Burden of illness among Medicare and non-Medicare US populations with acquired thrombotic thrombocytopenic purpura

BACKGROUND

Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare hematologic disorder that can lead to serious life-threatening medical complications.

OBJECTIVE

The aim of this study was to describe aTTP-related hospital resource utilization, cost, complications, and overall survival among US Medicare and non-Medicare populations following aTTP episodes prior to the US approval of caplacizumab.

METHODS

This retrospective study utilized administrative claims data for Medicare Fee-for-Service (FFS) beneficiaries (100% sample) and a sample of commercial, managed Medicaid [MM], Medicare Advantage [MA] plan members from the Inovalon MORE² Registry. aTTP patients ages 18+ were identified between 2010 and 2018 using a published validated algorithm: ≥1 hospitalization for thrombotic microangiopathy + therapeutic plasma exchange (TPE). 2,279 patients were identified; 65.2% were enrolled in Medicare FFS, 13.6% in commercial, 15.7% in MM, and 5.4% in MA. Mean hospitalization days for aTTP index episode ranged between 12 and 17 days; ∼60% of patients required intensive care. Mean payments for index hospitalization varied by payer [Medicare FFS: $29,024; MA: $12,860; commercial: $9,996 and MM: $10,470]. Among FFS patients, 15.7% died during initial hospitalization and 21.0% died within first 30 days of the event. During follow-up, 11.6-19.6% experienced aTTP-related exacerbation. Incidence rate of relapse and complications per 100 person-years was 5.6 [Medicare FFS: 3.6; MA: 8.7; commercial: 10.4 and MM: 14.7] and 16.7 [FFS: 15.5; MA: 20.5; commercial: 21.7 and MM: 19.1], respectively. Among Medicare patients with and without aTTP, mortality risk was 2.9 (95 % CI: 2.4-3.4) times higher for aTTP vs. non-aTTP patients.

CONCLUSION

This is the first real-world study evaluating burden of illness among aTTP patients in the US across payer types. Despite being treated with TPE, patients with aTTP have lower survival rates in comparison to a matched cohort without aTTP. These findings highlight the need for more effective and novel therapies to reduce disease burden for this population.Key pointsIn US Medicare and managed care populations with aTTP between 2010 and 2018, aTTP can lead to significant utilization of ICU services due to clinical complications, and/or relapse following hospital discharge.Despite treatment with therapeutic plasma exchange, acute mortality remains high (15.7%) indicating the need for more effective and novel treatments.

Quality of life analysis of patients treated with cetuximab or cisplatin for locoregionally advanced squamous cell carcinoma of head and neck in the United States

Background

To compare quality of life of patients treated with cetuximab with or without radiation therapy (±RT) vs. cisplatin±RT for locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) in the real-world setting.

Methods

In this retrospective observational study, electronic medical records and Patient Care Monitor (PCM) survey data from the Vector Oncology Data Warehouse were utilized from adult patients in the United States who received initial treatment with cetuximab±RT or cisplatin±RT for locoregionally advanced SCCHN between January 1, 2007 and January 1, 2017. Quality of life was assessed using PCM index scores and individual PCM items. Cetuximab±RT and cisplatin±RT cohorts were balanced using propensity score weighting. Linear mixed models were used to assess the impact of baseline demographic and clinical characteristics on PCM endpoints.

Results

Of 531 patients with locoregionally advanced SCCHN, 187 received cetuximab±RT, and 344 received cisplatin±RT. Before propensity score weighting, the cetuximab±RT cohort was older (mean [SD] age of 63.9 [9.6] years vs. 57.4 [8.6] years), and more likely to be white (82.4% vs. 72.4%) compared to the cisplatin±RT cohort. After propensity score weighting, the two cohort subsamples (cetuximab±RT, N = 60; cisplatin±RT, N = 177) with PCM data showed no significant differences in General Physical Symptoms, Treatment Side Effects, Impaired Ambulation, or Impaired Performance index scores. Patients in the cetuximab±RT cohort had higher Acute Distress index (p = 0.023), Despair index (p = 0.011), and rash (p = 0.003) scores but lower numbness/tingling scores (p = 0.022) than patients in the cisplatin±RT cohort.

