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Li M, Cai B, Mauldin P, Lu ZK. Medical costs and associated racial/ethnic and sex disparities in erythropoiesis-stimulating agent use: anemia management under the Medicare reimbursement policy. J Manag Care Spec Pharm 2021; 27:1142-1152. [PMID: 34337992 PMCID: PMC10391219 DOI: 10.18553/jmcp.2021.27.8.1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Before 2007, erythropoiesis-stimulating agents (ESAs) were the highest-expenditure drug in the Medicare system. In 2007, CMS issued a reimbursement policy change for ESAs used by cancer patients. However, empirical evidence is currently lacking to evaluate medical costs after the policy change, especially by sex and racial/ethnic groups. OBJECTIVE: To examine the impact of the Medicare reimbursement policy change and associated racial/ethnic and sex disparities on medical costs for cancer patients who were new users of ESAs. METHODS: This study was an exploratory retrospective treatment effectiveness study, which used SEER-Medicare linked data. A difference-in-difference design was used that incorporated a control group of patients with chronic kidney disease. A generalized linear model, with a log link and a gamma distribution, was used to examine medical costs. RESULTS: The Medicare reimbursement policy change was statistically significantly associated with an 11% (95% CI = 2%-20%) reduction in anemia-related costs, including a 10% (95% CI = 1%-19%) reduction in Medicare payment and an 18% (95% CI = 10%-26%) reduction in patient cost sharing. For total medical costs, the policy change was statistically significantly associated with a 12% (95% CI = 6%-18%) reduction, including an 11% (95% CI = 5%-18%) reduction in Medicare payment and a 14% (95% CI = 7%-20%) reduction in patient cost sharing. Medical costs were reduced in patients who were male and those who were White but remained the same for patients who were female and those who were Black, Hispanic, and other races or ethnicities. CONCLUSIONS: Anemia-related and total medical costs associated with ESAs used by cancer patients with chemotherapy-induced anemia were reduced after the Medicare reimbursement policy change. However, the policy change was only effective for patients who were male and those who were White. The policy change had no effect on patients who were female and those of racial/ethnic minorities. DISCLOSURES: This study was funded by the SPARC Research Grant. The funder had no role in any part of this study. This study used the linked SEER-Medicare database. The interpretation and reporting of the data are the sole responsibility of the authors. The authors have nothing to disclose.
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Affiliation(s)
- Minghui Li
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis
| | - Bo Cai
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia
| | - Patrick Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Z Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia
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Vega A, Zhang R, Wong HL, Wernecke M, Alexander M, Feng Y, Lo AC, Lufkin B, Ryan Q, Izem R, MaCurdy TE, Kelman JA, Graham DJ. Trends in Erythropoiesis-stimulating agent use and blood transfusions for chemotherapy-induced anemia throughout FDA's risk evaluation and mitigation strategy lifecycle. Pharmacoepidemiol Drug Saf 2021; 30:626-635. [PMID: 33534188 DOI: 10.1002/pds.5202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/28/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Erythropoiesis-stimulating agents (ESAs), indicated for treating some patients with chemotherapy-induced anemia (CIA), may increase the risk of tumor progression and mortality. FDA required a Risk Evaluation and Mitigation Strategy (REMS) to mitigate these risks. We assessed REMS impact on ESA administration and red blood cell (RBC) transfusion as surrogate metrics for REMS effectiveness. METHODS Retrospective cohort study including data from January 1, 2006 to December 31, 2018 for beneficiaries ≥65 years enrolled in Centers for Medicare & Medicaid Services (CMS) Medicare Parts A/B with a cancer diagnosis; patients with other indications for ESA use were excluded. Study time was divided into five periods demarcated by issuance of CMS National Coverage Determination (NCD) (Pre-NCD, Pre-REMS) and REMS milestones (Grace Period, REMS, post-REMS). Study outcomes were monthly proportion of chemotherapy episodes (CTEs) with concomitant ESA administration, with post-CTE ESA administration, and with RBC transfusions. RESULTS Of 1 778 855 beneficiaries treated with CT, 308742 received concomitant ESA for CIA. The proportion of CTEs with concomitant and post-CTE ESA administration decreased Pre-REMS (9.0 percentage points [pp] and 3.5 pp, respectively). There were no significant post-REMS changes in the proportion of CTEs with concomitant (0.0 pp) and post-CTE ESA administration (0.1 pp). Fluctuation in RBC transfusions was <4 pp throughout the study period. CONCLUSIONS Medicare beneficiaries showed a substantive decrease in ESA administration after NCD, with minimal impact by the REMS and its removal. Small changes in RBC transfusion over the study period were likely due to a national secular trend.
