Real-World Effectiveness of Dolutegravir/Lamivudine in People With HIV-1 in Test-and-Treat Settings or With High Baseline Viral Loads: TANDEM Study Subgroup Analyses

INTRODUCTION

Dolutegravir/lamivudine (DTG/3TC) was first approved by the US Food and Drug Administration in 2019 for the treatment of antiretroviral therapy (ART)-naive people with HIV-1 based on results from the pivotal GEMINI-1/GEMINI-2 trials. Around that time, immediate initiation of treatment upon diagnosis was recommended in the US Department of Health and Human Services guidelines. Here we report results from 126 treatment-naive people with HIV-1 who initiated DTG/3TC as part of a test-and-treat strategy (n = 61) or with high baseline viral loads (HIV-1 RNA ≥ 100,000 copies/ml; n = 16) from the TANDEM study.

METHODS

TANDEM was a US-based, retrospective chart review study that included a cohort of 126 individuals aged ≥ 18 years with no prior history of ART who initiated DTG/3TC before September 30, 2020, and had ≥ 6 months of follow-up. Test-and-treat was defined as ART initiation shortly after diagnosis without available viral load, CD4 + cell count, or HIV-1 resistance data. Outcomes included virologic suppression (HIV-1 RNA < 50 copies/ml; overall and by baseline viral load) and discontinuations. Analyses were descriptive.

RESULTS

Among 61 individuals who initiated DTG/3TC in a test-and-treat setting (median [interquartile range (IQR)] treatment duration, 1.3 [0.9-1.7] years), 57 (93%) achieved virologic suppression, and 51 (84%) remained suppressed; 1 (< 1%) individual discontinued DTG/3TC due to persistent low-level viremia. The most common healthcare provider (HCP)-reported reason for initiating DTG/3TC was avoidance of long-term toxicities among individuals in the test-and-treat subgroup. Of 16 treatment-naive individuals with high baseline viral loads (median [IQR] treatment duration, 100,000-250,000 copies/ml: 1.2 [0.8-1.8] years; > 250,000 copies/ml: 1.0 [0.7-1.1] years), 14 (88%) achieved virologic suppression, 13 (81%) remained suppressed, and none discontinued DTG/3TC. Patient preference was the most common HCP-reported reason for initiating DTG/3TC in this subgroup.

CONCLUSIONS

Results demonstrate real-world effectiveness of DTG/3TC, with few discontinuations, in people with HIV-1 in test-and-treat settings or with high baseline viral loads.

Two-Drug Regimens Dolutegravir/Lamivudine and Dolutegravir/Rilpivirine Are Effective with Few Discontinuations in US Real-World Settings: Results from the TANDEM Study

INTRODUCTION

Dolutegravir/lamivudine (DTG/3TC) and dolutegravir/rilpivirine (DTG/RPV) are fixed-dose, complete, single-tablet, two-drug regimens (2DRs) indicated for HIV-1. DTG/3TC is approved for antiretroviral therapy (ART)-naive people with HIV-1 and virologically suppressed individuals to replace current ART; DTG/RPV is indicated for virologically suppressed individuals as a switch option. Virologic efficacy and effectiveness of these DTG-based 2DRs have been demonstrated in phase 3 clinical trials and real-world cohorts, primarily from Europe. This study characterized real-world use of DTG-based 2DRs for HIV-1 treatment in the USA.

METHODS

TANDEM was a retrospective medical chart review across 24 US sites. Individuals aged ≥ 18 years who initiated DTG/3TC or DTG/RPV before September 30, 2020, with ≥ 6 months of follow-up were included. One cohort included ART-naive people who initiated DTG/3TC (n = 126), and two other cohorts included virologically suppressed (HIV-1 RNA < 50 copies/mL) people on stable ART regimens for ≥ 3 months before switch to either DTG/3TC (n = 192) or DTG/RPV (n = 151). Clinical characteristics, treatment history, and outcomes are described.

RESULTS

Virologically suppressed individuals were older than those who were ART-naive, and the ART-naive cohort had higher proportions of individuals assigned male at birth and of Hispanic ethnicity. The most common healthcare provider-reported reason for choosing a DTG-based 2DR was avoidance of long-term toxicities (25-33% across cohorts), followed by simplification/streamlining of treatment. Among ART-naive people on DTG/3TC, 94% achieved virologic suppression after initiation, and 83% maintained suppression at last follow-up; discontinuation rate was < 1%. Among cohorts who switched to DTG-based 2DRs, 96% maintained virologic suppression on DTG/3TC and 93% on DTG/RPV; 2% on DTG/3TC and 3% on DTG/RPV discontinued.

CONCLUSION

Motivation for selecting DTG-based 2DRs was primarily driven by a desire to avoid or manage toxicities and simplify treatment. Results demonstrate that DTG/3TC and DTG/RPV are effective in real-world settings, with few discontinuations, reflecting data from clinical trials.

Comparing Real-World Healthcare Costs Associated with Single-Tablet Regimens for HIV-1: The 2-Drug Regimen Dolutegravir/Lamivudine vs. Standard 3- or 4-Drug Regimens

INTRODUCTION

Dolutegravir/lamivudine (DTG/3TC) is a 2-drug regimen for HIV-1 treatment with long-term efficacy and good tolerability comparable to 3- or 4-drug regimens. This study evaluated DTG/3TC cost versus other standard single-tablet regimens during its first year of approval.

METHODS

This retrospective study analyzed US claims data from adults with HIV-1. Eligibility criteria included ≥ 1 dispensing of DTG/3TC, DTG/abacavir (ABC)/3TC, bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), elvitegravir (EVG)/cobicistat (COBI)/FTC/TAF, and darunavir (DRV)/COBI/FTC/TAF (index date was first dispensing) and ≥ 6 months of continuous eligibility before index date (baseline period). All-cause and HIV-related healthcare costs were evaluated during the observation period (index date until earliest of end of continuous eligibility or data availability). Adjusted cost differences and adjusted cost ratios were estimated using multivariable regression models controlling for differences in baseline characteristics between cohorts.

RESULTS

Overall, 22,061 individuals with HIV-1 and dispensed treatment with DTG/3TC (n = 590), DTG/ABC/3TC (n = 4355), BIC/FTC/TAF (n = 9068), EVG/COBI/FTC/TAF (n = 7081), or DRV/COBI/FTC/TAF (n = 967) were included. Most claims data were from men (mean age ~ 46 years). Mean unadjusted all-cause total healthcare costs per patient per month were significantly lower for DTG/3TC versus BIC/FTC/TAF and DRV/COBI/FTC/TAF, and mean unadjusted HIV-related healthcare costs per patient per month were significantly lower for DTG/3TC versus DRV/COBI/FTC/TAF. Cost differences were primarily driven by significantly lower pharmacy costs for DTG/3TC versus other regimens (P < 0.001), while medical costs were similar across cohorts. Results were similar among treatment-naive and treatment-experienced individuals. After adjusting for baseline covariates, significant adjusted cost differences were generally consistent with unadjusted findings. Adjusted cost ratios generally favored DTG/3TC for all-cause healthcare and HIV-related costs, with all pharmacy cost ratios favoring DTG/3TC (P < 0.001).

CONCLUSION

Dolutegravir/lamivudine had the lowest healthcare costs of BIC/FTC/TAF, EVG/COBI/FTC/TAF, and DRV/COBI/FTC/TAF, and the lowest pharmacy costs of all regimens, in unadjusted and adjusted analyses and by treatment experience, supporting the economic benefits of DTG/3TC as an initial or switch regimen for HIV-1.

1278. Real World Treatment Experience of Single Tablet Dolutegravir/Lamivudine in Those Naïve to Treatment with Baseline Viral Loads ≥ 100,000 copies/mL in the US

Background

Treatment for people living with HIV-1 (PLWH) continues to advance with a two-drug regimen (2DR) approach. Dolutegravir/lamivudine (DTG/3TC) is indicated as a 2DR for both treatment-naïve and virally suppressed PLWH. Despite high and sustained virologic efficacy for DTG-based 2DRs observed in clinical trials, there is limited evidence in US real world clinical settings. This study characterizes prescribing behaviors and treatment outcomes for DTG-based 2DR in the real world.

Methods

TANDEM was a retrospective medical chart review conducted across 24 US sites. Eligible PLWH were adults initiated on single tablet DTG/3TC or DTG/rilpivirine prior to Sept/30/2020 with a minimum clinical follow-up of six months. Treatment-naïve PLWH had no prior history of HIV therapy. Clinical characteristics, treatment history and outcomes were abstracted. Analyses were descriptive. Reported here are viral outcomes for the DTG/3TC cohort of treatment-naïve PLWH with baseline viral loads (VLs) ≥ 100,000 (c/mL).