Conclusions

Significant group differences were observed in this comparative analysis, as the cetuximab±RT cohort had significantly higher Acute Distress index, Despair index, and rash scores compared with the cisplatin±RT cohort but lower numbness/tingling scores. These patterns of symptoms appear consistent with previously reported symptoms associated with the treatment of SCCHN.

Real-world treatment patterns among patients with unresected stage III non-small-cell lung cancer

Aim: Little is known about recent treatment patterns among patients with unresected stage III NSCLC in the real world. This retrospective study used medical records from USA community oncology practices to address this knowledge gap. Materials & methods: Eligible patients were stage III NSCLC adults diagnosed between 1 January 2011 and 1 March 2016 without surgical resection. Treatment patterns were assessed across three progression intervals, from stage III diagnosis through third progression. Results: The most common regimen in interval 1 was platinum doublet chemotherapy + radiation therapy, in interval 2 was chemotherapy only, and in interval 3 was non-platinum chemotherapy monotherapy. Conclusion: Most patients were treated following national guidelines, but important unmet needs remain.

Understanding health-related quality of life (HRQoL) in unresected stage III non-small cell lung cancer (NSCLC)

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Background: Despite curative treatment intent, most patients (pts) with unresected Stage III NSCLC progress to metastatic disease. Prior research has shown significant benefits on clinical outcomes when HRQoL is assessed in clinical care, but understanding is limited in Stage III NSCLC. Methods: A retrospective review of community oncology medical records was conducted to examine real-world clinical outcomes such as overall and progression-free survival. Eligible pts were adults diagnosed from 1/1/2011 to 3/1/2016 with unresected Stage III NSCLC. In a subset of patients with available data, HRQoL was assessed using the 86-item Patient Care Monitor (PCM), a patient reported measure. Linear mixed models (LMM) were used to assess the impact of pt characteristics and change in PCM scores associated with progression. Results: The main sample included 478 pts: mean [SD] age was 67 [10] years, 55% male, 72% Caucasian, and 71.1% initially treated with concurrent chemoradiation. HRQoL analysis included 167 pts. LMM showed significant worsening of Index scores for General Physical Symptoms, Treatment Side Effects, Despair, and Impaired Ambulation (p < 0.001) as well as Acute Distress (p = 0.044) at progression. Of the six symptoms analyzed, significant worsening of scores at progression occurred in pain, difficulty breathing, and fatigue (p < 0.001). HRQoL consistently worsened at progression, but the pattern of severity for Index scores varied when separately evaluated in the pre- and post-progression periods. Symptom patterns showed improvement for Treatment Side Effects, Acute Distress, and Despair during the pre-progression period, but worsened post-progression, an effect that exceeded the pre-progression improvement. Receipt of radiation and increasing age were associated with better overall HRQoL; HRQoL tended to be worse in pts with greater comorbidity burden and impaired performance status. Conclusions: Our study demonstrated a pattern of clinically meaningful worsening of HRQoL at progression, with pts reporting worsening physical symptoms and negative psychological states. The results also appear consistent with clinical expectations and show HRQoL benefit of radiation therapy.

Lipid-lowering treatment modifications among patients with hyperlipidemia and a prior cardiovascular event: a US retrospective cohort study

BACKGROUND

Numerous studies demonstrate that, even with use of statins, many patients are unable to meet their LDL-C goals. This study examined modifications to statin and/or ezetimibe therapy among patients with hyperlipidemia and prior history of cardiovascular (CV) events in a US commercially insured population.

METHODS

Adults (age ≥18 years) initiating statins and/or ezetimibe between 1 January 2007 and 31 December 2008 were identified from HealthCore Integrated Research Database. The index date was the initiation date of statins and/or ezetimibe. All patients had ≥1 medical claims related to myocardial infarction, unstable angina, ischemic stroke, transient ischemic attack, coronary artery bypass graft, or percutaneous coronary intervention within 12 months prior to the index date. Treatment modifications to statins and/or ezetimibe initiated on the index date (index therapy) included permanent discontinuation of any lipid lowering therapy (LLT), rechallenge, switching, subtraction, augmentation, and dose changes.

RESULTS

Among 17,902 patients, around 90% initiated with statin monotherapy, followed by statin and ezetimibe combination (3.0%: 18-64 years; 3.8%: ≥65 years). Ten percent or less initiated on high intensity statins. Most common treatment modifications were rechallenging index therapy (25.2%: 18-64 years, 27.0%: ≥65 years), switching (27.5%: 18-64 years, 24.6%: ≥65 years), and permanent discontinuation of any LLT (18.6%: 18-64 years, 21.0%: ≥65 years). Only 10% of patients in both groups underwent dose escalation.

