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.

Association Between Glucocorticoid Exposure and Healthcare Expenditures for Potential Glucocorticoid-related Adverse Events in Patients with Rheumatoid Arthritis

OBJECTIVE

Oral glucocorticoid (OGC) use for rheumatoid arthritis (RA) is debated because of the adverse event (AE) profile of OGC. We evaluated the associations between cumulative doses of OGC and potential OGC-related AE, and quantified the associated healthcare expenditures.

METHODS

Using the MarketScan databases, patients ≥ 18 years old who have RA with continuous enrollment from January 1 to December 31, 2012 (baseline), and from January 1 to December 31, 2013 (evaluation period), were identified. Cumulative OGC dose was measured using prescription claims during the baseline period. Potential OGC-related AE (osteoporosis, fracture, aseptic necrosis of the bone, type 2 diabetes, ulcer/gastrointestinal bleeding, cataract, hospitalization for opportunistic infection, myocardial infarction, or stroke) and AE-related expenditures (2013 US$) were gathered during the evaluation period. Multivariable regression models were fitted to estimate OR of AE and incremental costs for patients with AE.

RESULTS

There were 84,357 patients analyzed, of whom 48% used OGC during the baseline period and 26% had an AE during the evaluation period. A cumulative OGC dose > 1800 mg was associated with an increased risk of any AE compared with no OGC exposure (OR 1.19, 99.65% CI 1.09-1.30). Incremental costs per patient with any AE were significantly greater for cumulative OGC dose > 1800 mg compared with no OGC exposure (incremental cost = $3528, 99.65% CI $2402-$4793).

CONCLUSION

Chronic exposure to low to medium doses of OGC was associated with significantly increased risk of potential OGC-related AE in patients with RA, and greater cumulative OGC dose was associated with substantially higher AE-related healthcare expenditures among patients with AE.

Economic impact of longer battery life of cardiac resynchronization therapy defibrillators in Sweden

OBJECTIVE

The objective of this study was to quantify the impact that longer battery life of cardiac resynchronization therapy defibrillator (CRT-D) devices has on reducing the number of device replacements and associated costs of these replacements from a Swedish health care system perspective.

METHODS

An economic model based on real-world published data was developed to estimate cost savings and avoided device replacements for CRT-Ds with longer battery life compared with devices with industry-standard battery life expectancy. Base-case comparisons were performed among CRT-Ds of three manufacturers - Boston Scientific Corporation, St. Jude Medical, and Medtronic - over a 6-year time horizon, as per the available clinical data. As a sensitivity analysis, we evaluated CRT-Ds as well as single-chamber implantable cardioverter defibrillator (ICD-VR) and dual-chamber implantable cardioverter defibrillator (ICD-DR) devices over a longer 10-year period. All costs were in 2015 Swedish Krona (SEK) discounted at 3% per annum.

RESULTS

Base-case analysis results show that up to 603 replacements and up to SEK 60.4 million cumulative-associated costs could be avoided over 6 years by using devices with extended battery life. The pattern of savings over time suggests that savings are modest initially but increase rapidly beginning in the third year of follow-up with each year's cumulative savings two to three times the previous year. Evaluating CRT-D, ICD-VR, and ICD-DR devices together over a longer 10-year period, the sensitivity analysis showed 2,820 fewer replacement procedures and associated cost savings of SEK 249.3 million for all defibrillators with extended battery life.

CONCLUSION

Extended battery life is likely to reduce device replacements and associated complications and costs, which may result in important cost savings and a more efficient use of health care resources as well as a better quality of life for heart failure patients in Sweden.

Intermediate Services After Behavioral Health Hospitalization: Effect on Rehospitalization and Emergency Department Visits

OBJECTIVE

This study examined the effect of intermediate service use on behavioral health inpatient readmissions and subsequent emergency department (ED) visits among Medicaid enrollees.

METHODS

Data were from fee-for-service inpatient admissions from the 2008 Medicaid Analytic eXtract files for adults with a primary diagnosis of a mental or substance use disorder. A multivariate survival analysis estimated the association between posthospital services-particularly intermediate services (residential, partial hospital, intensive outpatient, and other rehabilitative services)-and time to readmission or ED visit. A propensity score-matched sample was used to examine the relationship between time to readmission and ED visit in the nondisabled and disabled populations more closely.

