Overall survival benefits of cancer drugs initially approved by the US Food and Drug Administration on the basis of immature survival data: a retrospective analysis

BACKGROUND

New cancer drugs can be approved by the US Food and Drug Administration (FDA) on the basis of surrogate endpoints while data on overall survival are still incomplete or immature, with too few deaths for meaningful analysis. We aimed to evaluate whether clinical trials with immature survival data generated evidence of overall survival benefit during the period after marketing authorisation, and where that evidence was reported.

METHODS

In this retrospective analysis, we searched Drugs@FDA to identify cancer drug indications approved between Jan 1, 2001, and Dec 31, 2018, on the basis of immature survival data. We systematically collected publicly available data on postapproval overall survival results in labelling (Drugs@FDA), journal publications (MEDLINE via PubMed), and clinical trial registries (ClinicalTrials.gov). The primary outcome was availability of statistically significant overall survival benefits during the period after marketing authorisation (until March 31, 2023). Additionally, we evaluated the availability and timing of overall survival findings in labelling, journal publications, and ClinicalTrials.gov records.

FINDINGS

During the study period, the FDA granted marketing authorisation to 223 cancer drug indications, 95 of which had overall survival as an endpoint. 39 (41%) of these 95 indications had immature survival data. After a minimum of 4·3 years of follow-up during the period after marketing authorisation (and median 8·2 years [IQR 5·3-12·0] since FDA approval), additional survival data from the pivotal trials became available in either revised labelling or publications, or both, for 38 (97%) of 39 indications. Additional data on overall survival showed a statistically significant benefit in 12 (32%) of 38 indications, whereas mature data yielded statistically non-significant overall survival findings for 24 (63%) indications. Statistically significant evidence of overall survival benefit was reported in either labelling or publications a median of 1·5 years (IQR 0·8-2·3) after initial approval. The median time to availability of statistically non-significant overall survival results was 3·3 years (2·2-4·5). The availability of overall survival results on ClinicalTrials.gov varied considerably.

INTERPRETATION

Fewer than a third of indications approved with immature survival data showed a statistically significant overall survival benefit after approval. Notable inconsistencies in timing and availability of information after approval across different sources emphasise the need for better reporting standards.

FUNDING

None.

Cancer drug indication approvals in China and the United States: a comparison of approval times and clinical benefit, 2001-2020

Background

Perceived delays in cancer drug approvals have been a major concern for policymakers in China. Policies have been implemented to accelerate the launch of new cancer drugs and indications. This study aimed to assess similarities and differences between China and the United States in the approvals, timing, and clinical benefit evidence of cancer drug indications between 2001 and 2020.

Methods

This study retrospectively identified all cancer drugs and indications approved in both China and the United States from January 1st, 2001 to December 31, 2020, and described differences in approval times as well as in submission and review times. Information on the availability of overall survival benefit evidence by December 31, 2020, was collected. Univariate and multiple logistic regression analyses were used to assess whether evidence of benefit and other factors affected the propensity and timing of approvals of cancer drug indications in China.

Findings

Between 2001 and 2020, 229 indications corresponding to 145 cancer drugs approved in the United States were identified. Of those, 80 indications (34.9%) were also approved in China by the end of 2020. Cancer drug indications were approved in China at a median of 1273.5 days after approval in the United States. The median submission and review time differences for cancer drug indications in China were 1198.0 days and 180.0 days respectively. Submission time differences accounted for most of the approval time differences (p < 0.001). Indications supported by overall survival benefit evidence had shorter median review time differences (145.0 days) than those without such evidence (235.0 days, p = 0.008). Indications with overall survival benefit evidence were 3.94 times more likely to be approved in China compared to those without such evidence (p = 0.001), controlling for approval year, cancer type, and the prevalence of cancer by site.

Interpretation

FDA-approved cancer drug indications demonstrating a survival benefit were more likely to receive approvals in China with shorter regulatory review times compared to indications without such evidence. Given that manufacturer submission times were the main driver of cancer drug approval times in China, factors influencing submission timing should be explored.

Funding

No funding.

Effect of a national antibiotic stewardship intervention in China targeting carbapenem overuse: An interrupted time-series analysis

OBJECTIVES

To assess trends and patterns of carbapenem use and to evaluate the effects of a nationwide antibiotic stewardship policy to reduce carbapenem overuse.

METHODS

In this quasi-experimental study, using longitudinal data from the national drug procurement database and interrupted time-series analyses with carbapenems as the intervention group and possible carbapenem substitutes as the comparison group, we evaluated the effects of a national stewardship policy on carbapenem consumption and expenditures, by region and types of healthcare institutions.

RESULTS

The carbapenem procurement volume declined by -28.8% (95% CI -35.0 to -22.6) (-334.4 thousand defined daily doses [DDDs] per month), and carbapenem expenditures showed a relative reduction of -38.1% (-43.9 to -32.2). The gap between the use of carbapenems and each drug in the comparison group narrowed after the policy intervention, with an increase in tigecycline use (14.9 thousand DDDs [10.8-18.9]) and a slower decrease in use of certain third-generation cephalosporin combinations (-85.7 [-143.0 to -28.4]), penicillin combinations (-200.9 [-421.4-19.6]), and fourth-generation cephalosporins (-116.9 [-219.8 to -14.0]). Consumption was highest during the pre-policy period, and declines were largest following the intervention in the eastern region (-32.1%, -39.8 to -24.4) and among tertiary hospitals (-266.2 [-339.5 to -192.9] thousand DDDs per month).

CONCLUSION

This population-level drug utilization research represents the first comprehensive evaluation of the effectiveness of China's nationwide carbapenem stewardship. The national policy targeting carbapenem prescribing has led to a sustained reduction in carbapenem use with limited substitution. Effects varied geographically and were concentrated in tertiary and secondary hospitals.

Changing Tides? Anticancer Biologic and Biosimilar Use in Medicare Part B, 2019-2021

Anticancer biosimilar use is rising but significant potential savings remain unrealized @alison_mcclean @ChrisLuPhD

The impact of government reimbursement negotiation on targeted anticancer medicines use and cost in China: A cohort study based on national health insurance data

Background

High prices of targeted anticancer medicines (TAMs) result in financial toxicity for patients and the health insurance system. How national price negotiation and reimbursement policy affect the accessibility of TAMs for cancer patients remains unknown.

