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Bayani DB, Lin YC, Nagarajan C, Ooi MG, Tso ACY, Cairns J, Wee HL. Modeling First-Line Daratumumab Use for Newly Diagnosed, Transplant-Ineligible, Multiple Myeloma: A Cost-Effectiveness and Risk Analysis for Healthcare Payers. PHARMACOECONOMICS - OPEN 2024; 8:651-664. [PMID: 38900407 PMCID: PMC11362436 DOI: 10.1007/s41669-024-00503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to assess the cost-effectiveness of two regimens regarded as the standard of care for the treatment of newly diagnosed, transplant-ineligible multiple myeloma in Singapore: (1) daratumumab, lenalidomide, and dexamethasone and (2) bortezomib, lenalidomide, and dexamethasone. Additionally, it aimed to explore potential strategies to manage decision uncertainty and mitigate financial risk. METHODS A cost-effectiveness analysis from the healthcare system perspective was conducted using a partitioned survival model to estimate lifetime costs and quality-adjusted life years (QALYs) associated with daratumumab-based treatment and the bortezomib-based regimen. The analysis used data from the MAIA and SWOG S0777 trials and incorporated local real-world data where available. Sensitivity analyses were performed to evaluate the robustness of the findings, and a risk analysis was conducted to analyze various payer strategies in terms of their payer strategy and uncertainty burden (P-SUB), which account for the decision uncertainty and the additional cost of choosing a suboptimal intervention. RESULTS The incremental cost-effectiveness ratio (ICER) for daratumumab, lenalidomide, and dexamethasone (DRd) compared with bortezomib, lenalidomide, and dexamethasone (VRd) was US $90,364 per QALY gained. The results were sensitive to variations in survival for DRd, postprogression treatment costs, cost of hospice care, and hazard ratio for progression-free survival. The scenarios explored indicated that structural assumptions, such as the time horizon of the analysis, significantly influenced the results due to uncertainties arising from immature trial data and treatment efficacy over time. Among the various payer strategies compared, an upfront price discount for daratumumab emerged as the best approach with the lowest P-SUB at US $14,708. CONCLUSION In conclusion, this study finds that daratumumab as a first-line treatment for myeloma exceeds the cost-effectiveness threshold considered in this evaluation. An upfront price reduction is the recommended strategy to manage uncertainties and mitigate financial risks. These findings highlight the importance of targeted payer strategies to address specific types and sources of uncertainty.
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Affiliation(s)
- Diana Beatriz Bayani
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, Singapore, 117549, Republic of Singapore.
| | - Yihao Clement Lin
- Department of Hematology, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Melissa G Ooi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | | | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, Department of Pharmacy, National University of Singapore, Singapore, Singapore
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Bayani DB, Lin YC, Ooi MG, Tso ACY, Wee HL. Real-world utilization and healthcare costs for multiple myeloma: A retrospective analysis of patients in Singapore. EJHAEM 2023; 4:1013-1018. [PMID: 38024607 PMCID: PMC10660121 DOI: 10.1002/jha2.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 12/01/2023]
Abstract
Multiple myeloma, a hematological malignancy, imposes a significant financial burden on healthcare systems. Health technology assessments (HTA) and economic evaluations play vital roles in reimbursement decisions and cost containment. This study aimed to explore healthcare utilization patterns and costs among myeloma patients in Singapore through a retrospective analysis of 605 patients treated at two cancer centers. Data encompassing demographics, treatment utilization, and billing were extracted from electronic records, and a cost analysis was performed from the perspective of the Singapore healthcare system. The results revealed common usage of immunomodulatory agents (52%) and proteasome inhibitors (37%), with bortezomib being the most frequently used targeted treatment. Treatment costs increased with disease progression, displaying variations depending on the therapeutic agent used. Notably, hospitalization costs due to adverse events were substantial, with pneumonia as the leading cause. This study highlights the high cost of myeloma therapy in Singapore, posing a financial burden for households. Findings may inform economic evaluations, evidence generation, reimbursement, and subsidy decisions. Leveraging real-world data from electronic records provides valuable insights into local healthcare utilization patterns. Future studies may explore integrating billing databases with clinical repositories for a more comprehensive analysis, and consider limitations such as incomplete clinical information and potential selection bias.
