Risk Analysis of Respiratory Syncytial Virus Among Infants in the United States by Birth Month

BACKGROUND

Respiratory syncytial virus (RSV) is a major cause of morbidity and mortality among U.S. infants. A child's calendar birth month determines their age at first exposure(s) to RSV. We estimated birth month-specific risk of medically attended (MA) RSV lower respiratory tract infection (LRTI) among infants during their first RSV season and first year of life.

METHODS

We analyzed infants born in the USA between July 2016 and February 2020 using three insurance claims databases (two commercial, one Medicaid). We classified infants' first MA RSV LRTI episode by highest level of care incurred (outpatient, emergency department, or inpatient), employing specific and sensitive diagnostic coding algorithms to define index RSV diagnoses. In our main analysis we focused on infants' first RSV season. In our secondary analysis we compared the risk of MA RSV LRTI during infants' first RSV season to that of their first year of life.

RESULTS

Infants born from May through September generally had the highest risk of first-season MA RSV LRTI-approximately 6%-10% under the specific RSV index diagnosis definition and 16%-26% under the sensitive. Infants born between October and December had the highest risk of RSV-related hospitalization during their first season. The proportion of MA RSV LRTI events classified as inpatient ranged from 9%-54% (specific) and 5%-33% (sensitive) across birth month and comorbidity group. Through the first year of life, the overall risk of MA RSV LRTI is comparable across birth months within each claims database (6%-11% under the specific definition, 17%-30% under the sensitive), with additional cases progressing to care at outpatient or ED settings.

CONCLUSIONS

Our data support recent national recommendations for the use of nirsevimab in the USA. For infants born at the tail end of an RSV season who do not receive nirsevimab, a dose administered prior to the onset of their second RSV season could reduce the incidence of outpatient and ED-related events.

Increasing Rates of RSV Hospitalization among Preterm Infants: A Decade of Data

OBJECTIVE

In 2014, the American Academy of Pediatrics (AAP) changed its policy on the use of respiratory syncytial virus immunoprophylaxis (RSV-IP) so that RSV-IP was no longer recommended for use among infants without other medical conditions born >29 weeks of gestational age (wGA). This study examines 10-year trends in RSV-IP and RSV hospitalizations among term infants and preterm infants born at 29 to 34 wGA, including the 5 RSV seasons before and 5 RSV seasons after the AAP guidance change.

STUDY DESIGN

A retrospective observational cohort study of a convenience sample of infants less than 6 months of age during RSV season (November-March) born between July 1, 2008, and June 30, 2019, who were born at 29 to 34 wGA (preterm) or >37 wGA (term) in the IBM MarketScan Commercial and Multi-State Medicaid databases. We excluded infants with medical conditions that would independently qualify them for RSV-IP. We identified RSV-IP utilization along with RSV and all-cause bronchiolitis hospitalizations during each RSV season. A difference-in-difference model was used to determine if there was a significant change in the relative rate of RSV hospitalizations following the 2014 policy change.

RESULTS

There were 53,535 commercially insured and 85,099 Medicaid-insured qualifying preterm infants and 1,111,670 commercially insured and 1,492,943 Medicaid-insured qualifying term infants. Following the 2014 policy change, RSV-IP utilization decreased for all infants, while hospitalization rates tended to increase for preterm infants. Rate ratios comparing preterm to term infants also increased. The relative rate for RSV hospitalization for infants born at 29 to 34 wGA increased significantly for both commercially and Medicaid-insured infants (1.95, 95% CI: 1.67-2.27, p <0.001; 1.70, 95% CI: 1.55-1.86, p <0.001, respectively). Findings were similar for all-cause bronchiolitis hospitalizations.

CONCLUSION

We found that the previously identified increase in RSV hospitalization rates among infants born at 29 to 34 wGA persisted for at least 5 years following the policy change.