Results

From an overall sample of 469 PLWH on DTG-based 2DR, 318 received DTG/3TC. Of the DTG/3TC cohort, 126 were treatment-naïve. Of the treatment-naïve, 58 PLWH had known VLs available at DTG/3TC initiation. For those with baseline VLs ≥ 100,000 c/mL, 9 had values 100,000-250,000 c/mL while 7 were > 250,000 c/mL. Characteristics of this sub-cohort are described in Table 1. Overall, the most common reason for DTG/3TC initiation in this sub-cohort was patient preference (n=5), followed by avoidance of long-term toxicities and convenience (both n=3). For those with VLs between 100-250k, median CD4 count was 312 while 8/9 became virally suppressed (HIV-1 RNA < 50c/mL) and 1 PLWH had missing data. For those with VLs > 250k, median CD4 count was 114 while 6/7 became virally suppressed and 1 PLWH had missing data. One of these 6 PLWH experienced virologic rebound yet remained on DTG/3TC. Table 1:

1279. Real World Treatment Experience of Treatment-Naïve People with HIV who Initiated Treatment with Single Tablet Dolutegravir/Lamivudine in a Test and Treat setting in the US

Background

Dolutegravir/lamivudine (DTG/3TC) is indicated as a 2DR for both treatment-naïve and virally suppressed PLWH. The feasibility of DTG/3TC use in a Test & Treat (T&T) setting has been demonstrated in a clinical trial, but there is limited evidence with this approach in US real world clinical settings.

Methods

TANDEM was a retrospective medical chart review conducted across 24 US sites. Eligible PLWH were adults initiated on DTG/3TC or DTG/rilpivirine (DTG/RPV) prior to Sept/30/2020 with a minimum clinical follow-up of six months. Treatment-naïve (TN) PLWH had no prior history of HIV therapy. Clinical characteristics, treatment history and outcomes were abstracted. Analyses were descriptive. Reported here are results for the sub-group of TN PLWH that were initiated DTG/3TC as part of a T&T strategy, defined as clinician attestation of treatment initiation shortly after diagnosis and in the absence of known lab values for HIV-1 RNA viral load, CD4 cell count and HIV-1 resistance mutations.

Results

From an overall sample of 469 PLWH on DTG-based 2DR, 318 received DTG/3TC, of whom, 126 were TN and 192 were stable switch. Almost half 48% of PLWH received DTG/3TC as part of a T&T paradigm. Characteristics of the cohort are described in Table 1. In the T&T sub-group, the most common reasons for initiating DTG/3TC were avoidance of long-term toxicities (n=26), followed by simplification/streamlining (n=8) and convenience (n=7). Overall, 114 (90.5%) of TN PLWH achieved the desired health outcome per clinician attestation. At data cut-off, 61 (94%) non T&T achieved virologic suppression, 57 (93%) of the T&T sub-group achieved virological suppression, 3 (5%) did not, and 1 (2%) was still unknown. Of the 3 who did not achieve suppression, 2 remained on DTG/3TC while 1 was switched to bictegravir/emtricitabine/tenofovir alafenamide. Virologic rebound occurred in 6 TN PLWH overall with only 1 occurring in the T&T sub-group.

Baseline Characteristics and Virologic Outcomes

Conclusion

Reflecting results from clinical trials, DTG/3TC achieved its desired health outcomes in the majority of cases regardless of treatment paradigm, with virtually no difference in virological suppression rates across the two cohorts (93-94% achieving suppression in a median duration of 10-11 weeks).

Disclosures

Cindy Donovan, PharmD, Johnson & Johnson: Stocks/Bonds|ViiV Healthcare: Employee/Salary|ViiV Healthcare: Stocks/Bonds Gavin Harper, BA, ViiV Healthcare: Adelphi Real World were paid consultants (CRO) to conduct the observational research study on behalf of ViiV Healthcare.|ViiV Healthcare: Adelphi Real World were paid consultants (CRO) to conduct the observational research study on behalf of ViiV Healthcare Deanna Merrill, PharmD, MBA, AAHIVP, ViiV Healthcare: Salaried employee|ViiV Healthcare: Stocks/Bonds Katie L. Mycock, MChem, ViiV Healthcare: Adelphi Real World were paid consultants (CRO) to conduct the observational research study on behalf of ViiV Healthcare|ViiV Healthcare: Adelphi Real World were paid consultants (CRO) to conduct the observational research study on behalf of ViiV Healthcare Alan Oglesby, MPH, GlaxoSmithKline (GSK): Employment|GlaxoSmithKline (GSK): Stocks/Bonds Aimee Metzner, PharmD, AAHIVP, ViiV Healthcare: Salaried employee|ViiV Healthcare: Stocks/Bonds Jimena Patarroyo, PharmD, AAHIVP, ViiV Healthcare: Salaried employee|ViiV Healthcare: Stocks/Bonds|ViiV Healthcare: Stocks/Bonds.

853. Real-World Persistency of Patients Receiving Tenofovir-Based Pre-Exposure Prophylaxis for the Prevention of HIV Infection in the US

Background

Once-daily oral tenofovir-based combinations as pre-exposure prophylaxis (PrEP) have shown to be an effective biomedical HIV prevention strategy for populations at-risk of acquiring HIV-1. However, low adherence can lead to poor effectiveness. This study described the characteristics of commercially-insured US PrEP users.

Methods

This retrospective study used IQVIA™ PharMetrics Plus data (1/1/2015–3/31/2020) to identify adults newly initiated (index date) on emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF) as daily PrEP. Users had ≥6 months of continuous enrollment pre-index (baseline); those diagnosed with HIV or with antiretroviral therapy (ART) use during baseline were excluded. User characteristics were described during the baseline period. For FTC/TDF users, proportion of days covered (PDC), persistence, treatment breaks, and switching were described during the follow-up period, which spanned from index to the earliest of disenrollment or end of data. Non-persistence was defined as a >90-day gap from last day of supply, with re-initiation after this gap indicating treatment break. For PDC and persistence, follow-up was censored at HIV infection, defined by both multi-class ART initiation and HIV diagnosis.

Results

In total 24,232 FTC/TDF and 1,187 FTC/TAF users were identified. Overall, mean age was 35.1 years and 94.5% were male (Table 1). Mean [median] length of follow-up was longer for FTC/TDF (504 [390] days) than FTC/TDF users (77 [70] days). On average, FTC/TDF users had 9.0 dispensings with 38.3 days of supply per dispensing over follow-up; 11.1% had ≥1 treatment break (mean length, 249 days). Among those initiated on FTC/TDF, 10.8% switched to FTC/TAF. The mean PDC for FTC/TDF users at 6 and 12 months was 0.74 and 0.67, respectively, corresponding to 63.7% and 57.9% of patients with PDC ≥0.70 (Figure 1). Persistence to FTC/TDF at 6 and 12 months was 70.2% and 57.4%, respectively (Figure 2).

Table 1. Baseline Demographics and Clinical Characteristics of PrEP Users by Regimen

Figure 1. Proportion of Days Covered of FTC/TDF Users

Figure 2. Kaplan-Meier Persistence Rates of FTC/TDF Users

Conclusion

Patient characteristics of PrEP users are broadly similar between regimens, though switching from FTC/TDF to FTC/TAF is common. FTC/TDF users had lower real-world PDC and persistence than in recent clinical trials (DISCOVER and HPTN 083).

Disclosures

Alan Oglesby, MPH, GlaxoSmithKline (GSK) (Employee, Shareholder) Guillaume Germain, MSc, ViiV Healthcare (Other Financial or Material Support, I am an employee of Groupe d’analyse, Ltée, a consulting company that provided paid consulting services to ViiV Healthcare for the conduct of the present study.) Francois Laliberte, MA, Viiv (Research Grant or Support) Staci Bush, NP, GlaxoSmithKline (GSK) (Employee, Shareholder) Heidi Swygard, MD, ViiV Healthcare (Employee) Sean MacKnight, MScPH, Analysis Group (Employee) Annalise Hilts, BA, Analysis Group, Inc. (Employee) Mei Sheng Duh, MPH, ScD, ViiV Healthcare (Grant/Research Support)

Virologic Outcomes Among People Living With Human Immunodeficiency Virus With High Pretherapy Viral Load Burden Initiating on Common Core Agents

Background

People living with human immunodeficiency virus (PLWH) initiating antiretroviral therapy (ART) with viral loads (VLs) ≥100 000 copies/mL are less likely to achieve virologic success, but few studies have characterized real-world treatment outcomes.

Methods

ART-naive PLWH with VLs ≥100 000 copies/mL initiating dolutegravir (DTG), elvitegravir (EVG), raltegravir (RAL), or darunavir (DRV) between 12 August 2013 and 31 July 2017 were identified from the OPERA database. Virologic failure was defined as (i) 2 consecutive VLs ≥200 copies/mL after 36 weeks of ART; (ii) 1 VL ≥200 copies/mL with core agent discontinuation after 36 weeks; (iii) 2 consecutive VLs ≥200 copies/mL after suppression (≤50 copies/mL) before 36 weeks; or (iv) 1 VL ≥200 copies/mL with discontinuation after suppression before 36 weeks. Cox modeling estimated the association between regimen and virologic failure.

Results

There were 2038 ART-naive patients with high VL who initiated DTG (36%), EVG (46%), DRV (16%), or RAL (2%). Median follow-up was 18.1 (interquartile range, 12.4–28.9) months. EVG and DTG initiators were similar at baseline, but RAL initiators were older and more likely to be female with low CD4 cell counts while DRV initiators differed notably on factors associated with treatment failure. Virologic failure was experienced by 9.2% DTG, 13.2% EVG, 18.4% RAL, and 18.8% DRV initiators. Compared to DTG, the adjusted hazard ratio (95% confidence interval) was 1.46 (1.05–2.03) for EVG, 2.24 (1.50–3.34) for DRV, and 4.13 (1.85–9.24) for RAL.

