or above the MTD within 4 weeks of diagnosis or less.

The economic and clinical burden of early versus late initiation of celecoxib among patients with osteoarthritis

Objective

This study aimed to evaluate the characteristics associated with early versus late initiation of celecoxib treatment after osteoarthritis (OA) diagnosis and whether economic and safety outcomes differ between patients with early versus late initiation of celecoxib.

Methods

Adults (≥18 years) with a confirmed OA diagnosis (International Classification of Diseases, 9th Edition, Clinical Modifications code: 715.XX), ≥12 months of continuous pre- and post-index enrollment, and ≥1 post-index claim for celecoxib were included from the MarketScan® Commercial Claims and Encounter Database (2009-2013). Index date was defined as initial OA diagnosis. Patients were categorized as initiating celecoxib early (within 6 months of index date) or late (≥6 months after index date). Logistic regressions were used to assess characteristics associated with early versus late celecoxib initiation. Key outcomes included health care resource utilization (HCRU) and costs post-index, and adverse event incidence post-celecoxib initiation. Unadjusted and adjusted comparisons (using generalized linear models with a gamma distribution for costs and Poisson distribution for event and resource utilization) were made between early and late celecoxib initiators.

Results

Of the 62,434 OA patients identified, 27,402 were early and 35,032 were late initiators. Post-index hospital admissions and length of stay did not differ statistically between early versus late initiators after controlling for pre-index event rates and covariates, but early patients had significantly fewer outpatient (incidence rate ratio [IRR]: 0.96; 95% confidence interval [CI]: 0.95, 0.97) and emergency room visits (IRR: 0.89; 95% CI: 0.84, 0.95). After adjustment for key covariates, early initiators (versus late initiators) had lower all-cause (US$12,909 versus US$13,781, P<0.001) and OA-related (US$4,988 versus US$5,178, P=0.015) costs per person-year. Early initiators had no statistically significant difference in the incidence of post-celecoxib cardiovascular (IRR: 0.92; 95% CI: 0.73, 1.14), gastrointestinal (IRR: 1.25; 95% CI: 0.81, 1.92), or renal (IRR: 1.19; 95% CI: 0.65, 2.18) events, controlling for pre-index event rates and covariates when compared to late initiators.

Conclusion

In this real-world cohort, patients initiated on celecoxib early (versus late) had significantly lower costs and HCRU; this may warrant consideration when making treatment decisions for OA patients.

Value of Propensity Score Matching for Equalizing Comparator Groups in Observational Database Studies: A Case Study in Anti-infectives

PURPOSE

Propensity score methodologies can reduce bias and confounding in nonrandomized studies, including pharmaceutical comparative effectiveness studies. An observational case study was developed to demonstrate the impact of propensity score adjustments on outcomes (ie, discharge status) of patients hospitalized for complicated intra-abdominal infections.

METHODS

Two cohorts were examined: intensive care unit (ICU) (vs non-ICU) patients and tigecycline-treated patients (vs patients receiving other antibiotics). Discharge status was captured before propensity scoring.

FINDINGS

The impact of propensity scoring on discharge outcome was greater when comparing ICU patients versus non-ICU patients than when comparing tigecycline recipients versus nonrecipients.

IMPLICATIONS

Propensity scoring should be examined carefully to optimize its effects. Moreover, propensity scoring only addresses bias and confounding in nonrandomized studies that are attributable to variables contained within the dataset (ie, so called "observables") and not to other variables that may influence the relationship between outcomes and other independent variables.

Evaluation of Tigecycline Efficacy and Post-Discharge Outcomes in a Clinical Practice Population with Complicated Intra-Abdominal Infection: A Propensity Score-Matched Analysis

Background: The utility of tigecycline as compared with other antibiotic therapies in the treatment of patients with complicated intra-abdominal infection (cIAI) and the short- and long-term outcomes of a large cohort of severely ill patients were examined. We provide the first published data on post-discharge events for these patients.

Methods: Retrospective data for the cIAI cohort were obtained from a large clinical database. Patients aged ≥18 y were selected for inclusion based on hospitalization with a relevant diagnosis code and procedure code, and guideline-compliant antimicrobial therapy. Propensity scoring was used to reduce treatment-selection bias introduced by the use of observational data. Tigecycline patients were placed into quintiles based on propensity score and were matched 1:3.