CONCLUSIONS

Real-world evidence indicates that few high-risk patients initiate therapy with high-intensity statins. More than 50% of patients underwent a rechallenge or switching. Despite high CVD risk profile, approximately 20% of patients permanently discontinued any LLT. Key limitations: Pharmacy claims do not provide information on whether patients who had a pharmacy fill actually took the medication as prescribed. It is unknown whether rechallenge was a simple delay in filling a prescription or an actual rechallenge of their index therapy. Reasons for treatment discontinuations or modifications were unavailable in claims data.

Burden of First and Recurrent Cardiovascular Events Among Patients With Hyperlipidemia

BACKGROUND

Acute cardiovascular (CV) events have been evaluated in patients with specific comorbidities but have not focused on patients with hyperlipidemia or on the their long-term costs.

OBJECTIVES

To evaluate incidence of CV events, costs, and resource utilization among patients with hyperlipidemia and baseline risk of CV disease (CVD).

METHODS

Patients (age 18 to 64 years) diagnosed with hyperlipidemia or using lipid-modifying medications were identified from administrative claims. Patients were categorized into 3 cohorts based on pre-index clinical characteristics-secondary prevention (SP; history of CV event, n = 15 613); high risk (HR; CVD, n = 47 600); and primary prevention (PP; no CV event history or CVD, n = 60 637)-and followed up to 2 years after the CV event.

RESULTS

During follow-up, ≥1 new CV event occurred in 43.0% of the SP cohort, 33.9% of HR, and 20.9% of PP; and ≥3 new events occurred in 19.8% of the SP cohort, 12.9% of HR, and 5.5% of PP. Incremental total costs were $19 320 for SP, $20 003 for HR, and $17 650 for PP. Compared with patients with only 1 CV event, the mean 2-year cost was 30% higher in patients with 2 CV events and 48% higher in patients with 3 CV events. Only 50% of HR patients (with or without CV events) received statins.

CONCLUSIONS

Patients with recurrent CV events had higher total health care costs during 24-month follow-up for each type of CV event. Total health care costs among patients with a CV event were higher for the initial as well as subsequent events. Statins and lipid-modifying medications were significantly underutilized in all cohorts, despite the presence of CVD.

Abstract 263: Incidence of Recurrent Cardiovascular Events and Disease Burden Among High-Risk Patients with Hyperlipidemia

Background: This study evaluated the real-world patterns and time to first and recurrent cardiovascular (CV) events among patients with hyperlipidemia.

Methods: Patients (age 18-64) with hyperlipidemia diagnosis or using lipid-lowering therapy (LLT) from 1/1/2007 to 12/31/2008 were selected from the HealthCore Integrated Research Database SM (HIRD) and followed until the end of study period (02/28/2013) or health plan enrollment or death (whichever occurred first). Patients who had ≥ 1 CV events (myocardial infarction, ischemic stroke, unstable angina, coronary artery bypass graft or percutaneous coronary intervention) 12 months before the first occurrence of hyperlipidemia diagnosis or LLT use (baseline period) were included in the CV event history cohort. Patients without any CV event(s), but who had ischemic heart disease, stable angina, peripheral arterial disease, abdominal aortic aneurysm, transient ischemic attack, or type 2 diabetes during the baseline period were included in the modified CV RE cohort. Baseline use of LLT, incidence and time to first and subsequent CV events were quantified.

Results: In the CV event history cohort (n=9890, mean age=55 years), 41.8% had ≥1 new CV event with 18.9% having 3 or more new CV events; 33.3% of patients with CV RE (n=27,352, mean age=55 years) had ≥1 new CV event with 12.5% having 3 or more new CV events. At baseline, in both cohorts, about 64% were using LLT. In the CV event history cohort, time to first new CV event was 786 days and time between the first and second and second and third CV events was 270 days and 208 days, respectively. In the CV RE cohort, time to first new CV event was 939 days and time between the first and second and second and third CV events was 258 days and 193 days, respectively. Mean 1-year total cost of the second CV event and the third CV event was 30%-48% and 34%-46% higher than the first CV event in both cohorts.