Conclusions

ART-naive PLWH with high VLs initiating on DTG were significantly less likely to experience virologic failure compared to EVG, RAL, and DRV initiators.

Antiretroviral therapy-naïve people living with HIV (PLWH) initiating therapy with viral loads ≥100,000 copies/mL varied markedly at baseline. In adjusted models, PLWH initiating dolutegravir-based regimens were less likely to experience virologic failure as compared to elvitegravir, raltegravir and darunavir initiators.

Cost-effectiveness and budget impact of dolutegravir/lamivudine for treatment of human immunodeficiency virus (HIV-1) infection in the United States

BACKGROUND: Dolutegravir(DTG)/lamivudine(3TC) is the first 2-drug regimen recommended as an initial treatment for people living with HIV (PLHIV). OBJECTIVE: To assess the cost-effectiveness and potential budget impact of DTG/3TC in the US healthcare setting. METHODS: A previously published hybrid decision-tree and Markov cohort state transition model was adapted to estimate the incremental costs and health outcome benefits over a patients' lifetime. DTG/3TC was compared with current standard of care in treatment naive and treatment experienced virologically suppressed PLHIV. Health states included in the model were based upon virologic response and CD4 cell count, with death as an absorbing state. Clinical data was informed by the Phase III GEMINI 1 and 2 clinical trials, a published network meta-analysis (NMA) in treatment-naive patients and the Phase III TANGO clinical trial in treatment experienced patients. Costs and utilities were informed by published data and discounted annually at a rate of 3%. A separate 5-year budget impact analysis was conducted assuming 5%-15% uptake in eligible treatment naive and 10%-30% uptake in eligible treatment experienced patients. RESULTS: In the treatment naive analyses based on GEMINI 1 and 2, DTG/3TC dominated, i.e., was less costly and more effective, than all comparators. DTG/3TC resulted in 0.083 incremental quality-adjusted life-years (QALYs) at a cost saving of $199,166 compared with the DTG + tenofovir disoproxil(TDF)/emtricitabine(FTC) comparator arm. The incremental QALY and cost savings for DTG/3TC compared with DTG/abacavir(ABC)/3TC, cobicistat-boosted darunavir(DRV/c)/tenofovir alafenamide(TAF)/FTC, and bictegravir (BIC)/TAF/FTC, based on NMA results were 0.465, 0.142, and 0.698, and $42,948, $122,846, and $44,962, respectively. In the analyses of treatment-experienced virologically suppressed patients based on TANGO, DTG/3TC offered slightly lower QALYs (-0.037) with an estimated savings of $78,730 when compared with continuation of TAF-based regimen (TBR). Sensitivity analyses demonstrated that these conclusions were relatively insensitive to alternative parameter estimates. The budget impact analysis estimated that by 5th year a total of 70,240 treatment naive patients and 1,340,480 treatment experienced patients could be eligible to be prescribed DTG/3TC. The estimated budget savings over 5 years ranged from $1.12b to $3.35b (corresponding to 27,512 to 82,536 on DTG/3TC by year 5) in the lowest and highest uptake scenarios, respectively. CONCLUSION: In conclusion, DTG/3TC with its comparable efficacy and lower drug acquisition costs, has the potential to offer significant cost savings to US healthcare payers for the initial treatment of treatment naive patients and as a treatment switching option for virologically suppressed patients. DISCLOSURES: This study was funded in full by ViiV healthcare, Brentford, UK. Medical writing to support this study was also funded in full by ViiV Healthcare, Brentford, UK. Butler, Hayward, and Jacob are employees of HEOR Ltd, the company performing this study funded by ViiV Healthcare. Anderson is an employee of GlaxoSmithKline and owns shares in the company. Punekar, Evitt, and Oglesby are employees of ViiV Healthcare and own stocks in GlaxoSmithKline.

Retrospective analysis of adherence to HIV treatment and healthcare utilization in a commercially insured population

AIMS

Single-tablet regimens (STRs) can improve antiretroviral therapy (ART) adherence; however, the relationship between long-term adherence and patient healthcare resource utilization (HRU) is unclear. The objective of this study was to assess long-term ART adherence among people living with HIV (PLHIV) using STRs and multi-tablet regimens (MTRs) and compare HRU over time by adherence.

MATERIALS AND METHODS

This retrospective study analyzed medical and pharmacy claims (Optum Clinformatics Data Mart Database). Included PLHIV were aged ≥18 years, had ≥1 medical claim with an HIV diagnosis, and had pharmacy claims for a complete STR or MTR. Adherence was analyzed as the proportion of days covered (PDC), stratified as ≥95%, very high; 90-95%, high; 80-90%, moderate; <80%, low. Cumulative all-cause and HIV-related HRU were calculated across 4 years. Among PLHIV with ≥4-year follow-up, HRU was assessed by adherence.

RESULTS

Among 15,153 PLHIV included, 63% achieved PDC ≥90% during Year 1. Among the subgroup of PLHIV with ≥4-year follow-up (N = 3,818), the proportion maintaining PDC ≥90% fell from 67% in Year 1 to 54% by Year 4. The difference from Years 1 to 4 in the proportion of PLHIV with PDC ≥90% was 13% and 17% in the STR and MTR groups, respectively. Cumulative HRU across the 4-year follow-up was higher in PLHIV with low vs high adherence (27% with low adherence had ≥1 emergency room visit vs 17% for very high, p < .0001; 15% with low adherence had ≥1 inpatient stay vs 7% for very high, p < .0001).

CONCLUSIONS

ART adherence showed room for improvement, particularly over the long term. PLHIV receiving STRs exhibited higher adherence vs those receiving MTRs; this difference increased over time. The proportion of PLHIV with higher HRU was significantly higher among those with lower adherence and became greater over time. Interventions and alternative therapies to improve adherence among PLHIV should be explored.

1704. Regional and Racial Disparities in Response to Antiretroviral Therapy (ART) among People Living with Human Immunodeficiency Virus (PLWH)

Background

This study evaluated differences in viral suppression by race and region among PLWH in care at 10 community practices.

Methods

PLWH (≥18 yrs) starting a new ART between Jan’15-Sept’19 with viral load at regimen prescription (Rx) and ≥6 months (mo) of prior history were selected from Trio Health HIV EMR database. Logistic regression [LR] estimated the association of covariates with outcome “viremic” (viral load >50 cells/ml) among those with viral load recorded 12-15 mo after baseline (BSL). Sensitivity analyses were conducted using viral loads at 9-15 mo, in patients (pts) on their BSL regimens for ≥12 mo, and pts with dispensing data. Covariates: BSL suppression, gender, race, age, payer, region (South vs non-South), BSL single vs multi-tablet regimen (STR vs MTR), and switch status from BSL regimen. Multicollinearity was not present.

Results

Of 20271 PLWH, 10373 (51%) were treated in South (41% not suppressed at BSL including 30% treatment-naïve [TN]) and 9898 (49%) in non-South (32% not suppressed including 26% TN). The following groups had higher suppression rates at 12-15 mo: males (83%) vs females (80%) p=0.003; white (85%) vs black (78%) and other known race (78%) p< 0.001; insured by commercial or Medicare insurance (both 85%) vs Medicaid (76%) or uninsured (71%) p< 0.001; treated in non-South (88%) vs South (77%) p< 0.001; age ≥50 (87%) vs < 50 (80%) p< 0.001, those who did not switch from BSL regimen (84%) vs switchers (82%) p< 0.001; on STR (84%) vs MTR (81%) p< 0.001.

In LR, pts less likely to be suppressed at 12-15 mo were: < 50 adjusted odds ratio (aOR)=0.76 (0.67-0.88), unspecified gender vs female aOR=0.51 (0.28-0.92), black vs white aOR=0.65 (0.56-0.74), other race (Asian, etc.) vs white aOR=0.73 (0.59-0.91), insured by Medicaid vs commercially aOR=0.64 (0.50-0.82), uninsured vs commercially insured aOR=0.63 (0.53-0.75), treated in South aOR=0.43 (0.38-0.50), switched from BSL regimen aOR=0.75 (0.66-.086), on MTR vs STR aOR=0.81 (0.72-0.92), viremic at BSL aOR=0.41 (0.36-0.47). Sensitivity analyses results were similar.

Conclusion

Our findings highlighted higher rates of viremia among younger, black or other non-white race, pts treated in the South, on Medicaid or uninsured, on MTR, even after accounting for other characteristics.

