Cost Efficiency Analysis for Spasticity Management Based on Physician Botulinum Toxin Prescribing Habits

OBJECTIVE

To estimate differences in botulinum toxin type A (BoNT-A) treatment costs per patient for spasticity-injecting physicians, with a focus on physicians' use of alternative BoNT-A agents other than onabotulinumtoxinA.

DESIGN

Retrospective cohort study.

SETTING

National Medicare data for fee-for-service beneficiaries in 2017.

PARTICIPANTS

A total of 116 physicians, 6829 BoNT-A procedures, and 3051 patients were included in this analysis. Most physicians were physiatrists (84%) and used only onabotulinumtoxinA (82%).

INTERVENTIONS

Type of BoNT-A selected by physicians was the independent variable of interest. Included physicians were separated into 2 groups: (1) onabotulinumtoxinA only injectors and (2) abobotulinumtoxinA and/or incobotulinumtoxinA injectors (may still use onabotulinumtoxinA).

MAIN OUTCOME MEASURE

Average cost per patient per year.

RESULTS

The total average BoNT-A cost per patient per year was significantly less for physicians who used abobotulinumtoxinA and/or incobotulinumtoxinA vs those who used only onabotulinumtoxinA ($3684 vs $4739; P=.01). Patients' average annual out-of-pocket costs also reflected a similar difference ($855 vs $1082; P=.02) between the groups. Doses used and numbers of injections per patient per year were not significantly different between groups.

CONCLUSIONS

The present analysis demonstrated lower cost per patient for both the payer and patient when physicians used types of BoNT-A other than onabotulinumtoxinA for spasticity. Nevertheless, most physicians in this spasticity-focused study used exclusively onabotulinumtoxinA, the most expensive BoNT-A available. Reasons for this are complex and include history on the market and approved indications beyond those associated with spasticity. However, future research should continue to identify such issues with a goal of finding solutions to improve cost inefficiencies.

Real-World Six-Year National Cost-Minimization Analysis of IncobotulinumtoxinA and OnabotulinumtoxinA in the VA/DoD Healthcare Systems

Purpose

This study sought to perform a real-world, long-term cost-minimization analysis for incobotulinumtoxinA (Xeomin^®) versus onabotulinumtoxinA (Botox^®), given the established non-inferiority when utilized at similar doses.

Methods

The Department of Veterans Affairs (VA) and Department of Defense (DoD) national healthcare systems were included in this analysis. Real-world purchase data for incobotulinumtoxinA were used to estimate the direct drug costs between calendar years 2014 and 2019. Publicly available federal pharmaceutical prices (Federal Supply Schedule and Big 4) were used. The primary outcome was the difference in total direct costs nationally for incobotulinumtoxinA (real-world) versus having hypothetically utilized onabotulinumtoxinA (projected) for similar utilization. Sites utilizing ≥100 vials (of 100 Unit equivalents) of incobotulinumtoxinA annually were categorized as “major adopters”. IncobotulinumtoxinA 50 Unit vials were assumed to be an alternative to a 100 Unit vial of onabotulinumtoxinA for 50% of such vial purchases in the base case scenario to account for differences in wastage.

Results

Over the six-year study time frame, 156 sites (76.8%) utilized incobotulinumtoxinA of the 203 total VA healthcare systems and DoD medical centers. Of these sites, 67 were major adopters for at least one year, with a mean of 3.4 years spent as a major adopter over the study period. Average annual savings per major adopter was $105,782. IncobotulinumtoxinA costs for all VA/DoD sites was $46.39 million for the six-year period versus a projected $71.92 million onabotulinumtoxinA cost—a total savings of $25.53 million (35.5% relative reduction). Approximately, 82.8% of savings stemmed from lower drug acquisition cost ($21.14 million) and 17.2% of savings ($4.39 million) was related to reduced wastage. It was estimated that a total of 9958 extra onabotulinumtoxinA 100 Unit vials would have been wasted during the six-year period, translating to the need for a 5.9% increase in vial purchases versus incobotulinumtoxinA.

Conclusion

Meaningful cost savings were realized related to incobotulinumtoxinA adoption over a long-term time frame in the VA/DoD healthcare systems.