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Affiliation(s)
- Amarilys Vega
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rongmei Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Hui-Lee Wong
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Yuhui Feng
- Acumen, LLC, Burlingame, California, USA
| | - An-Chi Lo
- Acumen, LLC, Burlingame, California, USA
| | | | - Qin Ryan
- Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rima Izem
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Thomas E MaCurdy
- Acumen, LLC, Burlingame, California, USA.,Department of Economics, Stanford University, Stanford, California, USA
| | - Jeffrey A Kelman
- Centers for Medicare & Medicaid Services, Washington, District of Columbia, USA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Li M, Schulz R, Chisholm-Burns M, Wang J, Lu ZK. Racial/ethnic and gender disparities in the use of erythropoiesis-stimulating agents and blood transfusions: cancer management under Medicare's reimbursement policy. J Manag Care Spec Pharm 2020; 26:1477-1486. [PMID: 33119441 PMCID: PMC10390950 DOI: 10.18553/jmcp.2020.26.11.1477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Because of increasing safety concerns related to erythropoiesisstimulating agents (ESAs), the Centers for Medicare & Medicaid Services issued a Medicare reimbursement policy change regarding these medications in cancer patients. However, the policy established an absolute hemoglobin or hematocrit threshold to qualify for reasonable use but did not take the effect of gender and racial/ethnic differences in hemoglobin levels into consideration. OBJECTIVE: To examine disparities in the use of ESAs and blood transfusions after the Medicare policy change. METHODS: This study was an exploratory treatment effectiveness study and used the SEER-Medicare linked database. The treatment group was composed of cancer patients, whereas the control group was composed of chronic kidney disease patients. An interrupted time series design was used to examine the effect of the Medicare policy change on the use of ESAs and blood transfusions in different gender and racial/ethnic groups. RESULTS: The Medicare reimbursement policy change had an immediate effect on reducing the use of ESAs by 50% and increasing the use of blood transfusions by 10%. The immediate effect of the policy change on the monthly utilization of ESAs was 2 times greater in females (60% reduction) than males (30% reduction). Females had a 10% immediate increase in the monthly utilization of blood transfusions after the policy change. The policy change had the same immediate effect of a 50% reduction on the use of ESAs for Whites, African Americans/Blacks, and Latinos. African Americans/Blacks had a 50% immediate increase in the monthly utilization of blood transfusions after the policy change. CONCLUSIONS: Gender and racial/ethnic disparities were associated with the Medicare reimbursement policy change in the use of ESAs and blood transfusions. Thus, future policy considerations should keep biologic differences across gender and racial/ethnic groups in mind. DISCLOSURES: This study was funded by the SPARC Research Grant. The funder had no role in any part of this study. The authors have nothing to disclose.