Results: The final model based on propensity score matching included 2,424 patients: Tigecycline (n = 606) and other antibiotic therapy (n = 1,818). Treatment was successful in 426 (70.3%) tigecycline-treated patients and in 1,294 (71.2%) patients receiving other antibiotics. Similar treatment success occurred across all infection sites. Among survivors, treatment failure was associated with a greater need for all-cause re-hospitalization at 30 d and 180 d. No differences in cIAI-related re-hospitalization and discharge status were observed.

Conclusions: Using propensity scores to match populations, similar outcomes were demonstrated between treatment with tigecycline and other antibiotics as expressed by treatment success, the need for re-admission, similar 30-d discharge status, and the need for re-admission at 180 d.

Analysis of treatment patterns and persistence on branded and generic medications in major depressive disorder using retrospective claims data

BACKGROUND

In major depressive disorder (MDD), treatment persistence is critical to optimize symptom remission, functional recovery, and health care costs. Desvenlafaxine tends to have fewer drug interactions and better tolerability than other MDD drugs; however, its use has not been assessed in the real world.

OBJECTIVE

The aim of the present study is to compare medication persistence and concomitant MDD drug use with branded desvenlafaxine (Pristiq^®) compared with antidepressant drug groups classified as 1) branded selective serotonin reuptake inhibitors (SSRIs; ie, escitalopram [Lexapro™]) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs; ie, venlafaxine [Effexor^®], duloxetine [Cymbalta^®]) and 2) generic SSRIs/SNRIs (ie, escitalopram, citalopram, venlafaxine, fluvoxamine, fluoxetine, sertraline, paroxetine, and duloxetine).

PATIENTS AND METHODS

MDD patients (ICD-9-CM codes 296.2, 296.3), with ≥2 prescription fills for study drugs and 12-month preindex continuous enrollment from the MarketScan Commercial Claims and Encounters Database (2009-2013), were included. Time-to-treatment discontinuation (prescription gap ≥45 days) was assessed using the Kaplan-Meier curve and Cox model. Concomitant MDD drug use was compared.

RESULTS

Of the 273,514 patients included, 14,379 patients were initiated with branded desvenlafaxine, 50,937 patients with other branded SSRIs/SNRIs, and 208,198 patients with generic SSRIs/SNRIs. The number of weeks for treatment discontinuation for branded desvenlafaxine were longer (40.7 [95% CI: 39.3, 42.0]) compared with other branded SSRIs/SNRIs (28.9 [95% CI: 28.4, 29.1]) and generic SSRIs/SNRIs (33.4 [95% CI: 33.1, 33.7]). Adjusting for baseline characteristics, patients who were prescribed with other branded SSRIs/SNRIs were 31% and generic SSRIs/SNRIs were 11% more likely to discontinue treatment compared with branded desvenlafaxine. In sensitivity analysis, the risk of discontinuation was within 10% of branded desvenlafaxine for branded duloxetine, generic escitalopram, and generic venlafaxine. Concomitant MDD drug use was higher among branded desvenlafaxine patients (43.8%) compared with other branded SSRIs/SNRIs (39.8%) and generic SSRIs/SNRIs (36.4%).

CONCLUSION

MDD patients on branded desvenlafaxine were more persistent with treatment compared with those on other branded or generic SSRI/SNRI therapies. Future research should include assessments of underlying factors on the treatment persistence in MDD patients.

Economic burden of inpatient and outpatient antibiotic treatment for methicillin-resistant Staphylococcus aureus complicated skin and soft-tissue infections: a comparison of linezolid, vancomycin, and daptomycin

Background

Previous economic analyses evaluating treatment of methicillin-resistant Staphylococcus aureus (MRSA) complicated skin and soft-tissue infections (cSSTI) failed to include all direct treatment costs such as outpatient parenteral antibiotic therapy (OPAT). Our objective was to develop an economic model from a US payer perspective that includes all direct inpatient and outpatient costs incurred by patients with MRSA cSSTI receiving linezolid, vancomycin, or daptomycin.

Methods

A 4-week decision model was developed for this economic analysis. Published literature and database analyses with validation by experts provided clinical, resource use, and cost inputs on data such as efficacy rate, length of stay, adverse events, and OPAT services. Base-case analysis assumed equal efficacy and equal length of stay for treatments. We conducted several sensitivity analyses where assumptions on resource use or efficacy were varied. Costs were reported in year-end 2011 US dollars.