KEY POINTS

· Immunoprophylaxis rates decreased after the 2014 American Academy of Pediatrics guidelines update.. · Rate of RSV hospitalization increased among preterm infants after the 2014 AAP guidelines update.. · Increase in RSV hospitalization persisted for at least 5 years after AAP guidelines update..

Burden of Illness and Treatment Patterns in Second-line Large B-cell Lymphoma

PURPOSE

This study examined real-world treatment patterns with curative intent, adverse events, and health care resource utilization and costs in patients with relapsed or refractory large B-cell lymphoma (LBCL) to understand the unmet medical need in the United States.

METHODS

Adult patients with ≥2 LBCL diagnoses between January 1, 2012, and March 31, 2019, were identified (index date was the date of the earliest LBCL diagnosis) from MarketScan® Commercial and Medicare Supplemental Databases. Patients had ≥1 claim for any LBCL treatment, ≥6 months of data before (baseline) and ≥12 months of data after (follow-up period) the index date, and no baseline LBCL diagnosis. Treatment patterns, adverse events, and all-cause and LBCL-related health care resource utilization and costs were examined. All patients had received first-line therapy of cyclophosphamide, doxorubicin, vincristine, and prednisone with or without rituximab; etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin hydrochloride with or without rituximab; or regimens with anthracycline and second-line therapy with stem cell transplant (SCT)-intended intensive therapy or platinum-based chemotherapy. Patients who received an SCT-intended second-line regimen or received an SCT regardless of second-line regimen were considered SCT eligible.

FINDINGS

A total of 188 patients met the criteria of eligibility for SCT. Among the 119 patients who received a second-line regimen intended for SCT, only 22.7% received an SCT. Patients eligible for SCT started first-line therapy within 1 month of their LBCL index date, and the mean duration of first-line therapy was 4.1 months. The mean gap in therapy between first- and second-line therapy was 6.6 months, and the mean duration of second-line therapy was 3.0 months. During the second-line therapy treatment window (mean duration with SCT, 12.4 months; mean duration without SCT, 4.8 months), the most common regimens for patients eligible for SCT were ifosfamide, carboplatin, and etoposide with or without rituximab and gemcitabine and oxaliplatin with or without rituximab; the top 4 most common treatment-related adverse events were febrile neutropenia (56.4%), anemia (49.5%), thrombocytopenia (42.6%), and nausea and vomiting (36.2%), which were similar regardless of receipt of SCT; mean (SD) per-patient-per-month all-cause costs were $46,174 ($49,057) for patients with SCT and $45,780 ($52,813) for patients without SCT.

IMPLICATIONS

Treatment patterns among patients with relapsed or refractory LBCL eligible for SCT were highly varied. Only 22.7% of patients who received an SCT-preparative regimen ultimately received SCT, which highlights the magnitude of unmet needs in this population. The occurrence of treatment-related adverse events was similar regardless of SCT status. Per-patient-per-month all-cause costs were also similar with upfront SCT costs averaged during a longer follow-up.

Cost of cystectomy-related complications in patients with bladder cancer in the United States

Aims: To describe healthcare utilization and cost associated with the short-term and long-term complications of cystectomy among commercially insured bladder cancer patients in the United States.Materials and methods: This retrospective, observational cohort study evaluated adults with bladder cancer receiving a transurethral resection of bladder tumor followed by a partial or radical cystectomy procedure using U.S. administrative claims from the 2005-2015 IBM MarketScan Commercial and Medicare Supplemental databases. Bladder cancer patients were classified into two cohorts: partial cystectomy or radical cystectomy. Cystectomy complications were identified during the cystectomy admission, short-term period, and long-term period. Complication-related utilization and cost outcomes were reported in aggregate during the cystectomy admission and per patient per month (PPPM) during the short-term and long-term follow-up periods.Results: Of 5136 patients who received a cystectomy, 488 (9.5%) received partial cystectomy and 4648 (90.5%) received radical cystectomy. The mean (SD) costs of complications during the cystectomy admission were $11,728 ($43,380) for radical cystectomy and $4657 ($25,668) for partial cystectomy. In the short-term period, PPPM complication-related healthcare costs were $638 [$3793] for partial cystectomy and $2681 [$14,705] for radical cystectomy. In the long-term period, PPPM complication-related healthcare costs were $544 [$2580] for partial cystectomy and $1619 [$7874] for radical cystectomy.Conclusions: Cystectomy-related complications, especially with radical cystectomy, present a substantial financial burden to patients and payers immediately after surgery as well as in the long term. Targeted interventions which improve clinical outcomes but reduce substantial costs associated with cystectomy for bladder cancer are needed.