Exploring the Psychosocial Impact of Botulinum Toxin Type A Injections for Individuals With Oromandibular Dystonia: A Qualitative Study of Patients' Experiences

Purpose The purpose of this study was to explore the psychosocial impact of botulinum toxin (BoNT) injections for oromandibular dystonia (OMD) and to gain a better understanding of how participants judge the success of this treatment. Method Eight individuals with OMD and dysarthria participated in one face-to-face, semistructured interview. Interviews were audio-recorded and transcribed verbatim. Qualitative, phenomenological methods of coding, immersion, and emergence were used in the analysis of interview data. Results Two major themes and six subthemes emerged from the analysis of interview data. The first theme, Botox has changed me and my experiences, explored the participants' perspective of receiving BoNT injections and its psychosocial impact. The second theme, What communication is like for me, explored the psychosocial impact of BoNT on speech production and participation. Conclusions Our results suggest that BoNT has a variable impact on domains related to quality of life, satisfaction with treatment, speech production, and communicative participation. This study adds novel information related to the psychosocial consequences of BoNT treatment in the management of OMD and builds on a literature that studies the consequences and experiences of living with OMD.

Comparison of botulinum toxins for treatment of movement disorders: real-world utilization and cost analysis in a national Medicare population

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) is the single largest payer for health care in the United States and the largest payer by spending globally. Medicare Part B, with more than 50 million beneficiaries, currently has no broad mechanisms in place for promoting cost-effective care of injectable drugs. OBJECTIVE: To conduct a real-world utilization and cost analysis comparing botulinum toxins in movement disorders. METHODS: The 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier dataset from CMS was used for this claims level analysis. Neurologists, ophthalmologists, or physiatrists who injected predominantly for movement disorders (defined as blepharospasm, cervical dystonia, sialorrhea, and/or spasticity) were included along with their patients. Botulinum toxins with FDA indications spanning these 3 specialties were included. RESULTS: A total of 891 physicians (406 ophthalmologists, 338 neurologists, and 147 physiatrists) along with their 29,954 botulinum toxin (27,441 onabotulinumtoxinA and 2,513 incobotulinumtoxinA) patients were included in the analysis. The average total drug cost per patient per year (PPPY) was significantly lower for incobotulinumtoxinA versus onabotulinumtoxinA ($2,099 vs. $3,115; P < 0.001), for an average savings of 32.6%. Annual average out-of-pocket costs were also significantly less expensive for incobotulinumtoxinA versus onabotulinumtoxinA ($486 vs. $719; P < 0.001), for an average savings of 32.4%. Across 74,346 total injection visits, there was no significant difference in dosing between the agents, with an average dosing ratio of 0.94 incobotulinumtoxinA to 1.0 onabotulinumtoxinA. Injections PPPY were 2.42 for onabotulinumtoxinA and 2.29 for incobotulinumtoxinA. Average reported wastage was 64% higher for onabotulinumtoxinA than it was for incobotulinumtoxinA. A budget impact analysis estimated that increasing incobotulinumtoxinA use in the movement disorder space to attain an overall 20% botulinum toxin market share would save Medicare $32.9 million over a 3-year period versus current use. CONCLUSIONS: IncobotulinumtoxinA was shown to be a less costly alternative than onabotulinumtoxinA with similar dosing in real-world practice in this large national Medicare population. Policies to increase use of agents that promote cost-effective evidence-based care should be further explored and implemented for this fundamental federal payer. DISCLOSURES: This research received no external funding. Kazerooni was an employee of Merz Pharmaceuticals at the time of the analysis. Watanabe received no compensation or funding for this research project. Watanabe is a member of the National Academies of Sciences, Engineering, and Medicine Forum on Drug, Discovery, Development, and Translation. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the U.S. government or the National Academies of Sciences, Engineering.

A Nurse-Led Clinic Model for the Treatment of Cervical Dystonia Using Botulinum Toxin

Dystonia is a neurological movement disorder characterised by sustained or intermittent muscle contractions, producing abnormal and often repetitive movements, abnormal posture or both. It is often accompanied by chronic pain, depression and anxiety. The treatment of dystonia is primarily symptomatic, designed to improve posture and function and to relieve associated pain. This can include oral medications, botulinum toxin (BoNT) injection, and deep brain stimulation (DBS). This article will focus on BoNT treatment, which is just one facet in the treatment of cervical dystonia. The involvement of clinical nurse specialists and the use of a nurse-led clinic can increase efficiency and effectiveness (namely, increased clinic efficiency and capacity, reduced appointment waiting times, and improved continuity of care for the patients), as well as patient access, education, psychosocial support, monitoring and, ultimately, empowerment. This article will discuss the key elements, considerations and benefits of setting up a nurse-led clinic for patients with dystonia.