Conclusions: CV event-related risk and long-term costs are significantly greater among high-risk patients with shorter time intervals between recurrent CV events. Underutilization of LLTs in these patients highlights the need for improving clinical management and treatment options for these patients.

Abstract 250: Real-world Rates and Costs of Heart Failure Events Among Patients with Hyperlipidemia

Background: This real-world retrospective cohort study estimated the rate of heart failure events and total healthcare costs among patients with hyperlipidemia.

Methods: Patients (aged 18-64 years) with hyperlipidemia diagnosis and/or lipid-lowering medications were identified from the HealthCore Integrated Research Database SM from 1/1/2007 to 12/31/2008 and followed until 2/28/2013. Patients were stratified by cardiovascular (CV) risk level as (1) secondary prevention with a history of myocardial infarction, stroke, unstable angina, or revascularization, (2) modified coronary heart disease (CHD) risk equivalent (RE) without a history of CV events but with peripheral artery disease, type 2 diabetes, abdominal aortic aneurysm, ischemic heart disease, stable angina, or TIA, and (3) primary prevention without a history of CV events or CHD RE. Patients with new CV event hospitalization during follow-up were propensity score-matched to patients without new CV events within each cohort. Proportion of patients with heart failure events and incremental total costs during 2 years of follow-up were evaluated.

Results: Before matching, 62,427 patients had ≥1 CV event (13.2% secondary prevention, 38.4% CHD RE, 48.5% primary prevention). For patients with ≥1 CV event during follow-up, 38.8% of secondary prevention, 42.6% of CHD RE, and 30.0% of primary prevention had heart failure as their index event. Of patients with heart failure index event, 58.3% of secondary prevention, 47.3% of CHD RE, and 30.5% of primary prevention patients had 1 or more heart failure events over 2 years. Among patients with ≥1 heart failure events, 36.2% of secondary prevention, 30.0% of CHD RE, and 17.7% of primary prevention patients had ≥3 heart failure events over 2 years. Among matched patients (85-87% of patients), incremental total cost over 2 years for patients with heart failure as their index event compared with patients without CV events was $56,078 for secondary prevention, $53,247 for CV RE, and $49,637 for primary prevention cohorts.

Conclusions: The rate and recurrence of heart failure among hyperlipidemic patients is very high and the long term healthcare costs substantial in this real-world 2-year study.

Abstract 307: Gender Differences in Recurrent Cardiovascular Events Among High-risk Patients With Hyperlipidemia

Background: Hyperlipidemia is associated with increased risk of cardiovascular (CV) events, especially among adults with a history of cardiovascular disease (CVD). It is unclear whether the increased risk is similar between men and women.

Purpose: This study evaluated the occurrence of subsequent cardiovascular events among high-risk patients with hyperlipidemia and a history of prior CV events who were enrolled in US health plans, stratified by gender.

Methods: Patients (age 18-64) with a hyperlipidemia diagnosis or using lipid-lowering therapy (LLT) from 1/1/2007 to 12/31/2008, and a history of ≥ 1 CV events (myocardial infarction [MI], ischemic stroke [IS], unstable angina [UA], coronary artery bypass graft (CABG) or percutaneous coronary intervention [PCI]) in the 12 months prior to hyperlipidemia diagnosis or LLT use were selected from the large payer claims database (HealthCore Integrated Research Database SM ). Patientswere followed until the end of study period (02/28/2013) or end of health plan eligibility or death (whichever occurred first). Incidence and time to subsequent CV events were calculated.

Results: In the CV event history cohort (n=9890, mean age=55 years), 67% were men and 33% were women. A significantly greater proportion of women (44.6%) had ≥1 subsequent CV event compared with men (40.5%, p<0.0001), and women also had a greater proportion of ≥3 subsequent CV events (21.0% women vs. 17.8% men, p<0.0001). In patients with subsequent events, mean (SD) time to first subsequent CV event was significantly shorter for women [741 (541) days] than for men [810 (570) days], p<0.0001. This pattern of more recurrent CV events and shorter time to first subsequent CV event among women was observed for MI, UA, PCI, and heart failure (e.g. 48.3% of women and 37.7% of men had ≥1 MI, p<0.001 and time to first event was 836 (571) days for women versus 971 (599) days for men, p=0.001). There were no differences between women and men for stroke or TIA. Mean (SD) inpatient costs for patients with subsequent CV events did not differ by gender (e.g. for MI, $37,804 (104,478) for women versus $39,705 (81,914) for men, p=0.77).