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Affiliation(s)
| | | | - Melissa G. Ooi
- Department of Haematology‐OncologyNational University Cancer InstituteSingapore
| | | | - Hwee Lin Wee
- Saw Swee Hock School of Public HealthNational University of SingaporeSingapore
- Department of PharmacyNational University of SingaporeSingapore
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Choon-Quinones M, Hose D, Kaló Z, Zelei T, Harousseau JL, Durie B, Keown P, Barnett M, Jakab I. Patient and Caregiver Experience Decision Factors in Treatment Decision Making: Results of a Systematic Literature Review of Multiple Myeloma Decision Aids. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:39-49. [PMID: 35613958 DOI: 10.1016/j.jval.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/18/2022] [Accepted: 04/08/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Decision-aids (DAs) may facilitate shared decision-making for patients and caregivers, by providing evidence-based information to assist healthcare professionals, patients, and caregivers in making choices about aspects of care, and/or highlighting decision factors to discuss with the potential of altering the treatment decision. These decision factors may not be well integrated in DAs. METHODS A systematic literature review was conducted in the field of multiple myeloma (MM) on peer-reviewed publications, extended with a gray literature search. Data on whether and how patient and caregiver experience elements, other than survival and physical quality of life, were mentioned as decision factors in the identified MM DAs were extracted and analyzed qualitatively. RESULTS Seventy MM DAs were found and analyzed; 51% of DAs mentioned any patient non-routinely assessed experience decision factors and only 17% mentioned any caregiver-related information. One hundred and forty potential decision factors were extracted, deduplicated and categorized into the following categories: 1) financial, 2) mode of administration / transportation issues, 3) personal beliefs and values, 4) emotional and social quality of life, 5) other medical information, 6) availability of social support, 7) caregiver burden. None of the DAs presented a comprehensive framework on all seven categories of decision factors being consider when mapping patient and caregiver experience value elements in MM. CONCLUSIONS Based on available DAs, we recommend a set of patient and caregiver experience decision factors that have the potential to affect treatment choices of patients with MM, which should be included in DAs, including MM clinical guidelines.
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Affiliation(s)
| | - Dirk Hose
- Vrije Universiteit Brussel, Brussels, Belgium
| | - Zoltán Kaló
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary; Syreon Research Institute, Budapest, Hungary
| | - Tamás Zelei
- Syreon Research Institute, Budapest, Hungary
| | | | - Brian Durie
- International Myeloma Foundation, Studio City, CA, USA
| | - Paul Keown
- University of British Columbia, Vancouver, BC, Canada
| | - Mike Barnett
- University of British Columbia, Vancouver, BC, Canada
| | - Ivett Jakab
- Syreon Research Institute, Budapest, Hungary
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Wong XY, Chng WJ, Aziz MIA, Ng K. Cost-effectiveness of daratumumab in combination with lenalidomide and dexamethasone for relapsed and/or refractory multiple myeloma. Expert Rev Pharmacoecon Outcomes Res 2021; 22:207-215. [PMID: 34904498 DOI: 10.1080/14737167.2022.2017285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study evaluates the cost-effectiveness of daratumumab (D) in combination with lenalidomide and dexamethasone (Rd) for treatment of relapsed and/or refractory multiple myeloma in patients who have received at least one prior therapy in Singapore. METHODS A 3-state partitioned survival model was developed to evaluate the cost-effectiveness of lenalidomide and dexamethasone with or without daratumumab from a healthcare system perspective over 10 years. Clinical inputs were obtained from the POLLUX trial. Health state utilities were derived from the literature and direct medical costs obtained from public healthcare institutions. Sensitivity and scenario analyses were conducted to explore uncertainties. RESULTS DRd was associated with a high base-case incremental cost-effectiveness ratio (ICER) of US$576,247 per quality-adjusted life year (QALY) gained, compared with Rd. According to one-way sensitivity analysis, ICER was most heavily influenced by time horizon, discount rate for outcomes, progression-free utility and cost of daratumumab. Regardless of the variation, DRd remained not cost-effective. Even when the cost of both daratumumab and lenalidomide dropped by 20% and 80%, the ICERs remained high at US$470,400 and US$152,860 per QALY gained. CONCLUSIONS At current prices, the addition of daratumumab to lenalidomide and dexamethasone does not represent cost-effective use of healthcare resources in Singapore.