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Affiliation(s)
- Minghui Li
- University of Tennessee Health Science Center College of Pharmacy, Memphis
| | - Richard Schulz
- University of South Carolina College of Pharmacy, Columbia
| | | | - Junling Wang
- University of Tennessee Health Science Center College of Pharmacy, Memphis
| | - Z. Kevin Lu
- University of South Carolina College of Pharmacy, Columbia
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Thavarajah S, Choi MJ. The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and Cancer: A Clinical Approach. Am J Kidney Dis 2019; 74:667-674. [DOI: 10.1053/j.ajkd.2019.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/18/2019] [Indexed: 01/13/2023]
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5
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Cannavale K, Xu H, Xu L, Sattayapiwat O, Rodriguez R, Bohac C, Page J, Chao C. Epidemiology of Chemotherapy-Induced Anemia in Patients with Non-Hodgkin Lymphoma. Perm J 2019; 23:18-252. [PMID: 31314738 DOI: 10.7812/tpp/18-252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Anemia is a common adverse effect of myelosuppressive chemotherapy, and the development of chemotherapy-induced anemia (CIA) is more common in patients with hematologic malignant tumors. OBJECTIVE To assess the incidence and treatment pattern of CIA in patients diagnosed with non-Hodgkin lymphoma (NHL) from a large managed care organization in California. METHODS Patients diagnosed with NHL between 2010 and 2012 were studied to provide an updated picture of CIA in current hematology-oncology practice. Trends in anemia treatment patterns were examined from 2000 to 2013. All data were collected from Kaiser Permanente Southern California electronic health records. RESULTS Of 699 chemotherapy-treated patients with NHL diagnosed between 2010 and 2012, 36.9% and 11.6% developed moderate (hemoglobin < 10 g/dL) and severe (hemoglobin < 8 g/dL) CIA during chemotherapy, respectively. Proportions of moderate CIA events treated with erythropoiesis-stimulating agents (ESAs) decreased from 2000 to 2013: 34% in phase 1 (January 1, 2000, to December 31, 2006), 22% in phase 2 (January 1, 2007, to March 24, 2010), and 6% in phase 3 (March 25, 2010, to June 30, 2013). An increasing trend of red blood cell transfusion was observed: 12% in phase 1, 22% in phase 2, and 27% in phase 3. Similar calendar trends were observed for management of severe CIA events. DISCUSSION In contrast to previous European reports, we note a higher incidence of CIA in patients with NHL in this US community practice setting. CONCLUSION Moderate to severe CIA is common in patients with NHL receiving chemotherapy. Multiple ESA-related policy changes occurred from 2000 to 2013. A large proportion of CIA episodes were currently not treated with ESA, and transfusions have become more common. Further studies are needed to determine associations between CIA symptom burden and CIA treatment as they relate to patient outcomes and quality of life.
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Affiliation(s)
| | - Hairong Xu
- Atara Biotherapeutics, Thousand Oaks, CA
| | - Lanfang Xu
- Medhealth Statistical Consulting Inc, Solon, Ohio
| | | | | | - Chet Bohac
- Immune Design Corporation, San Francisco, CA
| | | | - Chun Chao
- Department of Research and Evaluation, Pasadena, CA
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6
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Gawade PL, Berlin JA, Henry DH, Tomita D, Brooks BD, Franklin J, Bradbury BD, Critchlow CW. Changes in the use of erythropoiesis-stimulating agents (ESAs) and red blood cell transfusion in patients with cancer amidst regulatory and reimbursement changes. Pharmacoepidemiol Drug Saf 2017; 26:1357-1366. [DOI: 10.1002/pds.4293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 06/13/2017] [Accepted: 07/23/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Prasad L. Gawade
- Center for Observational Research; Amgen Inc.; Thousand Oaks CA USA
| | | | - David H. Henry
- Department of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Dianne Tomita
- Global Biostatistical Science; Amgen Inc.; Thousand Oaks CA USA
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On-label and off-label prescribing patterns of erythropoiesis-stimulating agents in inpatient hospital settings in the US during the period of major regulatory changes. Res Social Adm Pharm 2016; 13:778-788. [PMID: 27595426 DOI: 10.1016/j.sapharm.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND A number of policy and labeling interventions aimed at reducing inappropriate prescribing of erythropoiesis-stimulating agents (ESAs) were implemented in the U.S. between 2006 and 2010. These interventions included the addition of an FDA Black Box Warning to ESA labeling, the implementation of a Risk Evaluation and Mitigation Strategy program, and the adoption of payment restrictions by the Centers for Medicare and Medicaid Services (CMS). The impact of these safety interventions on different types of ESA prescribing (on-label, off-label; evidence-based, not evidence-based) has not been investigated in a single study. OBJECTIVES The objective of this study was to explore the prescribing patterns of ESAs for on- and off-label indications in the U.S. hospital inpatients during the period of major policy and labeling changes. METHODS A retrospective analysis of ESAs utilization patterns was conducted using Cerner Health Facts® database from January 1, 2005 to June 30, 2011. The study population consisted of adult patients admitted to hospitals during the study period who received at least one ESAs order. Indications for ESA use were assigned based on ICD-9 CM diagnosis codes, procedure codes, and medication records. ESA use was then classified based on FDA-approval and the strength of scientific evidence supporting its use. Indication categories included (1) on-label use (ONS); (2) off-label use, supported (OFS); and (3) off-label use, unsupported (OFU). Descriptive statistics were used to examine ESA use by patient, hospital, and physician characteristics and over time. RESULTS ESAs were most frequently prescribed for ONS (48.7%), followed by OFU (42.7%) and OFS indications (8.6%). Of all off-label use, 83.2% were for unsupported indications. Between 2005 and 2010, the percent of inpatient visits with ESA use decreased for supported indications, both on-label (-63.2%) and off-label (-78.2%), but increased for unsupported indications (80%). OFU use surpassed ONS use as the most common type of ESA use in 2009. CONCLUSIONS Total and ONS ESA use decreased markedly, while OFU ESA use continued to increase during the period of major policy and labeling changes.