Disclosures

Keith M. Rawlings, MD, ViiV Healthcare (Employee) Joseph J. Eron, MD, Gilead Sciences (Consultant, Research Grant or Support)Janssen (Consultant, Research Grant or Support)Merck (Consultant)ViiV Healthcare (Consultant, Research Grant or Support) Julie Priest, MSPH, GlaxoSmithKline (Employee, Shareholder) Janna Radtchenko, MBA, Trio Health (Employee) Joseph Mrus, MD, MSc, ViiV Healthcare (Employee) Moti Rampogal, MD, Gilead Sciences (Consultant, Research Grant or Support, Speaker’s Bureau)Janssen (Consultant, Research Grant or Support, Speaker’s Bureau)Merck (Consultant, Research Grant or Support)ViiV Healthcare (Consultant, Research Grant or Support, Speaker’s Bureau) Alan Oglesby, MPH, ViiV Healthcare (Employee) Richard A. Elion, MD, Gilead Sciences (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau)Jannssen (Speaker’s Bureau)Proteus (Research Grant or Support)Trio Health (Employee)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support)

943. Older Gay Black Men Living with HIV Report Higher Quality of Life than Older Gay White Men, Despite Facing Additional Burdens

Background

Improving quality of life (QoL) is an important goal of care for people living with HIV (PLWH). This analysis uses data from the Aging with Dignity, Health, Optimism and Community (ADHOC) online registry to identify the different challenges faced by older white/Caucasian (“white”) and black/African American (“black”) gay or bisexual men living with HIV, and to assess differences in total QoL between the two groups.

Methods

QoL was measured using the PozQoL, a validated instrument for PLWH. The PozQoL assesses QoL across four domains: health concerns, psychological, social, and functional wellbeing. Total QoL was determined by combining domain scores for a total score. Student’s t-tests and chi-squared tests were used to identify disparities between black and white men. Factors with p< 0.05 were used as control variables in a multivariable linear regression model where PozQoL total score was the dependent variable.

Results

In the ADHOC database, 91% (n=612) of respondents were white men (WM) and 9% (n=59) were black men (BM). Both BM and WM had a median age of 59 years, and had a similar number of comorbidities (7.9 vs 9.2 respectively, p=0.12). Compared to WM, BM were more likely to be single (74% vs 51%, p< 0.001), less likely to have an income greater than $50,000 (25% vs 56%, p< 0.001), less likely to have a college degree or more (42% vs 69%, p=0.034), and less likely to be virally suppressed (87% vs 96%, p=0.001). Even after controlling for these differences in the multivariable model, BM had significantly higher total QoL than WM (Table 1).

Conclusion

In this analysis, there were substantial differences between older BM and WM living with HIV. After controlling for sociodemographic and clinical challenges, BM still reported higher QoL than WM. Programs designed to improve QoL for older gay and bisexual BM and WM living with HIV should take into consideration the unique strengths and challenges faced by each group.

Disclosures

Peter Mazonson, MD, MBA, ViiV Healthcare (Grant/Research Support) Theoren Loo, MS, BS, ViiV Healthcare (Grant/Research Support) Jeff Berko, MPH, BS, ViiV Healthcare (Grant/Research Support) Oluwatoyin Adeyemi, MD, ViiV Healthcare (Grant/Research Support) Alan Oglesby, MPH, ViiV Healthcare (Employee) Frank Spinelli, MD, ViiV Healthcare (Employee) Andrew Zolopa, MD, ViiV Healthcare (Employee)

Retrospective analysis of comorbidities and treatment burden among patients with HIV infection in a US Medicaid population

Objective: Comorbidities and comedications are important factors influencing optimal therapy because people are living longer with HIV infection. This study describes the long-term comorbidity profile and treatment burden among people with HIV-1 infection.Methods: This retrospective study included Medicaid claims data from patients with ≥1 antiretroviral (ARV) claim between 2016 and 2017 (most recent claim defined the index date), ≥1 HIV diagnosis within 1 year before index, age ≥18 years at first HIV diagnosis and <65 years at index, ≥12 months of continuous eligibility before index, and no history of HIV-2 infection. Comorbidities, concomitant medication use, and pill burden were assessed in the 4 years before index. Analyses were stratified by patient age and treatment experience.Results: Among 3456 patients, the mean (standard deviation [SD]) age was 47.1 (10.4) years; the majority were black (55%) and men (63%). In general, the prevalence of comorbidities increased from the fourth year to the first year before index and included cardiovascular disease (28-40%), hypertension (24-37%), hyperlipidemia (12-17%), and asthma/chronic obstructive pulmonary disease (13-19%). Concomitant medication use corresponding to these comorbidities slightly increased over time. In the year before index, mean (SD) daily pill burden was 2.1 (1.4) for ARVs and 5.9 (5.9) for non-ARVs. Older age and prior treatment experience were associated with higher rates of comorbidities and greater pill burden.Conclusions: In people with HIV infection, comorbidities and concomitant medication use increased with age, supporting considerations for streamlined ARV regimens highlighted in treatment guidelines.

Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review

BACKGROUND

As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change.

OBJECTIVES

To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers.

METHODS

A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management.

RESULTS

22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996.

CONCLUSIONS

This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses.

DISCLOSURES

This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.

Intratumoral delivery of tavokinogene telseplasmid yields systemic immune responses in metastatic melanoma patients

BACKGROUND

Interleukin 12 (IL-12) is a pivotal regulator of innate and adaptive immunity. We conducted a prospective open-label, phase II clinical trial of electroporated plasmid IL-12 in advanced melanoma patients (NCT01502293).

PATIENTS AND METHODS

Patients with stage III/IV melanoma were treated intratumorally with plasmid encoding IL-12 (tavokinogene telseplasmid; tavo), 0.5 mg/ml followed by electroporation (six pulses, 1500 V/cm) on days 1, 5, and 8 every 90 days in the main study and additional patients were treated in two alternative schedule exploration cohorts. Correlative analyses for programmed death-ligand 1 (PD-L1), flow cytometry to assess changes in immune cell subsets, and analysis of immune-related gene expression were carried out on pre- and post-treatment samples from study patients, as well as from additional patients treated during exploration of additional dosing schedules beyond the pre-specified protocol dosing schedule. Response was measured by study-specific criteria to maximize detection of latent and potentially transient immune responses in patients with multiple skin lesions and toxicities were graded by the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0).

RESULTS

The objective overall response rate was 35.7% in the main study (29.8% in all cohorts), with a complete response rate of 17.9% (10.6% in all cohorts). The median progression-free survival in the main study was 3.7 months while the median overall survival was not reached at a median follow up of 29.7 months. A total of 46% of patients in all cohorts with uninjected lesions experienced regression of at least one of these lesions and 25% had a net regression of all untreated lesions. Transcriptomic and immunohistochemistry analysis showed that immune activation and co-stimulatory transcripts were up-regulated but there was also increased adaptive immune resistance.

CONCLUSIONS

Intratumoral Tavo was well tolerated and led to systemic immune responses in advanced melanoma patients. While tumor regression and increased immune infiltration were observed in treated as well as untreated/distal lesions, adaptive immune resistance limited the response.

Clinical characteristics and treatment patterns among US patients with HIV

OBJECTIVES

Describe the clinical characteristics and treatment patterns of patients with HIV-1 who have commercial or Medicare health insurance in the United States.

STUDY DESIGN

Retrospective cohort study.

METHODS

Administrative claims for adult commercial and Medicare health plan enrollees with evidence of HIV-1 and antiretroviral therapy (ART) between January 1, 2007, and March 31, 2017, were assessed. Current and previous complete ART regimens were identified using a claims-based algorithm. Results were stratified by treatment status and insurance type.

RESULTS

Of 18,699 eligible patients, 5027 (27%) had no previous ART regimens; 15,275 (82%) had commercial insurance. Mean age was 47.5 years. Common comorbidities included hyperlipidemia, cardiovascular disease, hypertension, depression, and anxiety. The mean number of ART regimens was 1.43, with 31% of patients having 2 or more regimens. Mean (SD) daily pill burden was higher in patients with more than 1 ART regimen over time (5.7 [6.0] pills) or with Medicare insurance (9.2 [8.0] pills) than in patients with no previous ART (1.9 [4.4] pills) or with commercial insurance (3.7 [4.7] pills). Overall, 60% of patients achieved 90% or greater adherence to their ART regimen and 16% had a prescription filled for any contraindicated medication to an ART during their regimen.

CONCLUSIONS

This descriptive study demonstrated that people living with HIV enrolled in Medicare have a significant amount of comorbidities and total pill burden. Although advancements in ART have significantly improved life expectancy and quality of life for people living with HIV, it is important to take into account individual complexities such as comorbidities and pill burden when selecting ART regimens.

2488. Virologic Failure in ART Naïve Patients Initiating on a Dolutegravir or Elvitegravir-Based Regimen

Background

Robust pharmacoeconomic modeling is dependent on high quality inputs, preferably from randomized clinical trials (RCT), but not all needed head to head comparisons occur in RCTs. We compared virologic outcomes in an antiretroviral (ART) naïve population initiating a dolutegravir (DTG) or elvitegravir (EVG)-based regimen using clinical trial-like criteria.

Methods

ART-naïve adults, initiating a DTG- or EVG-based regimen and meeting all study eligibility criteria (Figure 1) were identified in the OPERA® Observational Database, a collaboration of HIV caregivers following 100,000+ people living with HIV (PLWH) through electronic medical records. PLWH were followed from the date of first prescription until DTG- or EVG discontinuation, death, or study end (July 31, 2018). The primary outcome was verified (2 consecutive viral load (VL) ≥200 copies/mL or 1 VL ≥200 copies + discontinuation) virologic failure (VF), defined as either failure to achieve suppression (<50 copies/mL) prior to 36 weeks or failure to maintain suppression once achieved. Survival analyses were conducted with Kaplan–Meier methods and multivariate Cox Proportional Hazards modeling.