Characteristics and health care utilization of otherwise healthy commercially and Medicaid-insured preterm and full-term infants in the US

Purpose

This study examined health care utilization and costs during the first year of life for preterm and full-term infants in the US.

Subjects and methods

Preterm (<37 weeks gestational age [GA]) and full-term infants born 2003 to 2012 without complex medical conditions were identified in the MarketScan^® Commercial and Multi-State Medicaid claims databases using ICD-9-CM diagnosis and diagnosis-related grouping codes. Inpatient and outpatient claims from birth through the first year were analyzed for preterm and full-term subgroups. Results were stratified by payer.

Results

There were 1,692,935 commercially insured infants (12.5% preterm) and 1,873,324 Medicaid-insured infants (13.9% preterm). The majority (>75%) of preterm infants were admitted to the neonatal intensive care unit during their birth hospitalization. Generally, mean length of stay and costs for birth hospitalizations increased with decreasing GA. The average cost of a birth hospitalization was US $62,931 (SD $134,347) for commercially insured preterm infants and $43,858 (SD $115,412) for Medicaid-insured preterm infants compared to $2,401 (SD $7,399) and $1,894 (SD $5,444) for commercially insured and Medicaid-insured full-term infants, respectively. Post-neonatal hospitalization rates increased as GA decreased (in full-term to <29 weeks GA: commercial =3.3%–19.5%; Medicaid =6.1%–26.2%). Preterm infants had greater average numbers of outpatient office visits and pharmacy claims than full-term infants. Following birth discharge, mean monthly health care costs per infant increased as GA decreased (commercial = $334 to $3,126; Medicaid = $205 to $2,473).

Conclusion

During the first year of life, post-neonatal hospitalization rates, outpatient office visits, pharmacy claims, and monthly costs increased as GA decreased.

Respiratory Syncytial Virus Hospitalizations among U.S. Preterm Infants Compared with Term Infants Before and After the 2014 American Academy of Pediatrics Guidance on Immunoprophylaxis: 2012-2016

OBJECTIVE

The objective of this study was to compare risk for respiratory syncytial virus (RSV) hospitalizations (RSVH) for preterm infants 29 to 34 weeks gestational age (wGA) versus term infants before and after 2014 guidance changes for immunoprophylaxis (IP), using data from the 2012 to 2016 RSV seasons.

STUDY DESIGN

Using commercial and Medicaid claims databases, infants born between July 1, 2011 and June 30, 2016 were categorized as preterm or term. RSVH during the RSV season (November-March) were identified for infants aged <6 months and rate ratios (RRs) for hospitalization comparing preterm and term infants were calculated. Difference-in-difference models were fit to evaluate the changes in hospitalization risks in preterm versus term infants from 2012 to 2014 seasons to 2014 to 2016 seasons.

RESULTS

In all seasons, preterm infants had higher RSVH rates than term infants. Seasonal RRs prior to the guidance change for preterm wGA categories versus term infants ranged from 1.6 to 3.4. After the guidance change, the seasonal RRs ranged from 2.6 to 5.6. In 2014 to 2016, the risk associated with prematurity of 29 to 34 wGA versus term was significantly higher than in 2012 to 2014 (P<0.0001 for commercial and Medicaid samples).

CONCLUSION

In infants aged <6 months, the risk for RSVH for infants 29 to 34 wGA compared with term infants increased significantly after the RSV IP recommendations became more restrictive.