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Affiliation(s)
- Xin Yi Wong
- Agency for Care Effectiveness, Ministry of Health, Singapore
| | - Wee Joo Chng
- Division of Haematology, Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, National University of Singapore (NUS), Singapore.,Yong Loo Lin School of Medicine, NUS, Singapore
| | | | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore
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Wang C, Soekojo CY, de Mel S, Ooi M, Chen Y, Goh AZK, Nagarajan C, Chng WJ. Natural History and Prognostic Factors at First Relapse in Multiple Myeloma. Cancers (Basel) 2020; 12:cancers12071759. [PMID: 32630644 PMCID: PMC7409309 DOI: 10.3390/cancers12071759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
The prognosis of multiple myeloma has considerably improved due to the introduction of novel agents in the upfront setting. However, the great majority of patients ultimately relapse, and choosing a salvage treatment at first relapse remains challenging. The natural history of first relapsed disease in the current era is also not well described. We retrospectively studied 300 patients with first relapsed myeloma seen between 2004 and 2019 from two institutes in Singapore. The median duration from diagnosis to first relapse was 22.7 months (1.1–97.0 months). Most patients received novel agent-based induction therapy, and 41.3% underwent autologous stem cell transplant. A very good partial response (VGPR) or better was achieved in 48.6%. Regarding first relapse, 50.5% were symptomatic and 19.0% received newer agent-containing regimens. Nearly a third of patients (31.7%) had a VGPR or better response. The median progression free and overall survival from first relapse was 12.0 and 44.8 months, respectively. Based on a randomized sample splitting, we first identified non-hyperdiploid karyotype at diagnosis, clinical relapse, and treatment sequence as impacting survival independently from a testing cohort, and we then further demonstrated their significance in a validation cohort. This study provides a real-world picture of first relapsed myeloma and highlights the prognostic importance of the treatment sequence.
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Affiliation(s)
- Chen Wang
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore 119074, Singapore; (C.W.); (C.Y.S.); (S.d.M.); (M.O.)
| | - Cinnie Yentia Soekojo
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore 119074, Singapore; (C.W.); (C.Y.S.); (S.d.M.); (M.O.)
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore 119074, Singapore; (C.W.); (C.Y.S.); (S.d.M.); (M.O.)
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore 119074, Singapore; (C.W.); (C.Y.S.); (S.d.M.); (M.O.)
| | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore 169608, Singapore; (Y.C.); (A.Z.K.G.); (C.N.)
| | - Allan Zhi Kai Goh
- Department of Haematology, Singapore General Hospital, Singapore 169608, Singapore; (Y.C.); (A.Z.K.G.); (C.N.)
| | - Chandramouli Nagarajan
- Department of Haematology, Singapore General Hospital, Singapore 169608, Singapore; (Y.C.); (A.Z.K.G.); (C.N.)
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore 119074, Singapore; (C.W.); (C.Y.S.); (S.d.M.); (M.O.)
- Department of Medicine, Yong Loo Lin School of Medicine and National University of Singapore, Singapore 119228, Singapore
- Cancer Science Institute of Singapore and National University of Singapore, Singapore 117599, Singapore
- Correspondence: ; Tel.: +65-6772-4612
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Linecker M, Krones T, Berg T, Niemann CU, Steadman RH, Dutkowski P, Clavien PA, Busuttil RW, Truog RD, Petrowsky H. Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits. J Hepatol 2018; 68:798-813. [PMID: 29133246 DOI: 10.1016/j.jhep.2017.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Tanja Krones
- Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Thomas Berg
- Division of Hepatology, University of Leipzig, Germany
| | - Claus U Niemann
- Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA
| | - Randolph H Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Philipp Dutkowski
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
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