Results

A total of 1,688 (DTG) and 2,537 (EVG) met all eligibility criteria. Median (IQR) length of follow-up in the DTG users was 21 months (14–30), in the EVG users was 20 (14–32) months. Figure 2 characterizes baseline demographic/clinical characteristics. Figures 3 and 4 depict Kaplan–Meier curves and Cox model results, respectively. VF was experienced by 8.2% DTG and 10.9% EVG initiators at a rate (95% CI) per 1,000 person-years of 40.2 (33.8, 47.8) and 51.3 (45.3, 58.1), respectively. Younger age (18–25), being African American, having a baseline CD4 count ≤ 200, or having a government-based payer (ADAP, Ryan White, Medicaid, or Medicare) at baseline were associated with a significant (P < 0.05), increased hazard of VF. Initiating on DTG or initiating therapy with a lower baseline VL was associated with a significant, reduced hazard of VF. Compared with DTG, the adjusted hazard ratio for VF was 1.29 (95% CI: 1.02, 1.63) for EVG.

Conclusion

Among ART-naïve patients, DTG users were significantly less likely to experience virologic failure than EVG users after adjustment for important baseline covariates.

Disclosures

All authors: No reported disclosures.

2484. Patient Reported Outcomes After Switching to a 2-Drug Regimen of Dolutegravir + Rilpivirine: Week 148 Results from the Sword-1 and Sword-2 Studies

Background

The SWORD-1 and SWORD-2 studies previously demonstrated that high rates of virologic suppression were maintained for 148 weeks after switching virologically suppressed HIV-1 infected adults from their current 3- or 4-drug antiretroviral regimen (CAR) to the 2-drug regimen (2DR) of dolutegravir + rilpivirine on Day 1 (Early Switch (ES) DTG+RPV group). This abstract reports the pooled SWORD-1/2 results of patient reported outcomes (PRO) measures through Week 148.

Methods

HIV Treatment Satisfaction Questionnaire (HIVTSQ) and Symptom Distress Module (SDM) were secondary PRO endpoints in the SWORD trials. For HIVTSQ, high scores represent greater treatment satisfaction (range 0 to 60). SDM was assessed using the Symptom Bother Score with low values indicating less symptom bother (range 0 to 80). The EQ-5D-5L measure of general health status was assessed as an exploratory endpoint with maximum utility score of 1 to indicate perfect health. Change from Baseline in these endpoints was calculated for the ES subjects (over 148 weeks). Subjects randomized to CAR switched to DTG+RPV at Week 52 (Late Switch (LS) DTG+RPV group) and change from LS Baseline (i.e., last pre-switch assessment) was calculated (over 96 weeks).

Results

Low Symptom Bother (9.6 and 10.3) and high TSQ scores (54.4 and 54.3) were reported pre-switch in the ES and LS groups, respectively.

ES subjects reported modest improvements from Baseline in both symptom burden and overall treatment satisfaction in all visits through Week 148 (Figures 1 and 2). Among the LS group, there was little change in symptom burden but similar improvement in treatment satisfaction. Pre-switch health status was high in ES and LS groups (EQ-5D mean utility: 0.96 and 0.94, respectively) and remained stable in both groups at all time points.

Conclusion

High treatment satisfaction and low symptom burden that were observed in patients under CAR were maintained long term after switching to DTG+RPV. These results corroborate DTG+RPV as a well-tolerated 2DR alternative treatment option in patients currently suppressed on other 3/4-drug regimens without previous virologic failure.

Disclosures

All authors: No reported disclosures.

2485. Real-world Experience with Dolutegravir Plus Rilpivirine Two-Drug Regimen

Background

Three-drug regimens (3DRs) have long been the mainstay of antiretroviral treatment (ART) for HIV. Dolutegravir-based two-drug regimens (DTG 2DRs) are now accepted alternatives to 3DRs, with the first 2DR single tablet regimen (STR), Juluca (DTG/rilpivirine [RPV]), FDA-approved in 2017. This study evaluated treatment patterns of DTG+RPV in clinical practice to understand use prior to availability of DTG/RPV STR.

Methods

A retrospective medical chart review was conducted across 10 US sites identified as using any DTG 2DRs. Eligible patients were adults initiated on DTG 2DR prior to July 31, 2017 and followed up to January 30, 2018. This analysis describes a subgroup who received DTG+RPV 2DR. Patient demographics, clinical characteristics and treatment history were abstracted from medical charts. Analyses were descriptive.

Results

From an overall sample of 278 DTG 2DR patients, 66 received DTG+RPV 2DR. In this DTG+RPV subgroup, mean age was 56 years, 79% were male and 68% were Caucasian. Most were treatment-experienced (97%), with an average 15.5 years of prior ART; 48% had received ≥ 4 prior regimens. The most common physician reported reasons for initiating DTG+RPV were avoidance of potential long-term toxicities (53%), toxicity/intolerance of ARVs (20%) and treatment simplification/streamlining (15%). Prior to initiation of DTG+RPV, 70% of patients were virologically suppressed (< 50 copies/mL); of those, 98% remained suppressed after switching to DTG+RPV. Of the 30% of patients with detectable viral load prior to DTG+RPV initiation, 60% achieved and maintained virologic suppression on DTG+RPV. Mean time on DTG+RPV was 1.6 years. Only 5 (8%) patients discontinued DTG+RPV by data cut-off, and one patient was lost to follow-up. Reasons for discontinuation were virologic failure (n = 2), treatment simplification/streamlining (n = 2) and toxicity/intolerance (n = 1). Physicians reported that most patients (91%) achieved the desired outcome from DTG+RPV use.

Conclusion

Prior to commercial availability of DTG/RPV STR in the United States, DTG+RPV was used primarily in treatment experienced patients, most commonly to avoid potential long-term toxicities. A high proportion of patients achieved the desired outcome and maintained virologic suppression while receiving DTG+RPV.

Disclosures

All authors: No reported disclosures.

Real-World Health Plan Data Analysis: Key Trends in Medication Adherence and Overall Costs in Patients with HIV

BACKGROUND

Adherence to effective antiretroviral therapy (ART) is essential to achieve long-term viral suppression in patients with HIV-1. Single-tablet regimens (STRs) have improved adherence and decreased health care costs and hospitalizations, but previous study results suggest that the relationship between ART adherence and health care costs and utilization is complex.

OBJECTIVE

To assess ART adherence trends in patients with HIV-1 to determine if differences in utilization, demographics, and overall costs exist among patients with varying levels of medication adherence.

METHODS

This retrospective study analyzed medical and pharmacy claims data from an administrative claims database between January 1, 2007, and June 30, 2016, for Medicaid or commercially insured patients continuously enrolled for ≥ 6 months before and ≥ 15 months after the index date (date of first medical claim with an HIV diagnosis or pharmacy claim for HIV ART medication between July 1, 2007, and June 30, 2014). Qualifying patients were aged ≥ 18 years with a diagnosis of HIV-1 infection or at least 1 pharmacy claim for HIV ART at index and at least 2 pharmacy claims during the follow-up period. Patients were categorized on the basis of adherence as measured by proportion of days covered (PDC; ≥ 95%, highly adherent; < 95%, less adherent) and treatment with an STR or multiple-tablet regimen (MTR). Commercially insured patients were stratified by duration of follow-up data (< 3 or ≥ 3 years). There were not enough Medicaid patients for follow-up analysis. Outcomes of interest were ART adherence and annual medical and pharmacy utilization and costs. Descriptive statistics were generated, and health care resource utilization and costs were reported as annual averages. Chi-square and t-tests were used to examine differences between the cohorts.

RESULTS

A total of 332 Medicaid patients and 1,698 patients insured commercially met inclusion criteria. Adherence to ART medication (mean PDC) during the first 15 months was lower in Medicaid patients (65%) versus commercial patients (79%; P < 0.0001). Patients treated with STRs comprised 47% and 37% of patients in the < 3-year and ≥ 3-year follow-up cohorts, respectively. More STR patients achieved ≥95% adherence than MTR patients (< 3-year follow-up, 53% vs. 39%; ≥ 3-year follow-up, 61% vs. 45%; P < 0.001). In both follow-up cohorts, less adherent patients had higher mean annual medical costs, and results were significant for patients with ≥ 3-year follow-up ($8,224 vs. $3,097; P = 0.0007). These results were largely driven by savings in mean annual inpatient costs among the highly adherent patients in both cohorts (< 3-year follow-up, -$2,525 [P = 0.0003]; ≥ 3-year follow-up, -$815 [P < 0.001]).

CONCLUSIONS

Patients on STRs were more adherent than patients on MTRs regardless of length of follow-up. Better adherence was associated with significant inpatient cost savings. The relationship between adherence and total medical costs is nuanced depending on the duration of follow-up.