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Douros A, Jobski K, Kollhorst B, Schink T, Garbe E. Risk of venous thromboembolism in cancer patients treated with epoetins or blood transfusions. Br J Clin Pharmacol 2016; 82:839-48. [PMID: 27206325 DOI: 10.1111/bcp.13019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/11/2016] [Accepted: 05/14/2016] [Indexed: 11/29/2022] Open
Abstract
AIMS Anaemia is common in cancer patients, with treatments including epoetins and blood transfusions. Although an increased risk of venous thromboembolism (VTE) has been associated with both therapeutics, studies comparing the risk of VTE between epoetins and transfusions in cancer patients are lacking. METHODS A nested case-control study investigated this risk using the German Pharmacoepidemiological Research Database. Cohort members were incident cancer patients receiving first time treatment with epoetin or transfusion. A subcohort including only patients receiving chemotherapy was created, since the formally approved indication of epoetins is chemotherapy-induced anaemia. Cases were defined as patients developing VTE. For each case up to 10 gender- and age-matched controls were selected from the cohort. Multiple confounder adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for VTE and recent treatment with epoetins or transfusions (last 28 days before index date) compared with past anti-anaemic treatment were calculated by conditional logistic regression. RESULTS Among 69 888 patients receiving first time treatment with epoetin or transfusion, 3316 VTE cases were identified. The aOR for VTE was 1.31 (95% CI 1.03, 1.65) for epoetins, 2.33 (95% CI 2.03, 2.66) for transfusions, and 2.24 (95% CI 1.34, 3.77) for epoetins and transfusions. Sensitivity analyses with a stricter VTE definition or an expanded time window yielded similar results. In the chemotherapy only subcohort the risk difference between epoetins and transfusions could not be verified (aOR 1.48, 95% CI 1.10, 1.98 vs. aOR 1.80, 95% CI 1.49, 2.19). Our study confirmed known VTE risk factors including previous VTE (aOR 14.76, 95% CI 12.79, 17.03) or surgery (aOR 1.83, 95% CI 1.67, 2.01). Epoetin-associated risk decreased after a safety warning by the European Medicines Agency setting maximum haemoglobin target values to 12 g dl(-1) . CONCLUSIONS Transfusions could be associated with a higher VTE risk than epoetins in cancer patients. Moreover, current prescribing patterns may have decreased the VTE risk for epoetins.