Methods

In this population-based cohort study, we used national health insurance claims data in 2017 and identified adult patients with cancer diagnoses for which price-negotiated TAMs were indicated. We estimated the half-month prevalence of price-negotiated TAMs use before and after the policy implementation in September 2017. We calculated direct medical costs, out-of-pocket (OOP) costs, and the proportion of OOP cost for each cancer patient to measure their financial burden attributable to TAMs use. We performed segmented linear and multivariable logistic regression to analyse the policy impact.

Results

We included 39 391 of a total 118 655 cancer beneficiaries. After September 2017, the prevalence of price-negotiated TAMs use increased from 1.4%-2.1% to 2.9%-3.1% (P = 0.005); TAMs users' daily medical costs increased from US$261.3 to US$292.5 (P < 0.001), while median daily OOP costs (US$68.2 vs US$65.7; P = 0.134) and OOP costs as a proportion of daily medical costs persisted (28.5% vs 28.5%; P = 0.995). Compared with resident beneficiaries, the relative probability of urban employee beneficiaries on TAMs uses decreased after the policy (adjusted odds ratio (aOR) = 2.4 vs aOR = 2.2).

Conclusions

The government price negotiation and reimbursement policy improved patient access to TAMs and narrowed disparities among insurance schemes. China's approach to promoting the affordability of expensive medicines provides valuable experience for health policy decision-makers.

Marketing authorisation and pricing of FDA-approved cancer drugs in Brazil: a retrospective analysis

Background

Most cancer drugs enter the US market first. US Food and Drug Administration (FDA) approvals of new cancer drugs may influence regulatory decisions in other settings. The study examined whether characteristics of available evidence at FDA approval influenced time-to-marketing authorisation (MA) in Brazil, and price differences between the two countries.

Methods

All new FDA-approved cancer drugs from 2010 to 2019 were matched to drugs with MA and prices approved in Brazil by December 2020. Characteristics of main studies, availability of randomised controlled trials (RCTs), overall survival (OS) benefit, added therapeutic benefit, and prices were compared.

Findings

Fifty-six FDA-approved cancer drugs with matching indications received a MA at the Brazilian Health Regulatory Agency (Anvisa) after a median of 522 days following US approval (IQR: 351-932). Earlier authorisation in Brazil was associated with availability of RCT (median: 506 vs 760 days, p = 0.031) and evidence of OS benefit (390 vs 543 days, p = 0.019) at FDA approval. At Brazilian marketing authorisation, a greater proportion of cancer drugs had main RCTs (75% vs 60.7%) and OS benefit (42.9% vs 21.4%) than that in the US. Twenty-eight (50%) drugs did not demonstrate added therapeutic benefit over drugs for the same indication in Brazil. Median approved prices of new cancer drugs were 12.9% lower in Brazil compared to the US (adjusted by Purchasing Power Parity). However, for drugs with added therapeutic benefit median prices were 5.9% higher in Brazil compared to the US, while 17.9% lower for those without added benefit.

Interpretation

High-quality clinical evidence accelerated the availability of cancer medicines in Brazil. The combination of marketing and pricing authorisation in Brazil may favour the approval of cancer drugs with better supporting evidence, and more meaningful clinical benefit albeit with variable degree of success in achieving lower prices compared to the US.

Funding

None.

Communication of anticancer drug benefits and related uncertainties to patients and clinicians: document analysis of regulated information on prescription drugs in Europe

OBJECTIVE

To evaluate the frequency with which relevant and accurate information about the benefits and related uncertainties of anticancer drugs are communicated to patients and clinicians in regulated information sources in Europe.

DESIGN

Document content analysis.

SETTING

European Medicines Agency.

PARTICIPANTS

Anticancer drugs granted a first marketing authorisation by the European Medicines Agency, 2017-19.

MAIN OUTCOME MEASURES

Whether written information on a product addressed patients' commonly asked questions about: who and what the drug is used for; how the drug was studied; types of drug benefit expected; and the extent of weak, uncertain, or missing evidence for drug benefits. Information on drug benefits in written sources for clinicians (summaries of product characteristics), patients (patient information leaflets), and the public (public summaries) was compared with information reported in regulatory assessment documents (European public assessment reports).

RESULTS

29 anticancer drugs that received a first marketing authorisation for 32 separate cancer indications in 2017-19 were included. General information about the drug (including information on approved indications and how the drug works) was frequently reported across regulated information sources aimed at both clinicians and patients. Nearly all summaries of product characteristics communicated full information to clinicians about the number and design of the main studies, the control arm (if any), study sample size, and primary measures of drug benefit. None of the patient information leaflets communicated information to patients about how drugs were studied. 31 (97%) summaries of product characteristics and 25 (78%) public summaries contained information about drug benefits that was accurate and consistent with information in regulatory assessment documents. The presence or absence of evidence that a drug extended survival was reported in 23 (72%) summaries of product characteristics and four (13%) public summaries. None of the patient information leaflets communicated information about the drug benefits that patients might expect based on study findings. Scientific concerns about the reliability of evidence on drug benefits, which were raised by European regulatory assessors for almost all drugs in the study sample, were rarely communicated to clinicians, patients, or the public.

CONCLUSIONS

The findings of this study highlight the need to improve the communication of the benefits and related uncertainties of anticancer drugs in regulated information sources in Europe to support evidence informed decision making by patients and their clinicians.

Association Between Preapproval Confirmatory Trial Initiation and Conversion to Traditional Approval or Withdrawal in the FDA Accelerated Approval Pathway

This study examines the Food and Drug Administration’s accelerated approval pathway and whether preapproval initiation was associated with faster conversion to traditional approval or withdrawal for drugs with nononcology indications.