DISCLOSURES

This study was funded by ViiV Healthcare, which participated in protocol development, the analysis plan, and interpretation of results but did not have final approval on the decision to publish. Kangethe, Polson, Lord, and Evangelatos are employees of Magellan Rx Management, which was contracted by ViiV Healthcare to conduct the research for this study. Oglesby is an employee of ViiV Healthcare and owns stock in GlaxoSmithKline. Data from this study were previously presented at AMCP Nexus; October 16-19, 2017; Dallas, TX.

588. Retrospective Analysis of Clinical Characteristics and Treatment Patterns Among HIV Patients with Commercial and Medicare Advantage Health Insurance in the United States

Background

Methods

Results

Conclusion

Disclosures

550. Adherence and Persistency With Modern Single vs. Multi-Tablet Antiretroviral (ARV) Regimens in First Treatment of HIV in Clinical Practice

Background

Prior studies have reported improved adherence, persistency, virologic outcomes and lower risk of hospitalizations with single tablet (STR) vs. multi-tablet regimens (MTR) in HIV treatment. However, most studies were conducted using prescription and medical claims data limited to EFV-based therapies. In this study, we utilized EMR, prescription, and pharmacy dispensing data to assess STR and MTR adherence and persistency as observed in a network of clinical practices.

Methods

Data were collected for HIV-infected patients in care at six US-based HIV treatment centers. Patients eligible for the study initiated their first ARV between January 2015 and December 2016. First ARV regimen was assigned based on absence of prior ARV prescriptions and a 30-day pre-treatment period with no ARV dispensed or for rapid starts, a high baseline viral load (≥10,000 copies/mL). Adherence was assessed using proportion of days covered (PDC). Follow-up was ≥365 days with duration capped at 365 days for persistency comparisons.

Results

A total of 1,499 patients met the criteria for the study; 66% (982/1,499) received STR and 34% (517/1,499) MTR. Top STRs were EVG/c/TDF/FTC (265/982, 27%), EVG/c/TAF/FTC (250/982, 26%), and DTG/ABC/3TC (171/982, 17%). Top MTRs were DTG + TDF/FTC (69/517, 13%), DRV + RTV + TDF/FTC (60/517, 12%), and DRV/c + TDF/FTC (40/517, 8%). Average persistency for STRs was significantly longer at 252 days vs. 233 days for MTRs (P = 0.002). Average PDC adherence rates were significantly higher for STRs at 91% vs. 83% for MTRs (P < 0.001). Within the STR group, older age was significantly associated with greater adherence (average age: 45 in 80%+ adherent group vs. 42 in <80% adherent group, P = 0.012). In both the STR and MTR groups, the percentage of black patients was significantly higher in the non-adherent group (45% in STR, 42% in MTR) compared with the adherent group (24% in STR, 32% in MTR) (P < 0.001 in STR, P = 0.027 in MTR).

Conclusion

This study of adherence with STR vs. MTR HIV therapy is novel, as it uses more currently relevant HIV regimens and was conducted utilizing EMR, prescription, and dispensing data. The results of better adherence and persistency with STR ART underscore the ongoing importance of simpler treatment for HIV care.

Disclosures

A. Mills, ViiV: Investigator and Scientific Advisor, Consulting fee and Research support. Gilead: Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. Merck: Investigator and Scientific Advisor, Consulting fee and Research support. J. Priest, ViiV Healthcare: Employee, Salary. A. Musallam, Trio Health: Employee, Salary. K. Althoff, Gilead: Scientific Advisor, Consulting fee. J. Eron, ViiV Healthcare: Consultant and Investigator, Consulting fee and Research support. Gilead: Consultant and Investigator, Consulting fee and Research support. Janssen: Consultant and Investigator, Consulting fee and Research support. G. Huhn, Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. ViiV Healthcare: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. Janssen: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. Theratechnologies: Scientific Advisor, Consulting fee. Proteus: Grant Investigator, Grant recipient. D. Jayaweera, Gilead: Grant Investigator, Research grant. ViiV Healthcare: Grant Investigator, Research grant. Janssen: Grant Investigator, Research grant. K. Mounzer, Gilead: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. ViiV Healthcare: Grant Investigator and Scientific Advisor, Consulting fee and Research grant. Janssen: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Merck: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. G. Moyle, Merck: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Gilead: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Janssen: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. TheraTechnologies: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. J. Mrus, ViiV Healthcare: Employee, Salary. M. Rampogal, Gilead: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Janssen: Speaker’s Bureau, Speaker honorarium. Allergen: Speaker’s Bureau, Speaker honorarium. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee and Grant recipient. Merck: Consultant, Consulting fee. S. Santiago, Gilead: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Janssen: Speaker’s Bureau, Speaker honorarium. P. Sax, Gilead: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Merck: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Janssen: Consultant, Consulting fee. BMS: Grant Investigator, Grant recipient and Research grant. G. Voskuhl, Gilead: Grant Investigator and Scientific Advisor, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Grant Investigator, Grant recipient and Research grant. Merck: Grant Investigator, Grant recipient and Research grant. Janssen: Grant Investigator, Grant recipient and Research grant. A. Oglesby, ViiV Healthcare: Employee and Shareholder, Salary. R. Elion, Gilead: Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. ViiV: Consultant, Consulting fee. Trio Health: Consultant, Consulting fee.

Impact of early versus late systemic lupus erythematosus diagnosis on clinical and economic outcomes

BACKGROUND AND OBJECTIVES

Systemic lupus erythematosus (SLE) is a multisystem complex autoimmune disease that often mimics symptoms of other illnesses, which complicates the ability of healthcare providers to make the diagnosis. The objective of this study was to assess clinical outcomes, resource utilization, and costs between patients with earlier versus later SLE diagnosis.

METHODS

Patients aged 18-64 years were identified from a large US commercial claims database between January 2000 and June 2010. Confirmed SLE diagnosis with a claims-based algorithm required either three or more claims for a visit to a rheumatologist on separate dates with an SLE diagnosis (International Classification of Diseases [ICD-9] code 710.0x), two or more claims for visits to a rheumatologist at least 60 days apart with SLE diagnoses, or two or more claims for visits to rheumatologist less than 60 days apart with SLE diagnoses with at least one dispensing for a typical SLE medication. SLE probable onset date was identified during the 12-month baseline period by the second claim for antinuclear antibody tests or prodromal symptoms of SLE. Patients were stratified into early or late diagnosis groups based on time between probable SLE onset and diagnosis (<6 months or ≥6 months, respectively). Each patient observation period began on the date of the first medical claim, with a diagnosis code for SLE that satisfied the inclusion criteria, and ended on the earliest date between health plan disenrollment and 30 June 2010. Patients in each group were propensity-score matched on age, gender, diagnosis year, region, health plan type, and comorbidities. Flare rates and resource utilization were compared post-diagnosis between groups using rate ratios. All-cause and SLE-related costs (adjusted to 2010 US dollars) per patient per month (PPPM) were calculated.

RESULTS

There were 4,166 matched patients per group. Post-SLE diagnosis, the early diagnosis group had lower rates of mild (rate ratio [RR] 0.95; 95 % CI 0.93-0.96), moderate (RR 0.96; 95 % CI 0.94-0.99), and severe (RR 0.87; 95 % CI 0.82-0.93) flares compared with the late diagnosis group. The rates of hospitalizations (RR 0.80; 95 % CI 0.75-0.85) were lower for the early diagnosis group than the late diagnosis group. Compared with late diagnosis patients, mean all-cause inpatient costs PPPM were lower for the early diagnosis patients (US$406 vs. US$486; p = 0.016). Corresponding SLE-related hospitalization costs were also lower for early compared with late diagnosis patients (US$71 vs. US$95; p = 0.013). Results were consistent for other resource use and cost categories.

CONCLUSIONS

Patients diagnosed with SLE sooner may experience lower flare rates, less healthcare utilization, and lower costs from a commercially insured population perspective. This finding needs to be further explored within the context of background SLE disease activity.

Impact of systemic lupus erythematosus on burden of illness and work productivity in the United States

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by clinical manifestations that can cause diminished activity and productivity. The objectives of this study were to: (a) longitudinally evaluate patient-reported SLE disease activity, and (b) measure work productivity, missed work hours, and associated lost income among employed patients with SLE. Three cohorts (employed subjects with SLE (n = 281), nonemployed subjects with SLE (n = 265), and a control group of employed individuals without SLE (n = 300)) completed a baseline survey. Employed subjects with SLE completed follow-up surveys every two weeks during a six-month period. Measured outcomes included perceived health, disease manifestations and severity, the Lupus Impact Tracker, the Modified Systemic Lupus Activity Questionnaire, and Work Productivity and Activity Impairment Questionnaire. Higher self-reported SLE disease severity was directly associated with experiencing more frequent and more severe symptoms as well as higher levels of lost work time and lost work productivity. Though patient self-assessment may differ from physician's clinical assessment, it is important to incorporate the patient perspective in clinical decision-making to optimally manage SLE patients. Given the evidence associating SLE with work disability and job loss, it may be beneficial for professionals addressing worksite modifications or compensatory strategies to be included as members of SLE medical teams.