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Affiliation(s)
- Antonios Douros
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany.,Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Jobski
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Bianca Kollhorst
- Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Tania Schink
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Edeltraut Garbe
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany.,Core Scientific Area 'Health Sciences' at the University of Bremen, Bremen, Germany
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9
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Xu L, Xu H, Cannavale K, Sattayapiwat O, Rodriguez R, Page JH, Chao C. Trends in anemia treatment among patients with five non-myeloid malignancies treated with chemotherapy in a large integrated health care delivery system in California, 2000–2013. Support Care Cancer 2016; 24:2989-98. [DOI: 10.1007/s00520-016-3078-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/03/2016] [Indexed: 11/30/2022]
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10
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Gross I, Trentino KM, Andreescu A, Pierson R, Maietta RA, Farmer S. Impact of a Patient Blood Management Program and an Outpatient Anemia Management Protocol on Red Cell Transfusions in Oncology Inpatients and Outpatients. Oncologist 2016; 21:327-32. [PMID: 26865590 DOI: 10.1634/theoncologist.2015-0406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/28/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patient blood management (PBM) programs are associated with reduced transfusion usage, reduced hospital costs, and improved patient outcomes. The application of PBM principles in patients with malignant disease might achieve similar results. However, this population presents unique challenges. The aim of the present study was to investigate the impact of a PBM program on blood usage and patient outcomes in cancer patients, particularly in the setting of restricted use of erythropoiesis-stimulating agents (ESAs). MATERIALS AND METHODS A retrospective observational study was performed of patients admitted with a primary diagnosis of malignancy treated at Eastern Maine Medical Center as inpatients or outpatients, or both, from January 2008 through July 2013. RESULTS The proportion of inpatients and outpatients receiving ESAs decreased from 2.9% in 2008 to 1.1% in 2013 (p < .001). During the same period, an increase occurred in the mean dose of intravenous (IV) iron from 447 mg (95% confidence interval [CI], 337-556) to 588 mg (95% CI, 458-718). The mean red blood cell (RBC) units transfused per inpatient and outpatient episode decreased from 0.067 to 0.038 unit (p < .001). In inpatients, significant increases occurred in the proportion of single-unit RBC transfusions (p < .001) and patients infused with IV iron (p = .02), and significant decreases in the mean pretransfusion hemoglobin (p = .02) and RBC transfusion rate (p = .04). In-hospital mortality and length of stay did not change significantly during this period. CONCLUSION Despite the decreased use of ESA therapy, the implementation of a PBM program and outpatient anemia management protocol in cancer patients at our medical center was associated with significant reductions in RBC usage.
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Affiliation(s)
- Irwin Gross
- Eastern Maine Medical Center, Bangor, Maine, USA Accumen LLC, San Diego, California, USA
| | - Kevin M Trentino
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia, Australia
| | | | | | | | - Shannon Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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Hollingsworth K, Romney MC, Crawford A, McAna J. The Impact of the Risk Evaluation Mitigation Strategy for Erythropoiesis-Stimulating Agents on Their Use and the Incidence of Stroke in Medicare Subjects with Chemotherapy-Induced Anemia with Lung and/or Breast Cancers. Popul Health Manag 2016; 19:63-9. [DOI: 10.1089/pop.2015.0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - John McAna
- Thomas Jefferson University, Philadelphia, Pennsylvania
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12
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Butler AM, Kshirsagar AV, Olshan AF, Nielsen ME, Wheeler SB, Brookhart MA. Trends in Anemia Management in Hemodialysis Patients with Cancer. Am J Nephrol 2015; 42:206-15. [PMID: 26439712 DOI: 10.1159/000440771] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs), intravenous iron, and blood transfusion are used to treat anemia in both end-stage renal disease (ESRD) and cancer. However, anemia treatment patterns have not been described among ESRD patients undergoing hemodialysis with concurrent cancer, especially in the recent era of ESA-related safety concerns. METHODS We analyzed Medicare data from a cohort of hemodialysis patients diagnosed with incident cancer. We used multivariable generalized linear models to estimate trends and patterns in ESA use, iron use, transfusion use, epoetin alfa (EPO) dose, iron dose, and resulting hemoglobin levels (2000-2011). RESULTS Of 43,760 eligible patients, quarterly ESA use declined slightly from a peak of 94.1 to 90.0%. Quarterly EPO dose increased from 2000 to 2004, then declined; quarterly hemoglobin levels followed a similar pattern. Iron use increased rapidly from 46.9 to 79.3%. Iron dose increased until 2010 and then declined. There was an increase in the quarterly transfusion use (6.3-11.7%) and in the mean number of transfusion days per year (1.4-1.8). Anemia treatment patterns varied by demographic/clinical subgroups, especially among patients receiving chemotherapy, who required higher ESA use, EPO dose, and frequency of transfusions. CONCLUSIONS Despite safety concerns about ESAs in both the ESRD and cancer populations, the proportion of hemodialysis patients with cancer who used ESAs between 2000 and 2011 remained extremely high. EPO dose and hemoglobin levels increased and then decreased. Iron use, iron dose, and transfusions increased substantially. Future research examining the risk-benefit profile of different anemia management strategies in the dialysis population with cancer is needed.