Temporal trends in end-stage renal disease in patients with heart failure with or without diabetes: a nationwide study from 2002 to 2017

Background

Advances in treatment of heart failure (HF) have increased survival rates. However, whether the improved life expectancy for HF patients has resulted in an increased risk of a significant comorbidity like end-stage renal disease (ESRD) is less clear. Renal dysfunction is associated with increased morbidity and mortality in HF and constitutes an important prognostic factor for HF. Further, diabetes (DM) is closely related to both HF and ESRD, but it is unknown how DM affects the risk of ESRD in patients with HF.

Purpose

To investigate temporal trends in ESRD in patients with HF and the subsequent risk of mortality stratified by DM.

Methods

Using Danish nationwide registies, we identified patients, aged 18 to 100 years, with incident HF between 2002 and 2017. The outcomes were ESRD (defined as dialysis treatment), worsening of HF (wHF, defined as rehospitalization for HF) and all-cause mortality. Three study periods were investigated 2002–2006, 2007–2011 and 2012–2017. We estimated crude 5-year incidence rates (per 1000/person-years) of the outcomes stratified by DM. Multivariate Cox regression models were performed for all outcomes stratified by DM. Further, we computed the 1-year all-cause mortality risk after diagnosis with ESRD.

Results

Of 124,141 patients with HF, 50,690 (41%) were women and the median age was 74.5 years [95% confidence interval (CI) 64.5–82.8]. At baseline DM was present in 20% of the patients. These patients were older, more often men and more comorbid than HF patients without DM. Over time (2002–2006 to 2012–2017) the incidence rates of ESRD (9.0 to 7.9 and 2.1 to 1.9 per 1000/person-years for DM and no-DM, respectively) and wHF (124.0 to 124.8 and 84.3 to 81.9 per 1000/person-years for DM and no-DM) remained stable, while all-cause mortality rates decreased (217.0 to 170.3 and 172.9 to 127.8 per 1000/person-years for DM and no-DM). The incidence of ESRD was lower compared with the incidence of wHF and all-cause mortality [Figure 1]. HF patients with DM had significantly higher associated rates of all three outcomes (in 2012–2017 the rates for DM vs no-DM of ESRD: 3.99 [3.27–4.86], wHF: 1.42 [1.36–1.49], all-cause mortality: 1.36 [1.31–1.41]) compared with patients without DM. We found no significant interaction between time period and DM on the rates of outcomes (p&gt;0.05 for all) [Figure 2]. One-year all-cause mortality risk after diagnosis with ESRD was high both for HF patients with and without DM through all time periods (identical risks and 95% CI in 2012–2017: 32% [0.25–0.39]).

Conclusions

We did not observe a change over time in the 5-year risk of ESRD for HF patients. The incidence of ESRD remained low compared to wHF and all-cause mortality. DM was associated with increased rates of all three events, not changed over time. Conversely, all-cause mortality after diagnosis with ESRD was markedly high, irrespectively of DM. Our analyses suggest that ESRD is a less common, but fatal event in HF patients.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends in infection-related hospitalizations in patients with heart failure: a nationwide study from 1997 to 2017

Background

Over the last 20 years mortality has decreased for patients with heart failure (HF). However, re-hospitalization for HF is still a challenge. Further, whether the improved survival has resulted in increased rates of non HF hospitalization is unknown.

Purpose

This study examined the temporal trends in infection-related hospitalizations among new-onset HF patients and compared it to temporal trends in risk of worsening HF and death.

Methods

The study population included all Danish patients aged between 18 and 100 years old, with new-onset HF (defined according to the ICD10-code system) diagnosed between 1st January 1997 and 31st December 2017. Patients who were diagnosed with any type of cancer up to five years before their HF diagnosis were excluded to avoid cancer related infections.

The outcomes of interest were infections (defined according to the ICD10-code system) and worsening of heart failure (defined as a hospital admission with HF covering at least to dates).

The Aalen Johansen's estimator was used to estimate unadjusted 5-year absolute risk for all outcomes. Furthermore, a multivariate Cox analysis was made, and hazard ratios were estimated for the four time periods presented in a forest plot with the period 1997–2001 being the reference group. Adjustments for sex, age and history of comorbidities were conducted. Additionally, we stratified the infection outcome on different types of infections illustrated in 5-year cumulative incidence curves.

Results

The total population consisted of 147,737 patients. Over time there was a slight decrease in median age (1997–2001: 76.8 years, 2011–2017: 73.1 years) and the patients were more likely to be male (1997–2001: 53.5%, 2011–2017: 60%).

Figure 1 illustrates overall absolute risk of death decreased over time 1997–2001 (62.7% [95% CI 62.2–63.2]) vs. 2011–2017 (57.9% [95% CI 41.5–42.7]). Unadjusted curves for absolute risk showed that patients with HF had a higher risk of infection over time 1997–2001 (16.4% [95% CI 16.0–16.8] vs. 2011–2017 (24.5% [95% CI 24.0–24.9]). In contrast, they have a lower risk of worsening HF 1997–2011 (26.5% [95% CI 26.1–27.0] vs. 2011–2017 (23.2% [95% CI 22.8–23.7]). Adjusted analyses provided the same result for all outcomes illustrated in figure 2.

The risk of infection stratified by infection type, mark the risk of pneumonia infection as the most significant in all subintervals 1997–2001 (11.4% [95% CI 11.1–11.7]) vs. 2011–2017 (16.1% [95% CI 15.7–16.5]). The second most important was the risk of urogenital infection 1997–2001 (3.5% [95% CI 3.31–3.69]) vs. 2011–2017 (7.8% [95% CI 7.52–8.12]).

Conclusion

In this nationwide study, we observed that overall mortality risk and risk of hospitalization for worsening HF decreased from 1997 to 2017. In contrast, an increase in the risk of hospitalization for infection, especially pneumonia infections, increased during the same period. Future HF management programs should include strategies to prevent infections.

Funding Acknowledgement

Type of funding sources: None.

Overall Survival Benefits of Cancer Drugs Approved in China From 2005 to 2020

IMPORTANCE

Of approximately 9 million patients with cancer in China in 2020, more than half were diagnosed with late-stage cancers. Recent regulatory reforms in China have focused on improving the availability of new cancer drugs. However, evidence on the clinical benefits of new cancer therapies authorized in China is not available.