The hospital burden of disease associated with bone metastases and skeletal-related events in patients with breast cancer, lung cancer, or prostate cancer in Spain

POCKETT R.D., CASTELLANO D., MCEWAN P., OGLESBY A., BARBER B.L. & CHUNG K. (2010) European Journal of Cancer Care19, 755–760 The hospital burden of disease associated with bone metastases and skeletal-related events in patients with breast cancer, lung cancer, or prostate cancer in Spain

Metastatic bone disease (MBD) is the most common cause of cancer pain and of serious skeletal-related events (SREs) reducing quality of life. Management of MBD involves a multimodal approach aimed at delaying the first SRE and reducing subsequent SREs. The objective of the study was to characterise the hospital burden of disease associated with MBD and SREs following breast, lung and prostate cancer in Spain. Patients admitted into a participating hospital, between 1 January 2003 and 31 December 2003, with one of the required cancers were identified and selected for inclusion into the study. The index admission to hospital, incidence of patients admitted and hospital length of stay were analysed. There were 28 162 patients identified with breast, lung and prostate cancer. The 3 year incidence rates of hospital admission due to MBD were 95 per 1000 for breast cancer, 156 per 1000 for lung cancer and 163 per 1000 for prostate cancer. For patients admitted following an SRE, the incidence rates were 211 per 1000 for breast cancer, 260 per 1000 for lung cancer and 150 per 1000 for prostate cancer. This study has shown that cancer patients consume progressively more hospital resources as MBD and subsequent SREs develop.

The longitudinal link between visual acuity and health-related quality of life in patients with diabetic retinopathy

Background

This study characterized the degree of change in health-related quality of life (HRQL) associated with change in visual acuity among patients with diabetic retinopathy.

Methods

Data are from a randomized, placebo-controlled trial of ruboxistaurin for vision loss in patients with diabetic retinopathy. Visual acuity was quantified as letters on the ETDRS visual acuity chart. HRQL was assessed with the 25-Item Visual Function Questionnaire (VFQ-25) and the SF-36. Patients were categorized into groups based on visual acuity change from baseline to month 18. HRQL change of these groups was compared using general linear models. Regression analyses examined visual acuity change defined continuously.

Results

Patients (N = 535) were primarily Caucasian (81.9%) and male (64.1%); mean age = 59.3 years. Compared to patients whose visual acuity did not change, the group with > 10 letters vision loss had significantly greater decreases in all VFQ-25 subscales except ocular pain. SF-36 change scores did not correspond as closely to change in vision. Change in visual acuity defined continuously was significantly associated with change in all VFQ-25 scales except ocular pain (p < 0.0001).

Conclusion

Change in visual acuity was associated with corresponding changes in HRQL among patients with diabetic retinopathy. Previous research has often defined vision loss as a loss of at least 15 letters on the ETDRS visual acuity chart. In the current study, however, a loss of at least 10 letters was associated with substantial declines in HRQL domains such as driving, dependency, role limitations, and mental health. These findings suggest that patients who experience vision loss of at least 10 letters may be appropriate targets of future research and clinical intervention.

Patient-reported outcomes in a trial of exenatide and insulin glargine for the treatment of type 2 diabetes

Background

Patient-reported measures can be used to examine whether drug differences other than clinical efficacy have an impact on outcomes that may be important to patients. Although exenatide and insulin glargine appear to have similar efficacy for treatment of type 2 diabetes, there are several differences between the two treatments that could influence outcomes from the patient's perspective. The purpose of the current study was to examine whether the two drugs were comparable as assessed by patient-reported outcomes using data from a clinical trial in which these injectable medications were added to pre-existing oral treatment regimens.

Methods

Patients were randomized to either twice daily exenatide or once daily insulin glargine during a 26-week international trial. At baseline and endpoint, five patient-reported outcome measures were administered: the Vitality Scale of the SF-36, The Diabetes Symptom Checklist – Revised (DSC-R), the EuroQol EQ-5D, the Treatment Flexibility Scale (TFS), and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). Change from baseline to endpoint was analyzed within each treatment group. Group differences were examined with General linear models (GLMs), controlling for country and baseline scores.

Results

A total of 549 patients with type 2 diabetes were enrolled in the trial, and current analyses were conducted with data from the 455 per protocol patients (228 exenatide and 227 insulin glargine). The sample was primarily Caucasian (79.6%), with slightly more men (55.2%) than women, and with a mean age of 58.5 years. Paired t-tests found that both treatment groups demonstrated statistically significant baseline to endpoint change on several of the health outcomes instruments including the DSC-R, DTSQ, and the SF-36 Vitality subscale. GLMs found no statistically significant differences between groups in change on the health outcomes instruments.

Conclusion

This analysis found that both exenatide and insulin glargine were associated with significant improvements in patient-reported outcomes when added to oral medications among patients with type 2 diabetes. Despite an additional daily injection and a higher rate of gastrointestinal adverse events, treatment satisfaction in the exenatide group was comparable to that of the glargine group, possibly because of weight reduction observed in patients treated with exenatide.

The development and validation of the Norfolk QOL-DN, a new measure of patients' perception of the effects of diabetes and diabetic neuropathy

BACKGROUND

This study was designed to develop and validate a patient-reported outcomes measure, sensitive to the different features of diabetic neuropathy (DN)-small fiber, large fiber, and autonomic nerve function.

METHODS

The review of 1,000 structured patient interviews guided the development of 28 items pertaining specifically to the symptoms and impact of large fiber, small fiber, and autonomic nerve function. These items, in addition to 14 generic health status items and five general information items formed the 47-item Norfolk Quality of Life Questionnaire-Diabetic Neuropathy (QOL-DN). Items were grouped according to small fiber, large fiber, and autonomic nerve function, symptoms, and activities of daily living (ADL). Scores in individual domains were aggregated to provide a total score. Item groupings were tested for their ability to distinguish between the effects of specific nerve fiber deficits in 262 subjects-81 healthy controls (C), 86 controls with diabetes (DC), and 95 patients with DN-using one-way analysis of variance (ANOVA). Internal consistency was estimated using Cronbach's alpha coefficient. Test-retest reliability over a 4-6-week period was estimated by intra-class correlation coefficients and ANOVA on data of a subset of patients and controls.

RESULTS

Differences between DN subjects and both DC and C subjects were significant (P < 0.05) for all item groupings. Total quality of life (QOL) scores correlated with total neuropathy scores. The ADL, total QOL, and autonomic scores were greater in DC than C subjects (P < 0.05). Intra-class correlation coefficients were > 0.9 for most domains. Internal consistency of the fiberspecific domains using Cronbach's alpha was > 0.6 and up to 0.8.

CONCLUSIONS

The fiber-specific domains of the QOL-DN demonstrated acceptable reliability and ability to discriminate between subjects with and without neuropathy. Not surprisingly, the DN group scored significantly (P < 0.05) higher than either of the two control groups (i.e., greater impairment). The positive scores for the DC group in the ADL and autonomic domains suggest that diabetes per se impacts these aspects of QOL.

Impact of changes in HbA1c, lipids and blood pressure on long-term outcomes in type 2 diabetes patients: an analysis using the CORE Diabetes Model

OBJECTIVES

Various factors influence the risk of complications in type 2 diabetes patients. The isolated impact of single risk factors on long-term outcomes is unclear. The aim of this study was to calculate the projected effects on life expectancy (LE), quality-adjusted LE (QALE) and total costs of complications (TC) of 10% improvements in baseline levels of either total cholesterol (T-CHOL), high-density lipoprotein cholesterol (HDL), systolic blood pressure (SBP), glycosylated haemoglobin (HbA1c), and all four parameters combined.

METHODS

A cohort of newly diagnosed patients (baseline age 52 years, HbA1c 9.1%, SBP 137 mmHg, T-CHOL 212 mg/dL, and HDL 39 mg/dL) was defined. The CORE Diabetes Model was used to simulate LE, QALE and TC (US third-party payer perspective discounted at 3% annually) over patients' lifetimes, assuming no change in risk factors, an isolated 10% improvement in each parameter, or a 10% improvement in all parameters simultaneously.

RESULTS

Improved HbA1c led to increases in LE and QALE of 1.00 and 0.81 years respectively, and decreased TC of (US) 10,800 dollars/patient. Improved SBP led to improvements in LE and QALE of 0.67 and 0.55 years respectively and decreased TC of 7,049 dollars. Decreased T-CHOL led to improvements in LE and QALE of 0.29 and 0.20 years, respectively, and increased TC of 1,923 dollars. Increased HDL led to improvements in LE and QALE of 0.28 and 0.18 years respectively, and increased TC of 2,162 dollars. Simultaneous improvements in all parameters led to projected improvements in LE and QALE of 2.17 and 1.72 years respectively, and decreased TC of 14,533 dollars.

CONCLUSIONS

Combined improvements in HbA1c, lipid levels and SBP produced the greatest benefits in terms of LE, QALE and TC. A 10% improvement in HbA1c had the greatest impact on these three outcomes.