749. Healthcare Utilization After Hospitalization for Respiratory Syncytial Virus or Unspecified Bronchiolitis in the First Year of Life

Background

Respiratory syncytial virus (RSV) is the leading cause of infant hospitalizations and risk varies by gestational age (GA). Healthcare utilization following early hospitalizations caused by RSV (RSVH) or unspecified bronchiolitis (UBH) is not well understood. This study examined healthcare resource utilization (HRU) across GA categories within 12 months after an initial RSVH or UBH occurring in the first year of life.

Methods

Infants born July 1, 2009 to June 30, 2015 were identified in the MarketScan Commercial (COM) and Multistate Medicaid (MED) databases and assigned to GA categories using DRG and ICD codes and to an initial hospitalization cohort using inpatient claim diagnosis codes (RSVH, UBH without RSVH, or COMP [a comparator without RSVH or UBH]). Index dates (first admission dates for hospitalized infants) were assigned to COMP infants using times from birth to index dates among RSVH infants. HRU (hospitalizations, outpatient pharmacy fills, and visits for emergency department [ED], urgent care, wellness, other office or outpatient) excluded index hospitalizations and was assessed from 14 days post-index (or discharge if later) through 12 months post-index. Results were propensity score weighted to balance pre-index characteristics (age, sex, region, GA, birth hospitalization characteristics) across cohorts. Proportions were compared with chi-squared tests.

Results

Among all infants (all GA categories combined), the proportions of RSVH and UBH cohorts with follow-up hospitalizations or ED visits were greater (P < 0.05) than COMP (hospitalizations: COM +5.8%, +9.3%; MED +9.1%, +12.0%; ED visits: COM +15.8%, +16.2%; MED +14.4%, +17.1%). Follow-up hospitalizations in COM and MED and ED visits in COM declined with greater GA (Figures 1 and 2). HRU in other categories (fills, visits) was significantly (P < 0.05) greater among RSVH or UBH infants relative to COMP for nearly all GA categories in both COM and MED.

Conclusion

Infants hospitalized for RSV or UB in their first year of life had greater use of inpatient and outpatient resources in the 12 months following their initial hospitalizations compared with nonhospitalized infants. Inpatient care during follow-up was greatest among infants born at earlier GA.

Funded by AstraZeneca

Disclosures

J. Ledbetter, AstraZeneca: Speaker’s Bureau, Speaker honorarium. L. Brannman, AstraZeneca: Employee, Salary and Stocks. S. Wade, Wade Outcomes Research and Consulting: Employee, Salary. D. Diakun, Truven Health Analytics, an IBM Company: Employee, Salary. T. Gonzales, AstraZeneca: Employee, Salary and Stocks. A. Kong, Truven Health Analytics, an IBM Company: Employee, Salary.

The 2014-2015 National Impact of the 2014 American Academy of Pediatrics Guidance for Respiratory Syncytial Virus Immunoprophylaxis on Preterm Infants Born in the United States

OBJECTIVE

This article aims to compare respiratory syncytial virus (RSV) immunoprophylaxis (IP) use and RSV hospitalization rates (RSVH) in preterm and full-term infants without chronic lung disease of prematurity or congenital heart disease before and after the recommendation against RSV IP use in preterm infants born at 29 to 34 weeks' gestational age (wGA).

STUDY DESIGN

Infants in commercial and Medicaid claims databases were followed from birth through first year to assess RSV IP and RSVH, as a function of infant's age and wGA. RSV IP was based on pharmacy or outpatient medical claims for palivizumab. RSVH was based on inpatient medical claims with a diagnosis of RSV.