OBJECTIVE

To characterize the clinical benefits of cancer drugs approved in China, as defined by the availability and magnitude of statistically significant overall survival (OS) results.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods study comprising a systematic review and cross-sectional analysis identified antineoplastic agents approved in China between January 1, 2005, and December 31, 2020, using publicly available data and regulatory review documents issued by the National Medical Products Administration. The literature published up to June 30, 2021, was reviewed to collect results on end points used in pivotal trials supporting cancer drug approvals.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was a documented statistically significant positive OS difference between a new cancer therapy and a comparator treatment. Secondary outcome measures were the magnitude of OS benefit and other primary efficacy measures in pivotal trials.

RESULTS

Between 2005 and 2020, 78 cancer drugs corresponding to 141 indications were authorized in China, including 20 drugs (25.6%) (for 30 indications) approved in China only. Of all indications, 26 (18.4%) were evaluated in single-arm or dose-optimization trials, most of which were authorized after 2017. By June 30, 2021, 34 drug indications (24.1%) had a documented lack of OS gain. For 68 indications (48.2%) that had documented evidence of OS benefit, the median magnitude of OS improvement was 4.1 (range, 1.0-35.0) months. After a median follow-up of 1.9 (range, 1.0-11.1) years from approval, OS data for 13 indications (9.2%) were either not reported or were still not mature. Fewer than one-third of cancer drug indications approved in China only had documented evidence of OS benefits (9 of 30 [30.0%]), whereas more than one-half of the cancer drug indications also available in the US or Europe had OS benefits (59 of 111 [53.1%]).

CONCLUSIONS AND RELEVANCE

In this study, almost half of cancer drug indications approved in China had demonstrated OS gain. With the increase of cancer drug approvals based on single-arm trials or immature survival data in recent years, these findings highlight the need to routinely monitor the clinical benefits of new cancer therapies in China.

New-onset cancer cases in FDA's Sentinel System: a large distributed system of US electronic healthcare data

BACKGROUND

Evaluations of cancer etiology and safety and effectiveness of cancer treatments are predicated on large numbers of patients with sufficient baseline and follow-up data. To assess feasibility of FDA's Sentinel System's electronic healthcare data for surveillance of malignancy onset and examination of product safety, this study examined patterns of enrollment surrounding new-onset cancers.

METHODS

Using a retrospective cohort of patients based on administrative claims, we identified incident events of 19 cancers among 292.5 million health plan members from January 2000 through February 2020 using International Classification of Diseases (ICD) diagnosis codes. Annual incident cases were stratified by sex, age, medical and drug coverage, and insurer type. Descriptive statistics were calculated for observable time prior to and following diagnosis.

RESULTS

We identified 10,697,573 incident cancer events among members with medical coverage. When drug coverage was additionally required, number of incident cancers was reduced by 41%. Medicare data contributed 61% of cases, with similar duration trends as other insurers. Mean duration of follow-up prior to diagnosis ranged from 4.0-4.6 years, while follow-up post diagnosis ranged from 1.1-3.3 years. Approximately a third (36.1%) had at least 2 years both prior to and following diagnosis.

CONCLUSIONS

The FDA Sentinel System's electronic healthcare data may be useful for characterizing relatively short latency cancer risk, examining cancer drug utilization and safety post diagnosis, and conducting surveillance for acute adverse events among patients with cancers.

IMPACT

A national distributed system with electronic health data, the Sentinel system provides opportunity for rapid pharmacoepidemiologic assessments relevant in oncology.

Use of Palliative Care Among Commercially Insured Patients With Metastatic Cancer Between 2001 and 2016

PURPOSE

Early palliative care, concomitant with disease-directed treatments, is recommended for all patients with advanced cancer. This study assesses population-level trends in palliative care use among a large cohort of commercially insured patients with metastatic cancer, applying an expanded definition of palliative care services based on claims data.

METHODS

Using nationally representative commercial insurance claims data, we identified patients with metastatic breast, colorectal, lung, bronchus, trachea, ovarian, esophageal, pancreatic, and liver cancers and melanoma between 2001 and 2016. We assessed the annual proportions of these patients who received services specified as, or indicative of, palliative care. Using Cox proportional hazard models, we assessed whether the time from diagnosis of metastatic cancer to first encounter of palliative care differed by demographic characteristics, socioeconomic factors, or region.

RESULTS

In 2016, 36% of patients with very poor prognosis cancers received a service specified as, or indicative of, palliative care versus 18% of those with poor prognosis cancers. Being diagnosed in more recent years (2009-2016 v 2001-2008: hazard ratio [HR], 1.8; P < .001); a diagnosis of metastatic esophagus, liver, lung, or pancreatic cancer, or melanoma (v breast cancer, eg, esophagus HR, 1.89; P < .001); a greater number of comorbidities (American Hospital Formulary Service classes > 10 v 0: HR, 1.71; P < .001); and living in the Northeast (HR, 1.43; P < .001) or Midwest (v South: HR, 1.39; P < .001) were the strongest predictors of shorter time from diagnosis to palliative care.

CONCLUSION

Use of palliative care among commercially insured patients with advanced cancers has increased since 2001. However, even with an expanded definition of services specified as, or indicative of, palliative care, < 40% of patients with advanced cancers received palliative care in 2016.

Real-world Use of and Spending on New Oral Targeted Cancer Drugs in the US, 2011-2018

Importance

Launch prices of new cancer drugs in the US have substantially increased in recent years despite growing concerns about the quantity and quality of evidence supporting their approval by the US Food and Drug Administration (FDA).

Objective

To assess the use of and spending on new oral targeted cancer drugs among US residents with employer-sponsored insurance between 2011 and 2018, stratified by the strength of available evidence of benefit.

Design, Setting, and Participants

In this cross-sectional study, dispensing claims for oral targeted cancer drugs first approved by the FDA between January 1, 2011, and December 31, 2018, were analyzed. The number of patients with drugs dispensed and the total payment for all claims were aggregated by calendar year, and these outcomes were arrayed according to evidence underlying FDA approvals, including pivotal study design (availability of randomized clinical trials) and overall survival (OS) benefit, as documented in drug labels. This study was conducted from July 17, 2019, to July 23, 2021.