What impact would pancreatic beta-cell preservation have on life expectancy, quality-adjusted life expectancy and costs of complications in patients with type 2 diabetes? A projection using the CORE Diabetes Model

OBJECTIVE

Type 2 diabetes is characterised by progressive failure of pancreatic beta-cell function against a background of insulin resistance. Multifactorial interventions, including intensive glycaemic and blood pressure control, reduce the risk of onset and progression of complications. However, current management of type 2 diabetes focuses on treatment of signs and symptoms of disease instead of targeting underlying causes. A number of newer pharmacological interventions, including thiazolidinediones and glucagon-like peptides, have shown early promise in preserving pancreatic beta-cell function. The aim of this study was to investigate the impact of stabilising beta-cell function on long-term outcomes in patients with type 2 diabetes.

METHODS

The CORE Diabetes Model was used to project life expectancy (LE), quality-adjusted LE (QALE) and total lifetime complication costs (TC) for a cohort of newly-diagnosed patients with type 2 diabetes, either with a typical increase of HbA1c over time as observed in the UKPDS, or assuming stabilisation of HbA1c after diagnosis with a hypothetical new treatment, representing beta-cell function stabilisation. Costs due to diabetes-related complications (from a US third-party payer perspective), were discounted at 3% annually. Both non-discounted and discounted (at 3% annually) LE and QALE were calculated. Sensitivity analyses were performed to test the robustness of results.

RESULTS

Over a time period of 50 years, in a cohort with no increase of HbA1c over time, LE and QALE were improved by mean (SD) 1.02 (0.36) and 0.96 (0.25) years, and total costs of complications were reduced by 6,377 dollars (2,568) per patient compared to the cohort with a typical increase in HbA1c over time. Results were robust under a wide range of plausible assumptions.

CONCLUSIONS

New interventions that stabilise pancreatic betacell function may have an important impact on length and quality of life, and lead to reduced costs of complications in patients with type 2 diabetes.

Optimization of BMD measurements to identify high risk groups for treatment--a test analysis

INTRODUCTION

The aim of this study was to develop a methodology to optimize the role of BMD measurements in a case finding strategy. We studied 2113 women > or = 75 years of age randomly selected from Sheffield, UK, and adjacent regions. Baseline assessment included hip BMD and clinical risk factors. Outcomes included death and fracture in women followed for 6723 person-years.

MATERIALS AND METHODS

Poisson models were used to identify significant risk factors for all fractures and for death with and without BMD and the hazard functions were used to compute fracture probabilities. Women were categorized by fracture probability with and without a BMD assessment. A 10-year fracture probability threshold of 35% was taken as an intervention threshold. Discordance in categorization of risk (i.e., above or below the threshold probability) between assessment with and without BMD was examined by logistic regression as probabilities of re-classification. Age, prior fracture, use of corticosteroids, and low body mass index were identified as significant clinical risk factors.

RESULTS

A total of 16.8% of women were classified as high risk based on these clinical risk factors. The average BMD in these patients was approximately 1 SD lower than in low-risk women; 21.5% of women were designated to be at high risk with the addition of BMD. Fifteen percent of all women were reclassified after adding BMD to clinical risk factors, most of whom lay near the intervention threshold. When a high probability of reclassification was accepted (without a BMD test) for high risk to low risk (p1< or = 0.8) and a low probability accepted for low to high risk (P2 < or = 0.2), BMD tests would be required in only 21% of the population.

CONCLUSION

We conclude that the use of clinical risk factors can identify elderly women at high fracture risk and that such patients have a low average BMD. BMD testing is required, however, in a minority of women--a fraction that depends on the probabilities accepted for classification and the thresholds of risk chosen. These findings need to be validated in other cohorts at different ages and from different regions of the world.

The health care costs of diabetic nephropathy in the United States and the United Kingdom

PROBLEM

Diabetic nephropathy (DN) is a common microvascular complication of diabetes and can result in end-stage renal disease (ESRD) necessitating long-term dialysis or kidney transplantation. The costs of these complications are relatively high. The aim of this study was to quantify and compare the rates and annual costs of DN in the USA and the UK.

METHODS

A cost of illness model was used to estimate the numbers of people with DN (microalbuminuria, overt nephropathy, and ESRD) or a previous kidney transplant at a given point in time and the numbers of new kidney transplants during a year. All costs were estimated in 2001 currencies. A sensitivity analysis assessed the robustness of the national annual cost estimates.

RESULTS

In the USA, the total annual medical costs incurred by all payers in managing DN were US dollars 1.9 billion for Type 1 diabetes (range: US dollars 1.0-2.8 billion), US dollars 15.0 billion for Type 2 diabetes (range: US dollars 7.6-22.4 billion), and US dollars 16.8 billion for all diabetes (range: US dollars 8.5-25.2 billion). In the UK, the total annual costs to the National Health Service (NHS) of managing DN were US dollars 231 million ( pound 152 million) for Type 1 diabetes (range: US dollars 190-350 million [ pound 125-230 million]), US dollars 933 million (pound 614 million) for Type 2 diabetes (range: US dollars 809 million-US dollars 1.4 billion [pound 532-927 million]), and US dollars 1.2 billion ( pound 765 million) for all diabetes (range: US dollars 999 million-US dollars 1.8 billion [pound 657 million- pound 1.2 billion]).

CONCLUSIONS

The total annual cost of DN is 13 times greater in the USA than in the UK. Controlling for the substantially higher number of people at risk, the total cost per person with DN and/or a kidney transplant is 40% higher: US dollars 3735 in the USA and US dollars 2672 (pound 1758) in the UK.

Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S

OBJECTIVE

The ability to perceive vibration (vibration detection) has been shown to be a good predictor of the long-term complications of diabetic peripheral neuropathy (DPN). We aimed to estimate the predicted complications and costs for the U.S. health care system associated with reduced vibration detection (vibration perception threshold >or=25 V), estimated using a quantitative sensory testing device.

RESEARCH DESIGN AND METHODS

A Markov model was constructed for a hypothetical cohort of people with DPN. The model was run over a 10-year period using Monte Carlo simulations to estimate disease progression, predicted costs, and complications according to vibration detection levels.

RESULTS

The average individual with reduced vibration detection incurs approximately five times more direct medical costs for foot ulcer and amputations, yields 0.18 fewer quality-adjusted life-years, and lives for approximately 2 months less than an average individual with normal vibration detection.

CONCLUSIONS

The treatment of foot ulceration and amputation is time-consuming and expensive. If individuals with reduced vibration detection could be identified, then preventative care could be concentrated on those patients, potentially saving valuable resources and improving health outcomes.

The health care costs of diabetic peripheral neuropathy in the US

OBJECTIVE

Peripheral neuropathy is common among people with diabetes and can result in foot ulceration and amputation. The aim of this study was to quantify the annual medical costs of peripheral neuropathy and its complications among people with type 1 and type 2 diabetes in the U.S.

RESEARCH DESIGN AND METHODS

A cost-of-illness model was used to estimate the numbers of diabetic individuals in the U.S. who have diabetic peripheral neuropathy (DPN) and/or neuropathic foot ulcers (both those with no deep infection and those accompanied by cellulitis or osteomyelitis) at a given point in time, and/or a toe, foot, or leg amputation during a year. Prevalence and incidence rates were estimated from published studies and applied to the general U.S. population. All costs were estimated in 2001 U.S. dollars. In a sensitivity analysis, we varied the rates of complications to assess the robustness of the cost estimates.

RESULTS

The annual costs of DPN and its complications in the U.S. were 0.8 billion US dollars (type 1 diabetes), 10.1 billion US dollars (type 2 diabetes), and 10.9 billion US dollars (total). After allowing for uncertainty in the point estimates of complication rates, the range of costs were between 0.3 and 1.0 billion US dollars (type 1 diabetes), 4.3b and 12.7 billion US dollars (type 2 diabetes), and 4.6 and 13.7 billion US dollars (type 1 and type 2 diabetes).

CONCLUSIONS

The total annual cost of DPN and its complications in the U.S. was estimated to be between 4.6 and 13.7 billion US dollars. Up to 27% of the direct medical cost of diabetes may be attributed to DPN.

Intervention thresholds for osteoporosis

The aim of this study was to determine the threshold of fracture probability at which interventions become cost-effective. We modeled the effects of a treatment costing $500/year, given for 5 years, that decreased the risk of all osteoporotic fractures by 35%, followed by a waning of effect for 5 years. Sensitivity analyses included a range of effectiveness (10%-50%) and a range of intervention costs (200-500 dollars/year). Data on costs and risks were from Sweden. Costs included direct costs and costs in added years of life, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of 60,000 dollars per quality-adjusted life-year (QALY) gained was used. Costs of added years were excluded in a sensitivity analysis for which a threshold value of 30,000 dollars per QALY was used. In the base case, intervention was cost-effective when treatment was targeted to women at average risk at age of >or=65 years. Irrespective of the efficacy modeled (10%-50%) or of cost of intervention (200-500 dollars/year) segments of the population at average risk could be targeted cost-effectively: The lower the intervention cost and the higher the effectiveness, the lower the age at which intervention was cost-effective. With the base case (500 dollars/year; 35% efficacy) treatment in women was cost-effective with a 10 year hip fracture probability that ranged from 1.4% at the age of 50 years to 4.4% at the age of 65 years. The exclusion of osteoporotic fractures other than hip fracture would increase the threshold to a 9%-11% 10 year probability because of the substantial morbidity from fractures other than hip fracture, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be cost-effectively targeted to individuals at moderately increased risk.