RESULTS

Commercial and Medicaid infants 29 to 34 wGA represented 2.9 to 3.5% of all births. RSV IP use in infants 29 to 34 wGA decreased 62 to 95% (p < 0.01) in the 2014-2015 season relative to the 2013-2014 season. Compared with the 2013-2014 season, RSVH increased by 2.7-fold (p = 0.02) and 1.4-fold (p = 0.03) for infants aged <3 months and 29 to 34 wGA in the 2014-2015 season with commercial and Medicaid insurance, respectively. In the 2014-2015 season, RSVH for infants 29 to 34 wGA were two to seven times higher than full-term infants without high-risk conditions.

CONCLUSION

Following the 2014 RSV IP guidance change, RSV IP use declined and RSVH increased among infants born at 29 to 34 wGA and aged <3 months.

The 2014-2015 National Impact of the 2014 American Academy of Pediatrics Guidance for Respiratory Syncytial Virus Immunoprophylaxis on Preterm Infants Born in the United States

OBJECTIVE

This article aims to compare respiratory syncytial virus (RSV) immunoprophylaxis (IP) use and RSV hospitalization rates (RSVH) in preterm and full-term infants without chronic lung disease of prematurity or congenital heart disease before and after the recommendation against RSV IP use in preterm infants born at 29 to 34 weeks' gestational age (wGA).

STUDY DESIGN

Infants in commercial and Medicaid claims databases were followed from birth through first year to assess RSV IP and RSVH, as a function of infant's age and wGA. RSV IP was based on pharmacy or outpatient medical claims for palivizumab. RSVH was based on inpatient medical claims with a diagnosis of RSV.

RESULTS

Commercial and Medicaid infants 29 to 34 wGA represented 2.9 to 3.5% of all births. RSV IP use in infants 29 to 34 wGA decreased 62 to 95% (p < 0.01) in the 2014-2015 season relative to the 2013-2014 season. Compared with the 2013-2014 season, RSVH increased by 2.7-fold (p = 0.02) and 1.4-fold (p = 0.03) for infants aged <3 months and 29 to 34 wGA in the 2014-2015 season with commercial and Medicaid insurance, respectively. In the 2014-2015 season, RSVH for infants 29 to 34 wGA were two to seven times higher than full-term infants without high-risk conditions.

CONCLUSION

Following the 2014 RSV IP guidance change, RSV IP use declined and RSVH increased among infants born at 29 to 34 wGA and aged <3 months.

Association of cinacalcet adherence and costs in patients on dialysis

OBJECTIVE

In addition to negative impacts on clinical effectiveness in treating secondary hyperparathyroidism, low adherence to cinacalcet may have negative impacts on healthcare costs. This study assessed the relationship between medication adherence and healthcare costs among US patients on dialysis given cinacalcet to manage secondary hyperparathyroidism.

METHODS

Retrospective cohort study of patients who were receiving dialysis with an initial cinacalcet prescription between January 2004 and April 2010 and who survived ≥12 months. Longitudinal, integrated medical, and pharmacy claims data from the MarketScan? database were used to calculate medication possession ratios (MPR) over 12 months and to examine the association of adherence with inpatient, outpatient, emergency room, outpatient medication, and total costs while controlling for patient characteristics, co-morbid medical conditions, and concomitant medication MPR in a multivariate regression model. Patients were dichotomized as adherent (<180 days refill gap) or non-adherent (≥180 day refill gap). Adherent patients were further dichotomized as low adherent (<0.8 MPR) and high adherent (≥0.8 MPR).

RESULTS

The final study cohort included 4923 patients. After 12 months, 46% were non-adherent, 27% were low adherent, and 28% were high adherent. Greater cinacalcet adherence was associated with significantly lower inpatient costs with cost-savings of a greater magnitude than the increased medication costs.

CONCLUSIONS

This study demonstrated that low adherence to cinacalcet, which may be associated with undesirable clinical and health-economic outcomes, is common. Despite limitations inherent in retrospective studies of claims databases, such as unobserved confounding, non-discrimination between prescription fill and actual use, and not knowing the reasons for non-adherence, these results suggest that inpatient cost savings of $8899, more than offset higher medication costs of $5858 associated with increased cinacalcet adherence.