Main Outcomes and Measures

Annual and cumulative numbers of patients who had dispensing events, and annual and cumulative sums of payment for eligible drugs.

Results

Of 37 348 patients who had at least 1 of the 44 new oral targeted drugs dispensed between 2011 and 2018, 21 324 were men (57.1%); mean (SD) age was 64.1 (13.1) years. Most individuals (36 246 [97.0%]) received drugs for which evidence from randomized clinical trials existed; however, a growing share of patients received drugs without documented OS benefit during the study period: from 12.7% in 2011 to 58.8% in 2018. Cumulative spending on all sample drugs totaled $3.5 billion by the end of 2018, of which 96.8% was spent on drugs that were approved based on a pivotal randomized clinical trial. Cumulative spending on drugs without documented OS benefit ($1.8 billion [51.6%]) surpassed that on drugs with documented OS benefit ($1.7 billion [48.4%]) by the end of 2018.

Conclusions and Relevance

The findings of this cross-sectional study suggest that drugs used for treatment of cancer without documented OS benefits are adopted in the health system and account for substantial spending.

Estimated Medicare Spending on Cancer Drug Indications With a Confirmed Lack of Clinical Benefit After US Food and Drug Administration Accelerated Approval

This exploratory study assesses estimated Medicare spending on 10 cancer drug indications that lacked overall survival benefit after receiving US Food and Drug Administration accelerated approval.

Communication of Survival Data in US Food and Drug Administration-Approved Labeling of Cancer Drugs

This cross-sectional study examines how information on overall survival benefits of novel cancer drug indications is communicated in labeling.

Efficacy and costs of spinal muscular atrophy drugs

Evaluating the benefits, risks, and costs of two drugs to treat spinal muscular atrophy raises questions about the future of rare disease medicines.

Forecasting asparaginase quantity required to treat pediatric ALL in LMICs using ACCESS FORxECAST

10031

Background: Asparaginase (ASN) is a crucial component of pediatric acute lymphoblastic leukemia (ALL) protocols. ASN is available in three enzyme formulations: native from Escherichia Coli ( E. coli), PEGylated from E. coli (PEG), and native erwinia from Erwinia chrysanthemi (Erwinase). PEG is typically preferred in high-income countries, while E. coli is more accessible in low and middle income countries (LMICs). Erwinase is reserved for patients who develop hypersensitivity. Short shelf lives, high prices, intermittent availability, and concern for substandard formulations in LMICs have created a need for proactive ASN demand estimates, particularly in LMICs. Methods: We modified FORxECAST, a publicly available tool that forecasts pediatric cancer drug quantity and cost, to estimate ASN quantity required to treat pediatric ALL in 2021 across all LMICs. Incidence data is based on the Global Childhood Cancer microsimulation model, which extrapolates country registries to estimate diagnosed pediatric ALL patients. We forecast ASN quantity for both a base regimen (BR), recommended by the International Pediatric Oncology Society (SIOP), and a more aggressive regimen (AR) used in some LMICs with more advanced supportive care capacity. For both BR and AR, we estimate ASN quantity across four scenarios, outlining how quantity would vary based on formulation and ability to switch in cases of hypersensitivity. Results: The estimated quantity of ASN required to treat all children diagnosed with ALL in LMICs in 2021, across scenarios and regimens, is provided (Table). If E. coli were used to treat all diagnosed pediatric ALL patients across LMICs, required quantity would range from 1,198 M IU (BR) to 1,661 M IU (AR) (Scenario 1). If PEG were used, required quantity would range 150 M IU (BR) to 473 M IU (AR) (Scenario 2). Accounting for hypersensitivity would require 77 M IU (BR) to 137 M IU (AR) Erwinase (Scenarios 3 and 4). Conclusions: We adapted FORxECAST to be ASN-specific and estimated demand in LMICs for a range of scenarios, including for second line Erwinase; accounting for hypersensitivity is particularly important because discontinuation typically results in lower cure rates. We also estimated how quantity of ASN required would increase with treatment intensity. These results provide the first quantification of ASN need for pediatric ALL in LMICs, creating a demand estimate that can inform private and public efforts to produce a reliable supply of high quality ASN for all children with ALL.[Table: see text]

Forecasting essential childhood cancer drug need: An innovative model-based approach

BACKGROUND

Childhood cancer outcomes in low-income and middle-income countries have not kept pace with advances in care and survival in high-income countries. A contributing factor to this survival gap is unreliable access to essential drugs.

METHODS

The authors created a tool (FOR_x ECAST) capable of predicting drug quantity and cost for 18 pediatric cancers. FOR_x ECAST enables users to estimate the quantity and cost of each drug based on local incidence, stage breakdown, treatment regimen, and price. Two country-specific examples are used to illustrate the capabilities of FOR_x ECAST to predict drug quantities.

RESULTS

On the basis of domestic public-sector price data, the projected annual cost of drugs to treat childhood cancer cases is 0.8 million US dollars in Kenya and 3.0 million US dollars in China, with average median price ratios of 0.9 and 0.1, respectively, compared with costs sourced from the Management Sciences for Health (MSH) International Medical Products Price Guide. According to the cumulative chemotherapy cost, the most expensive disease to treat is acute lymphoblastic lymphoma in Kenya, but a higher relative unit cost of methotrexate makes osteosarcoma the most expensive diagnosis to treat in China.

CONCLUSIONS

FOR_x ECAST enables needs-based estimates of childhood cancer drug volumes to inform health system planning in a wide range of contexts. It is broadly adaptable, allowing decision makers to generate results specific to their needs. The resultant estimates of drug need can help equip policymakers and health governance institutions with evidence-informed data to advance innovative procurement strategies that drive global improvements in childhood cancer drug access.

Intensity of End-of-Life Care in a Cohort of Commercially Insured Women With Metastatic Breast Cancer in the United States

PURPOSE

There is limited evidence on the intensity of end-of-life (EOL) care for women < 65 years old, who account for about 40% of breast cancer deaths in the United States. Using established indicators, we estimated the intensity of EOL care among these women.