RESULTS

The sample included 32,037 adults (nondisabled, 27.6%; disabled, 72.4%). Only 2.5% of nondisabled adults and 5.4% of disabled adults used intermediate services within seven days of hospital discharge. In the multivariate analysis, significant associations were found between intermediate service use and readmissions and ED visits in the nondisabled population (hazard ratio [HR]=.71, p=.04, and HR=.68, p<.01, respectively), but not in the disabled population. Significant associations were also found between use of other health care in the seven-day posthospitalization period and decreased time to readmission and ED visits in the nondisabled population and increased time to readmission and ED visits in the disabled population. In the propensity score--matched analysis, use of intermediate services was not significant in either population.

CONCLUSIONS

The low use of intermediate services may reflect limited availability as well as Medicaid coverage limits. Research is needed to determine the optimal number and type of intermediate services for this population to minimize the need for additional hospital services.

Cost-effectiveness of edoxaban versus rivaroxaban for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF) in the US

BACKGROUND

Understanding the value of new anticoagulation therapies compared with existing therapies is of paramount importance in today's cost-conscious and efficiency-driven health care environment. Edoxaban and rivaroxaban for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with CHADS2 scores ≥2 have been evaluated in pivotal trials versus warfarin. The relative value of edoxaban versus rivaroxaban would be of interest to health care stakeholders and patients who prefer a once-daily treatment option for long-term stroke prevention in NVAF.

OBJECTIVE

To evaluate the relative cost-effectiveness of two once-daily regimens of novel oral anticoagulation therapy - edoxaban (60 mg/30 mg dose-reduced) versus rivaroxaban (20 mg/15 mg dose-reduced) - for stroke prevention in NVAF patients from a US health-plan perspective.

MATERIALS AND METHODS

A Markov model simulated lifetime risk and treatment of stroke, systemic embolism, major bleeding, clinically relevant nonmajor bleeding, myocardial infarction, and death in NVAF patients treated with edoxaban or rivaroxaban. Efficacy and safety data were derived from a network meta-analysis that utilized data from patients enrolled in ENGAGE AF-TIMI 48 and ROCKET-AF. Health care cost and utility data were obtained from published sources. Incremental cost-effectiveness ratios of $150,000 per quality-adjusted life year (QALY) gained were used as thresholds for "highly cost-effective", "cost-effective", and "not cost-effective" treatment options, respectively, as per American Heart Association/American College of Cardiology guidelines.

RESULTS

Edoxaban was dominant relative to rivaroxaban, such that it was associated with lower total health care costs and better effectiveness in terms of QALYs in the base-case analysis. Results were supported by probabilistic sensitivity analyses that showed edoxaban as either dominant or a highly cost-effective alternative (incremental cost-effectiveness ratio <$50,000) to rivaroxaban in 88.4% of 10,000 simulations.

CONCLUSION

Results of this study showed that the once-daily edoxaban (60 mg/30 mg dose-reduced) regimen is a cost-saving or highly cost-effective treatment relative to rivaroxaban (20 mg/15 mg dose-reduced) for stroke prevention in NVAF patients with CHADS2 ≥2.

The Clinical and Economic Benefits of Co-Testing Versus Primary HPV Testing for Cervical Cancer Screening: A Modeling Analysis

Background: Consensus United States cervical cancer screening guidelines recommend use of combination Pap plus human papillomavirus (HPV) testing for women aged 30 to 65 years. An HPV test was approved by the Food and Drug Administration in 2014 for primary cervical cancer screening in women age 25 years and older. Here, we present the results of clinical-economic comparisons of Pap plus HPV mRNA testing including genotyping for HPV 16/18 (co-testing) versus DNA-based primary HPV testing with HPV 16/18 genotyping and reflex cytology (HPV primary) for cervical cancer screening.

Methods: A health state transition (Markov) model with 1-year cycling was developed using epidemiologic, clinical, and economic data from healthcare databases and published literature. A hypothetical cohort of one million women receiving triennial cervical cancer screening was simulated from ages 30 to 70 years. Screening strategies compared HPV primary to co-testing. Outcomes included total and incremental differences in costs, invasive cervical cancer (ICC) cases, ICC deaths, number of colposcopies, and quality-adjusted life years for cost-effectiveness calculations. Comprehensive sensitivity analyses were performed.

Results: In a simulation cohort of one million 30-year-old women modeled up to age 70 years, the model predicted that screening with HPV primary testing instead of co-testing could lead to as many as 2,141 more ICC cases and 2,041 more ICC deaths. In the simulation, co-testing demonstrated a greater number of lifetime quality-adjusted life years (22,334) and yielded $39.0 million in savings compared with HPV primary, thereby conferring greater effectiveness at lower cost.