Results

Total treatment costs in the base-case were lower for linezolid ($10,571) than vancomycin ($11,096), and daptomycin ($13,612). Inpatient treatment costs were $740 more, but outpatient costs, $1,266 less with linezolid than vancomycin therapy due to a switch to oral linezolid when the patient was discharged. Compared with daptomycin, both inpatient and outpatient treatment costs were lower with linezolid by $87 and $2,954 respectively. In sensitivity analyses, linezolid had lower costs compared with vancomycin and daptomycin when using differential length of stay data from a clinical trial, and using success rates from a meta-analysis. In a scenario without peripherally inserted central catheter line costs, linezolid became slightly more expensive than vancomycin (by $285), but remained less costly than daptomycin (by $2,316).

Conclusion

Outpatient costs of managing MRSA cSSTI may be reduced by 30%–50% with oral linezolid compared with vancomycin or daptomycin. Results from this analysis support potential economic benefit and cost savings of using linezolid versus traditional OPAT when total inpatient and outpatient medical costs are evaluated.

Risk factors for mixed complicated skin and skin structure infections to help tailor appropriate empiric therapy

BACKGROUND

Complicated skin and skin structure infections (cSSSIs) are a common reason for hospitalization. Inappropriate empiric therapy prolongs the hospital stay. Strategies that help clinicians target empiric therapy underlie antibiotic stewardship. We developed an algorithm to identify mixed (gram-positive+gram-negative organisms) cSSSI at hospital admission.

METHODS

We performed a retrospective cohort study at a single academic medical center among patients hospitalized from April 2006 to December 2007 with a cSSSI. Inappropriate empiric therapy was defined as failure to deliver an antibiotic with in vitro activity against the offending pathogen(s) within 24 h of presentation. We derived a predictive rule to identify patients at risk for a mixed skin infection (MSI) and compared it with the "healthcare-associated" (HCA) definition.

RESULTS

Among 717 patients hospitalized with a cSSSI, 68 (9.5%) had an MSI, with 38.2% of these receiving inappropriate empiric therapy. Intensive care unit admission (odds ratio [OR] 2.49; 95% confidence interval [CI] 1.12-5.52), infection other than an abscess (OR 2.01; 95% CI 1.06-3.81), and nursing home residence (OR 1.99; 95% CI 1.05-3.78) predicted MSI independently. The absence of all three factors identified non-MSI with 95.2% accuracy. The MSI rule improved the HCA classification accuracy for non-MSI by 21.9% without any loss in sensitivity.

CONCLUSIONS

Hospitalization with an MSI is a risk factor for inappropriate empiric therapy. Intensive care unit admission, infection other than an abscess, and nursing home residence help identify those patients with a higher MSI risk. Absence of all these factors reliably identified patients not needing empiric MSI coverage. Relative to the HCA definition, the MSI rule resulted in the potential to prevent more than one in five additional patients from receiving unnecessarily broad empiric coverage.

Clinical and economic burden of Clostridium difficile infection in Europe: a systematic review of healthcare-facility-acquired infection

PubMed, EMBASE and conference abstracts were reviewed systematically to determine the clinical and economic burden associated with Clostridium difficile infection (CDI) acquired and treated in European healthcare facilities. Inclusion criteria were: published in the English language between 2000 and 2010, and study population of at least 20 patients with documented CDI acquired/treated in European healthcare facilities. Data collection was completed by three unblinded reviewers using the Cochrane Handbook and PRISMA statement. The primary outcomes were mortality, recurrence, length of hospital stay (LOS) and cost related to CDI. In total, 1138 primary articles and conference abstracts were identified, and this was narrowed to 39 and 30 studies, respectively. Data were available from 14 countries, with 47% of studies from UK institutions. CDI mortality at 30 days ranged from 2% (France) to 42% (UK). Mortality rates more than doubled from 1999 to 2004, and continued to rise until 2007 when reductions were noted in the UK. Recurrent CDI varied from 1% (France) to 36% (Ireland); however, recurrence definitions varied between studies. Median LOS ranged from eight days (Belgium) to 27 days (UK). The incremental cost of CDI was £4577 in Ireland and £8843 in Germany, after standardization to 2010 prices. Country-specific estimates, weighted by sample size, ranged from 2.8% to 29.8% for 30-day mortality and from 16 to 37 days for LOS. CDI burden in Europe was most commonly described using 30-day mortality, recurrence, LOS and cost data. The continued spread of CDI and resultant healthcare burden underscores the need for judicious use of antibiotics.