METHODS

We used 2000-2014 claims data from a large US insurer to identify women with metastatic breast cancer who, in the last month of their lives, had more than one hospital admission, emergency department visit, or an intensive care unit (ICU) admission and/or used antineoplastic therapy in the last 14 days of life. Using multivariate logistic regression, we assessed whether intensity of EOL care differed by demographic characteristics, socioeconomic factors, or regions.

RESULTS

Adjusted estimates show an increase in EOL ICU admissions between 2000-2003 and 2010-2014 from 14% (95% CI, 10% to 17%) to 23% (95% CI, 20% to 26%) and a small increase in emergency department visits from 10% (95% CI, 7% to 13%) to 12% (95% CI, 9% to 15%), both statistically significant. There was no statistically significant change in the proportions of women experiencing more than one EOL hospitalization (14% in 2010-2014; 95% CI, 11% to 17%) and of those receiving EOL antineoplastic treatment (24% in 2010-2014; 95% CI, 21% to 27%). Living in predominantly mixed, Hispanic, Black, or Asian neighborhoods correlated with more intense care (odds ratio, 1.39; 95% CI, 1.10 to 1.77 for ICU).

CONCLUSION

Consistent with findings in the Medicare population, our results suggest an overall increase in the number of ICU admissions at the EOL over time. They also suggest that patients from non-White neighborhoods receive more intense acute care.

The Complex Cancer Care Coverage Environment - What is the Role of Legislation? A Case Study from Massachusetts

Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immuno-oncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications - including high prices and often limited evidence of efficacy at approval - compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates.

Article 3: 1-year impact of supervision, performance assessment, and recognition strategy (SPARS) on prescribing and dispensing quality in Ugandan health facilities

Background

To strengthen appropriate medicine use (AMU) including the prescribing and dispensing quality at public sector health facilities in Uganda, the Ministry of Health introduced a multipronged approach known as the Supervision, Performance Assessment, and Recognition Strategy (SPARS). This paper assesses the impact of the first year of SPARS implementation on key AMU indicators.

Methods

District-based health workers trained as supervisors provide in-service training in medicines management complemented by indicator-based performance assessment and targeted supervision during each SPARS facility visit. From 2010 to 2013, health facilities that started the SPARS intervention were assessed during the first and last visit during a period of 12 months of implementing SPARS. This study examines 12 AMU indicators with 57 individual outcomes covering prescribing and dispensing quality. We also explored factors influencing 1-year improvement.

Results

We found an overall increase in AMU indicators of 17 percentage points (p < 0.000) between the first and last visit during a period of 12 months of supervisions, which was significant in all levels of health care facilities and in both government and private not-for-profit faith-based sectors. Appropriate dispensing (25 percentage points, p < 0.005) improved more than appropriate prescribing (12 percentage points, p = 0.13). Specific facilities that reached an average score of over 75% across all AMU measures within the first year of supervision improved from 3 to 41% from the first visit (baseline). The greatest overall impact on AMU occurred in lower-level facilities; the level of improvement varied widely across indicators, with the greatest improvements seen for the lowest baseline measures. Supervision frequency had a significant impact on level of improvement in the first year, and private not-for-profit faith-based health facilities had notably higher increases in several dispensing and prescribing indicator scores than public sector facilities.

Conclusions

The multipronged SPARS approach was effective in building appropriate medicine use capacity, with statistically significant improvements in AMU overall and almost all prescribing and dispensing quality measures after 12 months of supervision. We recommend broad dissemination of the SPARS approach as an effective strategy to strengthen appropriate medicine use in low-income countries.

Forecasting global essential childhood cancer drug need and cost: An innovative model-based approach

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Background: Childhood cancer outcomes in low-middle income countries (LMICs) have not kept pace with advances in care and survival in high income countries (HICs). A contributing factor to this survival gap is unreliable access to essential cancer drugs. Lack of data on the aggregate need and cost of essential cancer drugs has hampered rational planning and acquisition in many LMICs. Methods: We created a pediatric-specific tool (FORxECAST) that estimates drug quantity and cost for 18 pediatric cancers, customizable to region, regimen, cancer stage distribution, and drug price. We used adapted treatment regimens developed by the International Society of Pediatric Oncology (SIOP), supplemented with input from disease experts, to model treatment approaches reflective of health-system capabilities. FORxECAST incorporates incidence data generated through microsimulation estimates of both diagnosed and undiagnosed (total) cases. Results: We created a pediatric-specific tool (FORxECAST) that estimates drug quantity and cost for 18 pediatric cancers, customizable to region, regimen, cancer stage distribution, and drug price. We used adapted treatment regimens developed by the International Society of Pediatric Oncology (SIOP), supplemented with input from disease experts, to model treatment approaches reflective of health-system capabilities. FORxECAST incorporates incidence data generated through microsimulation estimates of both diagnosed and undiagnosed (total) cases. Conclusions: Our results enable evidence-based forecasting of childhood cancer drug need and cost to inform health system planning in a wide range of countries. The model is adaptable to setting, diagnosis, and treatment approach, allowing decision-makers to generate results specific to their context and needs. Global estimates of essential childhood cancer drug need and cost demonstrate the comparatively small amount of aggregate resources required to treat all cases worldwide, and can help advance innovative procurement strategies with regional and international scale that drive global improvements in childhood cancer drug access.

Integrating public preferences into national reimbursement decisions: a descriptive comparison of approaches in Belgium and New Zealand

Background

Public health care payer organizations face increasing pressures to make transparent and sustainable coverage decisions about ever more expensive prescription drugs, suggesting a need for public engagement in coverage decisions. However, little is known about countries’ approaches to integrating public preferences in existing funding decisions. The aim of this study was to describe how Belgium and New Zealand used deliberative processes to engage the public and to identify lessons learned from these countries’ approaches.

Methods

To describe two countries’ deliberative processes, we first reviewed key country policy documents and then conducted semi-structured interviews with five leaders of the processes from Belgium and New Zealand. We assessed each country’s rationales for and approaches to engaging the public in pharmaceutical coverage decisions and identified lessons learned. We used qualitative content analysis of the interviews to describe key themes and subthemes.