Conclusions: Model results demonstrate that co-testing has the potential to provide improved clinical and economic outcomes when compared with HPV primary. While actual cost and outcome data are evaluated, these findings are relevant to U.S. healthcare payers and women's health policy advocates seeking cost-effective cervical cancer screening technologies.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Abstract 104: Cost-Effectiveness of Edoxaban vs. Rivaroxaban for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation (NVAF) in the US

Background: Edoxaban and rivaroxaban for stroke prevention in non-valvular atrial fibrillation (NVAF) patients with CHADS 2 ≥2 have been evaluated in pivotal trials versus warfarin. This study assessed the cost-effectiveness of once-daily edoxaban (60 mg/30 mg dose-reduced) regimen versus rivaroxaban (20 mg/15 mg dose-reduced) for stroke prevention in patients with NVAF patients from a US health plan perspective.

Methods: A Markov model simulated lifetime risk and treatment of stroke, systemic embolism, major bleeding, clinically relevant non-major bleeding, myocardial infarction, and death in NVAF patients treated with edoxaban or rivaroxaban. Efficacy and safety data were from a network meta-analysis using data from patients enrolled in ENGAGE AF-TIMI 48 and ROCKET-AF that were presented previously. 2015 wholesale acquisition cost (WAC) was used for edoxaban and rivaroxaban in the analysis. Healthcare cost and utility data were from published sources. Incremental cost-effectiveness ratios of <$50,000, $50,000-$150,000, and >$150,000 per quality-adjusted life year (QALY) gained were used as thresholds for highly cost-effective, cost-effective, and not cost-effective treatment option per guidance from the AHA/ACC statement on cost/value methodology in clinical practice guidelines and performance measures.

Results: Edoxaban was dominant relative to rivaroxaban, such that it was associated with lower total healthcare cost and better effectiveness in terms of QALYs in the base case analysis (Table). Results were supported by probabilistic sensitivity analyses that showed edoxaban as either dominant or a highly cost-effective alternative (ICER<$50,000) to rivaroxaban 88.4% of the time.

Conclusions: These results showed that once-daily edoxaban (60mg/30mg dose-reduced) regimen is a highly cost-effective treatment relative to rivaroxaban (20mg/15mg dose-reduced) for stroke prevention in NVAF patients.

Comparison of direct and indirect costs of abnormal uterine bleeding treatment with global endometrial ablation and hysterectomy

Aim: The objective was to compare abnormal uterine bleeding (AUB) direct healthcare costs and indirect work absence or short-term disability costs associated with treatment with second-generation global endometrial ablation (GEA) or hysterectomy. Methods: Women aged 30–55 years with AUB who underwent GEA or hysterectomy during 2006–2010 were identified in the Truven Health MarketScan ® Commercial and Health and Productivity Management databases. Results & conclusion: Two-thirds (66.3%) of the 61,602 study patients underwent GEA compared with hysterectomy (33.7%). Hysterectomy patients had higher treatment costs (US$12,147 vs 5837; p < 0.001), higher annual absenteeism costs (US$7543 vs 5621; p < 0.001), were four-times more likely to have a short-term disability claim (84 vs 21%; p < 0.001) and had higher per-patient short-term disability costs (US$5744 vs 1361; p < 0.001). Overall hysterectomy costs were approximately twice those of GEA.

Economic burden associated with adverse events in patients with metastatic melanoma

BACKGROUND

There are currently many approved agents for the treatment of metastatic melanoma (MM), the most aggressive form of skin cancer. Treatments may include systemic therapies such as ipilimumab, dacarbazine, temozolomide, high-dose interleukin 2, interferon α, dacarbazine- or temozolomide-based combination chemotherapy/biochemotherapy, paclitaxel, paclitaxel/cisplatin, and paclitaxel/carboplatin, as well as the targeted therapies vemurafenib, dabrafenib, and trametinib for patients with BRAF V600 mutation. However, all treatment options are associated with different adverse events (AEs) and, in some instances, considerable toxicity. The occurrence of such treatment-related AEs can lead to higher health care resource utilization and increasing treatment and patient management costs. An understanding of the economic burden of these AEs will therefore enable better management of health care expenditures, not just for existing therapies, but also for new and novel treatments in development.

OBJECTIVE

To estimate the incremental health care costs of specific AEs among patients with MM treated with paclitaxel, vemurafenib, ipilimumab, dacarbazine, temozolomide, high-dose interleukin 2, or interferon α, along with AEs known to be associated with dabrafenib and trametinib.