Economic evaluation of AbobotulinumtoxinA vs OnabotulinumtoxinA in real-life clinical management of cervical dystonia

Background

Botulinum neurotoxins type A (BoNT-As) are commonly used treatments for cervical dystonia (CD). Clinical trials have demonstrated the benefits of them in these patients, but data from real-life clinical practice as well as comparative data on the cost and outcome of different BoNT-A formulations are limited. The aim of this study was to compare abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A) on their clinical outcomes and drug costs in real-life clinical practice.

Methods

This analysis included 356 adult patients with idiopathic CD treated with aboBoNT-A (n = 253) or onaBoNT-A (n = 103) from 38 centres across Europe and Australia (NCT00833196). The clinical outcome measures were treatment responses, changes in TWSTRS scores and changes in health utility scores from baseline to study visit 2 and 3. Health utility score was mapped from the TWSTRS total scale, using a previous publication. Costs included drug cost for France.

Results

The aboBoNT-A treated group had 2.06 (95% CI: 1.15 to 3.69) times higher odds of achieving treatment response than the onaBoNT-A treated group. The adjusted mean change in TWSTRS total score from baseline to visit 3 were - 6.42 (95% CI: - 7.52 to - 5.33) for aboBoNT-A and - 3.94 (95% CI: - 5.68 to - 2.2) for onaBoNT-A, with a difference of - 2.48 (95% CI: - 4.57 to - 0.39). The corresponding difference in the adjusted mean change for health utility score was 0.008 (95% CI: 0.001 to 0.014). Mean treatment costs for aboBoNT-A and onaBoNT-A were 314.1 (95% CI: 299.1 to 329.0) and 346.6 (95% CI: 322.9 to 370.4) Euros, respectively.

Conclusions

This comparative analysis indicated that treatment with aboBoNT-A may be less costly and lead to improved clinical outcomes when compared with onaBoNT-A, from a French healthcare system perspective. Additional comparative clinical data from larger patient cohorts, as well as more information about cost consequences of an improvement in clinical outcome would be of value to further confirm the findings.

Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis

BACKGROUND

Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance.

RESULTS

Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary.

CONCLUSION

This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.

Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical Practice

Botulinum neurotoxin has revolutionized the treatment of spasticity and is now administered worldwide. There are currently three leading botulinum neurotoxin type A products available in the Western Hemisphere: onabotulinum toxin-A (ONA) Botox(®), abobotulinum toxin-A (ABO), Dysport(®), and incobotulinum toxin A (INCO, Xeomin(®)). Although the efficacies are similar, there is an intense debate regarding the comparability of various preparations. Here we will address the clinical issues of potency and conversion ratios, as well as safety issues such as toxin spread and immunogenicity, to provide guidance for BoNT-A use in clinical practice. INCO was shown to be as effective as ONA with a comparable adverse event profile when a clinical conversion ratio of 1:1 was used. The available clinical and preclinical data suggest that a conversion ratio ABO:ONA of 3:1-or even lower-could be appropriate for treating spasticity, cervical dystonia, and blepharospasm or hemifacial spasm. A higher conversion ratio may lead to an overdosing of ABO. While uncommon, distant spread may occur; however, several factors other than the pharmaceutical preparation are thought to affect spread. Finally, whereas the three products have similar efficacy when properly dosed, ABO has a better cost-efficacy profile.

IncobotulinumtoxinA for Migraine: A Retrospective Case Series

PURPOSE

IncobotulinumtoxinA is used for treating certain movement disorders but lacks published clinical data on use in chronic migraine.

METHODS

This retrospective case series was performed by using electronic chart reviews on patients receiving incobotulinumtoxinA for migraine at the Veterans Affairs San Diego Healthcare System between September 2013 and March 2014. Patients were administered 150 units each, with similar methods used for onabotulinumtoxinA injections.

FINDINGS

A total of 21 patients were included in the analysis. Patients were 40 years old on average, 67% white, and 52% female. Patients had trialed an average of 4.19 oral prophylactic agents for migraine with 43% having previous history of onabotulinumtoxinA use and 29% having a history of traumatic brain injury. Patients reported a decrease in headache days per month (19.1 vs 9.1; P < 0.001) and headache intensity (8.3 vs 4.1; P < 0.001) after incobotulinumtoxinA injections. Most patients experienced an improvement in headache frequency and/or intensity (81.8%). The duration of action for these patients averaged 81.9 days (median, 70 days).

IMPLICATIONS

Significant improvements in headache frequency and intensity were observed. Chronic migraine is not an indication approved by the US Food and Drug Administration for incobotulinumtoxinA; however, the drug's effectiveness was documented in this small patient population.