Results

In both countries, the national public payer organization initiated and led the process of integrating public preferences into national coverage decision making. Reimbursement criteria considered outdated and changing societal expectations prompted the change. Both countries chose a deliberative process of public engagement with a multi-year commitment of many stakeholders to develop new reimbursement processes. Both countries’ new reimbursement processes put a stronger emphasis on quality of life, the separation of individual versus societal perspectives, and the importance of final reimbursement decisions being taken in context rather than based largely on cost-effectiveness thresholds.

Conclusions

To face the growing financial pressure of sustainable funding of medicines, Belgium’s and New Zealand’s public payers have developed processes to engage the public in defining the reimbursement system’s priorities. Although these countries differ in context and geographic location, they came up with overlapping lessons learnt which include the need for 1) political commitment to initiate change, 2) broad involvement of all stakeholders, and 3) commitment of all to engage in a long-term process. To evaluate these changes, further research is required to understand how coverage decisions in systems with and without public engagement differ.

Costs after incident breast cancer diagnosis among high-deductible health plan members

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Background: High-deductible health plans (HDHP) are associated with breast cancer treatment delays of up to 10 months, but their impact on health outcomes is unknown. We hypothesized that, compared with women in generous plans, HDHP members would present with more advanced disease and thus experience higher total costs of early care. Methods: We studied 2004-2014 claims data from a large US health insurer. We included women aged 25-64 who were in traditional low-deductible (≤$500) health plans for 1 baseline year then experienced either an employer-mandated switch to HDHPs (≥$1000) for up to 4 or years or an employer-mandated continuation in low deductible plans. We defined the HDHP switch date as the index date. We then restricted to women who developed incident breast cancer after the index date. Using baseline characteristics, we closely matched HDHP members with incident breast cancer to contemporaneous women with incident breast cancer who remained in low-deductible plans. We measured total costs of all health care services in the 60 days after incident breast cancer diagnosis as a proxy for the intensity of incident breast cancer care. We used negative binomial regression adjusted for baseline characteristics to compare total 60-day costs among HDHP and control members. We also subset analyses to low-income women. Results: We included 1514 HDHP members and 9283 matched controls. 60-day costs after incident breast cancer diagnosis were $24,151 (95% CI: $22,766, $25,535) among HDHP members and $22,474 ($21,952, $22,996) among controls, an absolute difference of $1677 ($197, $3156) and a relative difference of 7.5% (8.1%, 14.1%). Low-income HDHP members had corresponding absolute and relative differences of $2653 ($368, $4939) and 12.5% (1.5%, 23.5). Conclusions: HDHP members with incident breast cancer had 7.5% higher health care costs in the 60 days after incident breast cancer than women with more generous coverage, a finding driven 12.5% higher costs among low-income HDHP members. Results raise concerns that delays in breast cancer care among HDHP members are associated with more advanced disease and adverse outcomes.

The Brazilian private pharmaceutical market after the first ten years of the generics law

Objectives

To describe changes in the private market for selected originators, branded generics (‘similares’), and generic products during the 10 years following passage of the Brazilian Generics Law.

Methods

We analyzed longitudinal data collected by IQVIA® on quarterly sales by wholesalers to retail pharmacies in Brazil from 1998 through 2010, grouped by originators, branded generics, and generic products in three therapeutic classes (antibiotics, antidiabetics, and antihypertensives). Outcomes included market share (proportion of the total private market volume), sales volume per capita, prices and number of manufacturers by group.

Results

In the private market share, generics became dominant in each therapeutic class but the speed of uptake varied. Originators consistently lost most market share while branded generics varied over time. By the end of the study period, generics were the most sold product type in all classes, followed by branded generics. The number of generic manufacturers increased in all classes, while branded generics increased just after the policy but then decreased slowly through the end of 2010. For approximately 50% of the antibiotics analyzed, branded generics and generics had lower prices than originators. For antidiabetics, branded generic and generic prices were quite similar during the period analyzed. Price trends for the various subclasses of antihypertensive exhibited very different patterns over time.

Conclusion

Sales of branded generics and originators decreased substantially in the three therapeutic classes analysed following the introduction of the generics policy in Brazil, but the time to market dominance of generics varied by class.

Abstract LB-156: New-onset cancer cases in FDA’s Sentinel System: A large distributed system of US electronic healthcare data

Background: Stemming from the US Cancer Moonshot initiative and 21st Century Cures Act, efforts to harness information technology to evaluate safety and effectiveness of cancer treatment are of high public health interest. Pharmacoepidemiologic cancer etiology and safety evaluations of cancer treatment are predicated upon sufficient number of patients and adequate follow-up time. Objective: To investigate whether Sentinel System’s electronic healthcare data is useful for these purposes, we assessed observable enrollment surrounding a member’s new-onset cancer diagnosis.

Methods: Using administrative claims paid by Medicare and 16 other insurers, we identified incident cases of 19 cancer types among 292.5 million members between January 2000 and August 2017. International Classification of Diseases (ICD) diagnosis codes were used to define the cancers, after confirming diagnostic code mappings across the 2015 switch from ICD-9 to ICD-10 era. Study inclusion required 1 year of enrollment without claims for each respective diagnostic code. For each cancer, we summed annual incident cases by sex, age group, medical and drug coverage type, and Medicare or other insurer. Prior to and following diagnosis, we examined median observable time and duration (≥1 yr, ≥2, ≥3, ≥4 yrs). End of observable time was defined by member disenrollment, death, or end of insurer data.

Results: We identified 7,926,450 members with medical coverage and an incident cancer diagnosis. Medicare data constituted 49.7% of the identified cases, with similar enrollment duration trends as the 16 commercial insurers. Across cancer types, median duration of observable time prior to and following diagnosis ranged from 2.5-3.8 and 0.5-2.5 years, respectively; 1,701,600 (21% of the cases) had at least 4 years of observable time following cancer diagnosis. Observable time following diagnosis varied greatest by cancer type, as expected. Observable time ended most frequently because insurer data ended; death was the least common reason. When drug coverage was additionally required, the number of incident cancers reduced to 4,705,968 (41% decrease). Range in median observable time did not change markedly (0.5-2.3 years post-diagnosis), albeit the sex differential increased after requiring drug coverage (with 54% women and 46% men having ≥4 years post-diagnosis).