METHODS

This cohort study employed a retrospective administrative claims-based analysis of MarketScan commercial and Medicare supplemental databases from July 1, 2004, to April 30, 2012. Patients included those aged ≥ 18 years who had diagnosed melanoma (ICD-9-CM code 172.xx)with ≥ 1 diagnosis of metastasis and ≥ 1 claim for any of the 7 study treatments. Health care encounters for AEs of interest were based on ICD-9-CM diagnosis/procedure codes. Incremental cost per AE was determined by comparing the 30-day expenditures in patients with the event to patients without the event based on a shadow event date. Multivariate generalized linear models (GLMs) with a log-link function and gamma distribution were utilized to control for baseline differences between groups.

RESULTS

A total of 2,621 patients with MM were included. Mean age was 56.0 years (SD ± 13.0); 64% were male; and 24% had a diagnosis of primary or secondary brain cancer at the time of MM diagnosis. GLM-based estimate of 30-day incremental costs by AE category were metabolic, $9,135 (95% CI = $6,404-$12,392); hematologic/lymphatic, $8,450 (95% CI = $6,528-$10,633); cardiovascular, $6,476 (95% CI = $4,667-$8,541); gastrointestinal, $6,338 (95% CI = $4,740-$8,122); skin/subcutaneous, -$900 (95% CI = -$1,899-$237); central nervous system/psychiatric, $5,903 (95% CI = $3,842-$8,313); and pain, $5,078 (95% CI = $3,392-$7,012).

CONCLUSIONS

Incremental costs associated with many MM treatment-related AEs are substantial. New approaches to prevent and/or better manage these events may reduce overall health care costs.

Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

OBJECTIVES

Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives.

METHODS

A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy.

RESULTS

Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy.

CONCLUSION

Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Retrospective database analysis of clinical outcomes and costs for treatment of abnormal uterine bleeding among women enrolled in US Medicaid programs

Background

Women with abnormal uterine bleeding (AUB) may be treated surgically with hysterectomy or global endometrial ablation (GEA), an outpatient procedure. We compared the costs and clinical outcomes of these surgical procedures for AUB among women in Medicaid programs.

Methods

The Truven Health MarketScan^® Medicaid Multi-State Database was used to identify Medicaid women aged 30–55 years with AUB who newly initiated GEA or hysterectomy (index event) during 2006–2010. Patients were required to have 12 months of continuous enrollment pre-index and post-index. Baseline characteristics were assessed in the pre-index period; health care utilization and costs (2011 USD), treatment complications, and reinterventions were assessed in the post-index period.

Results

Of 1,880 women who met the study criteria (mean age 40.7 years), 53.4% were Caucasian, 33.1% were African-American, and 2.3% were Hispanic; many (42.8%) received their Medicaid eligibility due to disability. Similar proportions received GEA (50.9%) or hysterectomy (49.1%). At baseline, both groups also had similar Deyo-Charlson Comorbidity scores (0.65), and use of antibiotics (69.4%), nonsteroidal anti-inflammatory drugs (56.3%), and oral contraceptives (5.3%). More hysterectomy patients than GEA patients had a treatment-related complication (52% versus 36%, respectively, P<0.001). Initial treatment costs were higher for hysterectomy ($11,270) than for GEA ($3,958, P<0.001); monthly gynecology-related costs in the remainder of the year were not significantly different for hysterectomy ($63) and GEA ($16, P=0.11).

Conclusion

Hysterectomy was nearly three times more costly than GEA for initial treatment of AUB, and associated with more treatment-related complications. These results may be informative in the context of new federal mandates for Medicaid expansion, which are likely to focus on cost savings through use of outpatient treatments such as GEA.

Factors affecting appropriateness of hospital use in Massachusetts

To determine the extent of inappropriate hospital use, and to investigate factors related to variations in appropriateness, 8,031 hospital records of patients discharged from 41 hospitals in 3 Massachusetts professional standards review organization (PSRO) areas were reviewed in 1973 and 1978. The Appropriateness Evaluation Protocol (AEP) was used for the reviews and logistic regression analysis was used to analyze factors associated with inappropriate use. Based on the results, the authors conclude that utilization review should focus on: longer stays among surgical patients and shorter stays among medical patients; (projected) last third of the stay; and on diagnoses or diagnosis-related groups in which there is less clinical consensus on treatment method. For maximum effectiveness, utilization review must include incentives beyond simple monitoring (e.g., financial incentives).