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Affiliation(s)
- Anne M Butler
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, N.C., USA
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13
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Hendrick F, Davidoff AJ, Zeidan AM, Gore SD, Baer MR. Effect of erythropoiesis-stimulating agent policy decisions on off-label use in myelodysplastic syndromes. MEDICARE & MEDICAID RESEARCH REVIEW 2014; 4:mmrr2014-004-04-a02. [PMID: 25485173 PMCID: PMC4254334 DOI: 10.5600/mmrr.004.04.a02] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are widely used to treat anemia associated with myelodysplastic syndromes (MDS) as an off-label indication. In early 2007, the U.S. Food and Drug Administration (FDA) released safety alerts and mandated label changes, and the Centers for Medicare & Medicaid Services (CMS) implemented a National Coverage Determination (NCD) in August 2007, dramatically restricting ESA coverage based on specific clinical parameters in non-MDS patients. We sought to determine the effect on ESA use in MDS, examining both treatment initiation and concordance with guidelines designed to target patients most likely to benefit from therapy. METHODS We determined receipt of ESA within 6 months of diagnosis. For ESA recipients, we operationalized three National Comprehensive Cancer Network guidelines: serum erythropoietin determination before ESA initiation, transfusion-independent at ESA initiation, and initial ESA treatment episode of >= 8 weeks. Logistic regression models tested the effect of time (half-year increments pre-post the August '07 CMS NCD implementation), controlling for demographics and health status. RESULTS 17,491 (61.1%) of 28,627 beneficiaries with MDS received ESAs. ESA use increased prior to the reference period (Jan.-July 2007), but declined beginning in August 2007, the date of NCD implementation (marginal probability =-0.05, p-value<0.01). Concordance with treatment guidelines changed during the observation period, with increased rates of serum erythropoietin levels, but declined in the other two guidelines. CONCLUSION These results suggest a mixed pattern of change in the face of the FDA safety warnings and CMS NCD in MDS and highlight the importance of monitoring for unintended consequences of policy changes.
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Affiliation(s)
- Franklin Hendrick
- University of Maryland School of Pharmacy—Pharmaceutical Health Services Research
| | | | | | | | - Maria R. Baer
- University of Maryland, School of Medicine—Greenebaum Cancer Center
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14
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Xu H, Kaye JA, Saltus CW, Crawford J, Gasal E, Goodnough LT. Blood utilization and hemoglobin levels in cancer patients after label and coverage changes for erythropoiesis-stimulating agents. Expert Rev Hematol 2014; 7:617-33. [DOI: 10.1586/17474086.2014.943730] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Hershman DL, Neugut AI, Shim JJ, Glied S, Tsai WY, Wright JD. Erythropoiesis-stimulating agent use after changes in medicare reimbursement policies. J Oncol Pract 2014; 10:264-9. [PMID: 24737875 DOI: 10.1200/jop.2013.001255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Since 2004, concerns about the safety of erythropoiesis-stimulating agents (ESAs) have resulted in label changes and restrictions on their use. We examined changes in ESA use and blood transfusions over time. METHODS The SEER-Medicare database was used to identify patients age ≥ 65 years with breast, lung, prostate, ovary, or colon cancer, diagnosed between 2000 and 2007, who had a chemotherapy claim after their cancer diagnosis. We calculated the mean number of ESA claims per patient per year. Follow-up claims were available through 2008. We used multivariable logistic regression models to analyze the association of ESA use and extended ESA use with clinical and demographic variables. RESULTS Among 121,169 patients identified, 46,063 (38%) received an ESA. ESA use increased from 12.4% to 16.2% by 2006 and then decreased to 7.9% by 2008. Similarly, the mean number of ESA claims per patient decreased steadily over the entire timeframe. The annual percentage of patients undergoing transfusion remained relatively constant (9% to 10%). In a Cox proportional hazards time-dependent model, ESA use was positively associated with black race (odds ratio [OR], 1.11; 95% CI, 1.07 to 1.15), metropolitan location (OR, 1.17; 95% CI, 1.13 to 1.21), metastatic disease (OR, 1.39; 95% CI, 1.35 to 1.41), female sex (OR, 1.17; 95% CI, 1.14 to 1.20), > one comorbidity (OR, 1.29; 95% CI, 1.25 to 1.32), and tumor type. The number of denied claims increased over time. CONCLUSION Our study demonstrated a rapid decline in the percentage of patients treated with ESAs after changes to reimbursement policy, but not after warnings about use. Reimbursement restrictions of other overused or off-label drugs may help reduce health care expenditures.