Conclusions: Among high-risk patients (i.e. history of CV events) enrolled in US health plans, women were more likely to have a subsequent CV event and multiple CV events sooner than men. Further research is needed to ascertain whether the gender differences might reflect differences in the intensity of treatment for hyperlipidemia between men and women.

Cardiovascular risk in patients achieving low-density lipoprotein cholesterol and particle targets

OBJECTIVES

Previous research suggests that LDL particle number (LDL-P) may be a better tool than LDL cholesterol (LDL-C) to guide LDL-lowering therapy. Using real-world data, this study has two objectives: [1] to determine the incidence of CHD across LDL-P thresholds; and [2] to compare CHD/stroke events among patients achieving comparably low LDL-P or LDL-C levels.

METHODS

A claims analysis was conducted among high-risk patients identified from the HealthCore Integrated Research Database(SM). The impact of LDL levels on risk was compared across cohorts who achieved LDL-P <1000 nmol/L or LDL-C <100 mg/dL. Cohorts were matched to balance demographic and comorbidity differences.

RESULTS

Among 15,569 patients with LDL-P measurements, the risk of a CHD event increased by 4% for each 100 nmol/L increase in LDL-P level (HR 1.04; 95% CI 1.02-1.05, p < .0001). The comparative analysis included 2,094 matched patients with ≥12 months of follow-up, 1,242 with ≥24 months and 705 with ≥36 months. At all time periods, patients undergoing LDL-P measurement were more likely to receive intensive lipid-lowering therapy and had a lower risk of CHD/stroke than those in the LDL-C cohort (HR: 0.76; 95% CI: 0.61-0.96; at 12 months).

CONCLUSIONS

In this real-world sample of commercially insured patients, higher LDL-P levels were associated with increased CHD risk. Moreover, high-risk patients who achieved LDL-P <1000 nmol/L received more aggressive lipid-lowering therapy than patients achieving LDL-C <100 mg/dL, and these differences in lipids and therapeutic management were associated with a reduction in CHD/stroke events over 12, 24 and 36 months follow-up.

Use of psychotropic medications by US cancer survivors

OBJECTIVES

This study aimed to describe national utilization of psychotropic medications by adult cancer survivors in the USA and to estimate the extra use of psychotropic medications that is attributable to cancer survivorship.

METHODS

Prescription data for 2001-2006 from the Medical Expenditure Panel Survey (MEPS) were linked to the data identifying cancer survivors from the National Health Interview Survey, the MEPS sampling frame. The sample was limited to adults 25 years of age and older. Propensity score matching was used to estimate the effects of cancer survivorship on utilization of psychotropic medications by comparing cancer survivors and other adults in MEPS. Utilization was measured as any use during a calendar year and the number of prescriptions purchased (including refills). Analyses were stratified by gender and age, distinguishing adults younger than 65 years from those 65 years and older.

RESULTS

Nineteen percent of cancer survivors under age 65 years and 16% of survivors age 65 years and older used psychotropic medications. Sixteen percent of younger survivors used antidepressants, 7% used antianxiety medications. For older survivors, utilization rates for these two drug types were 11% and 7%, respectively. The increase in any use attributable to cancer amounted to 4-5 percentage points for younger survivors (p < 0.05) and 2-3 percentage points for older survivors (p < 0.05), depending on gender.

CONCLUSION

Increased use of psychotropic medications by cancer survivors, compared with other adults, suggests that survivorship presents ongoing psychological challenges.

Why do some health centers provide more enabling services than others?

Enabling services (such as outreach, transportation, case management, and discharge planning) play a critical role in improving care for vulnerable populations. However, these services are generally not covered by third party payers, making them a challenge for safety net providers that are themselves often financially strained. The study reported here identified organizational and patient population characteristics associated with enabling services provided by community health centers funded by the Health Resources and Services Administration (HRSA). Lagged regressions on 2003-2004 data from HRSA's Uniform Data System (n=841) indicated that health centers with more managed care contracts and larger staffs provided both broader scopes of enabling services and higher volumes of these services. Grant revenue was negatively associated with the volume of enabling services; however, net revenue was positively associated with service volume. There were several positive associations between indicators of patient need and the scope and volume of enabling services.