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Affiliation(s)
- Dawn L Hershman
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
| | - Alfred I Neugut
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
| | - Jin Joo Shim
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
| | - Sherry Glied
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
| | - Wei-Yann Tsai
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY
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Gilreath JA, Stenehjem DD, Rodgers GM. Diagnosis and treatment of cancer-related anemia. Am J Hematol 2014; 89:203-12. [PMID: 24532336 DOI: 10.1002/ajh.23628] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 10/25/2013] [Accepted: 10/31/2013] [Indexed: 01/04/2023]
Abstract
Cancer-related anemia (CRA) is due to multiple etiologies, including chemotherapy-induced myelosuppression, blood loss, functional iron deficiency, erythropoietin deficiency due to renal disease, marrow involvement with tumor as well as other factors. The most common treatment options for CRA include iron therapy, erythropoietic-stimulating agents (ESAs), and red cell transfusion. Safety concerns as well as restrictions and reimbursement issues surrounding ESA therapy for CRA have resulted in suboptimal treatment. Similarly, many clinicians are not familiar or comfortable using intravenous iron products to treat functional iron deficiency associated with CRA. This article summarizes our approach to treating CRA and discusses commonly encountered clinical scenarios for which current clinical guidelines do not apply.
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Affiliation(s)
- Jeffrey A. Gilreath
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
| | - David D. Stenehjem
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pharmacotherapy; Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah; Salt Lake City Utah
| | - George M. Rodgers
- Department of Medicine; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pathology; University of Utah Hospitals and Clinics; Salt Lake City Utah
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Hill JW, Shreay S, McGarvey N, De AP, Hess GP, Corey-Lisle PK. Synchronization of administrations of chemotherapy and erythropoiesis-stimulating agents and frequency of associated healthcare visits. Support Care Cancer 2013; 21:2957-65. [DOI: 10.1007/s00520-013-1830-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 04/21/2013] [Indexed: 12/01/2022]
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Goodnough LT, Shander A. Update on erythropoiesis-stimulating agents. Best Pract Res Clin Anaesthesiol 2013; 27:121-9. [DOI: 10.1016/j.bpa.2012.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 11/07/2012] [Indexed: 12/21/2022]
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Tunceli O, Bailey RA, Stephenson JJ, Singer J. Propensity score matched assessment of treatment patterns and cost of erythropoiesis stimulating agent treatment in patients with cancer receiving myelosuppressive chemotherapy. J Oncol Pharm Pract 2012; 19:305-14. [PMID: 23235918 DOI: 10.1177/1078155212466123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine epoetin alfa (EPO) and darbepoetin alfa (DARB) treatment patterns and erythropoiesis stimulating agent (ESA) costs in patients with cancer receiving chemotherapy (CRC), and to compare the results observed in the pre-matched total study population (TSP) with a propensity score matched population (PSMP). METHODS A medical claims analysis was conducted from 1 January 2004 through 31 July 2009 using the HealthCore Integrated Research Database. Patients were at least 18 years old, newly initiated on EPO or DARB, received ≥ 2 ESA doses, and had ≥ 1 claim for cancer and chemotherapy proximate to ESA treatment. Patients were matched using propensity scores. January 2010 Wholesale Acquisition Cost was used to calculate drug cost. Mean cumulative ESA dose and drug costs were evaluated in the TSP and PSMP. RESULTS 4921 EPO and 9173 DARB patients with CRC were identified. In the TSP, mean cumulative ESA doses were EPO: 398,770 units and DARB: 1508 mcg, with similar treatment durations for each. Mean cumulative drug costs were EPO: $6041 and DARB: $7861 (30% higher for DARB). The cumulative dose ratio (EPO units: DARB mcg) was 264:1. The PSMP analysis identified 4831 ESA treated CRC patients in each group. Mean drug costs were EPO: $6055 and DARB: $7863 (30% higher for DARB). The observed dose ratio (EPO units: DARB mcg) was 265:1. CONCLUSION In both analyses, the costs of DARB were higher, even after accounting for baseline differences in the PSMP. Similar trends in dose ratios were also observed in both groups.
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Goodnough LT, Shander A. Current status of pharmacologic therapies in patient blood management. Anesth Analg 2012; 116:15-34. [PMID: 23223098 DOI: 10.1213/ane.0b013e318273f4ae] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.
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Affiliation(s)
- Lawrence Tim Goodnough
- Pathology Department, Stanford University, 300 Pasteur Drive Room H-1402, M/C 5626 Stanford, CA 94305, USA.
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Arneson TJ, Li S, Gilbertson DT, Bridges KR, Acquavella JF, Collins AJ. Impact of Centers for Medicare & Medicaid Services national coverage determination on erythropoiesis-stimulating agent and transfusion use in chemotherapy-treated cancer patients. Pharmacoepidemiol Drug Saf 2012; 21:857-64. [DOI: 10.1002/pds.3257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 01/31/2012] [Accepted: 02/15/2012] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas J. Arneson
- Chronic Disease Research Group; Minneapolis Medical Research Foundation; Minneapolis; MN; USA
| | - Shuling Li
- Chronic Disease Research Group; Minneapolis Medical Research Foundation; Minneapolis; MN; USA
| | - David T. Gilbertson
- Chronic Disease Research Group; Minneapolis Medical Research Foundation; Minneapolis; MN; USA
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Trends in anemia management in lung and colon cancer patients in the US Department of Veterans Affairs, 2002–2008. Support Care Cancer 2011; 20:1649-57. [DOI: 10.1007/s00520-011-1255-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 08/09/2011] [Indexed: 10/17/2022]
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Wright JD, Neugut AI, Wilde ET, Buono DL, Malin J, Tsai WY, Hershman DL. Physician characteristics and variability of erythropoiesis-stimulating agent use among Medicare patients with cancer. J Clin Oncol 2011; 29:3408-18. [PMID: 21810679 DOI: 10.1200/jco.2010.34.5462] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Drugs are usually approved for a specific indication on the basis of randomized trials. However, once approved, these treatments are often used differently than as tested in trials. We performed an analysis to determine the patterns of use of erythropoiesis-stimulating agents (ESAs). METHODS We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients age 65 years or older with breast, lung, or colon cancer diagnosed between 1995 and 2005 who had one ESA and chemotherapy claim. Associations of patient, tumor, and physician-related factors with receipt of ESAs were analyzed. RESULTS Of 21,091 patients analyzed, 5,099 (24.2%) received ESAs for 1 week or less (misuse), and 1,601 (7.6%) received ESAs for more than 14 weeks (prolonged use). Receipt of ESAs while not actively receiving chemotherapy (off label) occurred in 2,876 patients (13.6%). In a multivariable analysis, ESA misuse was associated with MD degree, female sex of physician, and earlier year of medical school graduation. Private practice physicians (odds ratio [OR], 0.78; 95% CI, 0.72 to 0.84) and high-volume physicians (OR, 0.78; 95% CI, 0.72 to 0.85) were less likely to use 1 week or less of ESA treatment. Treatment by high-volume oncologists (OR, 1.33; 95% CI, 1.14 to 1.55) and by oncologists who graduated from US medical schools (OR, 1.26; 95% CI, 1.12 to 1.42) predicted prolonged-duration ESA use, whereas female oncologists (OR, 0.79; 95% CI, 0.68 to 0.93) were less likely to prescribe prolonged ESA treatment. Private practice physicians (OR, 1.18; 95% CI, 1.02 to 1.38) and high-volume providers (OR, 1.58; 95% CI, 1.33 to 1.87) were more likely to prescribe more than 24 weeks of ESA treatment. CONCLUSION Our study demonstrated widespread variability in the use of ESAs. Physician characteristics exerted substantial influence on ESA use. Policies to discourage inappropriate use of cancer therapies are needed.
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