Conclusion: A distributed system with routinely updated data and standardized analysis tools provides opportunities for Sentinel System to contribute rapid and large-scale assessments of cancer incidence. Results suggest observable time following cancer diagnosis may provide sufficient duration of follow-up for drug-related adverse events of relatively short latency. Consideration of study-specific eligibility criteria and utilization of specific drug products is warranted prior to performing in-depth pharmacoepidemiologic studies.

Citation Format: Nicole R. Haug, Anita K. Wagner, Katherine A. McGlynn, Charles E. Leonard, Michael D. Nguyen, Jacqueline M. Major. New-onset cancer cases in FDA’s Sentinel System: A large distributed system of US electronic healthcare data [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-156.

Evaluation of Switching Patterns in FDA's Sentinel System: A New Tool to Assess Generic Drugs

INTRODUCTION

Nearly 90% of drugs dispensed in the US are generic products.

OBJECTIVE

The aim of this study was to develop and implement a tool for analyzing manufacturer-level drug utilization and switching patterns within the US Food and Drug Administration's Sentinel system.

METHODS

A descriptive tool was designed to analyze data in the Sentinel common data model and was tested with two case studies-metoprolol extended release (ER) and lamotrigine ER-using claims data from four Sentinel data partners. We plotted initiators of each brand and generic product over time. For metoprolol ER, we evaluated rates of switching from generics around the time of manufacturing issues. For lamotrigine ER, we examined rates of switching back to the brand among those who switched from brand to generic.

RESULTS

We identified 1,651,285 initiators of metoprolol ER products between July 2008 and September 2015. We observed a large decrease in monthly metoprolol ER initiators (from 25,465 in December 2008 to 13,128 in February 2009), corresponding to recalls by generic manufacturers. We observed simultaneous increases in utilization of the authorized generic and brand products. We identified 4266 initiators of lamotrigine ER with an epilepsy diagnosis between January 2012 and September 2015. Among those who switched from brand to generic, the cumulative incidence of switching back was close to 20% at 2 years. Switchback rates were higher for the first available generic products.

CONCLUSIONS

This developed tool was able to elucidate novel utilization and switching patterns in two case studies. Such information can be used to support surveillance of generic drugs and biosimilars.

TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions

Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

State Medicaid Reimbursement for Medications for Chronic Hepatitis C Infection from 2012 through 2015

BACKGROUND

New direct-acting antivirals (DAAs) can cure chronic hepatitis C virus (HCV) infection. High DAA prices combined with a large number of patients needing treatment may pose substantial economic burden on health systems.

OBJECTIVES

To examine Medicaid reimbursement for medications for HCV infection before and after the availability of new DAAs overall and by state and to also assess the impact of Medicaid expansion on reimbursement for DAAs.

METHODS

We calculated Medicaid reimbursements for medications for HCV infection between 2012 and 2015 in all 50 states and the District of Columbia. Outcomes included inflation-adjusted Medicaid reimbursement for medications for HCV infection, market share of individual DAAs, percentages of Medicaid outpatient pharmacy reimbursement for DAAs, and Medicaid reimbursement per Medicaid enrollee with HCV infection.

RESULTS

Medicaid reimbursement for medications for HCV infection increased from $723 million in 2012 to $2.35 billion in 2015. We found variations in Medicaid reimbursement for DAAs between states in 2014 (up to 7.4 times HCV infection prevalence) that widened in 2015 (0.1-11.4 times HCV infection prevalence). Expansion states had significantly higher increases in reimbursement for DAAs per enrollee with HCV infection compared with non- or late-expansion states ($2178.60; 95% confidence interval $1558.90-$2798.40), controlling for pre-expansion reimbursement.

CONCLUSIONS

Medicaid reimbursement for DAAs differs across states after controlling for HCV infection prevalence. A third of states contributed more than 5% to 15% of pharmacy reimbursements to DAAs. Medications for HCV infection are only one class of highly priced specialty drugs. Innovative policy strategies are needed for health systems to manage coverage for an increasing number of expensive specialty medications indicated for an increasing number of patients.

Breast Cancer Diagnosis and Treatment After High-Deductible Insurance Enrollment

Purpose High-deductible health plans (HDHPs) require substantial out-of-pocket spending and might delay crucial health services. Breast cancer treatment delays of as little as 2 months are associated with adverse outcomes. Methods We used a controlled prepost design with survival analysis to assess timing of breast cancer care events among 273,499 women age 25 to 64 years without evidence of breast cancer before inclusion. Women were included if continuously enrolled for 1 year in a low-deductible ($0 to $500) plan followed by up to 4 years in a HDHP (at least $1,000 deductible) after an employer-mandated switch. Study inclusion was on a rolling basis, and members were followed between 2003 and 2012. The comparison group comprised 2.4 million contemporaneously matched women whose employers offered only low-deductible plans. Measures were times to first diagnostic breast imaging (diagnostic mammogram, breast ultrasound, or breast magnetic resonance imaging), breast biopsy, incident early-stage breast cancer diagnosis, and breast cancer chemotherapy. Outcomes were analyzed by using Cox models and adjusted for age-group, morbidity score, poverty level, US region, index date, and employer size. Results After the index date, HDHP members experienced delays in receipt of diagnostic imaging (adjusted hazard ratio [aHR], 0.95; 95% CI, 0.94 to 0.96), biopsy (aHR, 0.92; 95% CI, 0.89 to 0.95), early-stage breast cancer diagnosis (aHR, 0.83; 0.78 to 0.90), and chemotherapy initiation (aHR, 0.79; 95% CI, 0.72 to 0.86) compared with the control group. Conclusion Women switched to HDHPs experienced delays in diagnostic breast imaging, breast biopsy, early-stage breast cancer diagnosis, and chemotherapy initiation. Additional research should determine whether such delays cause adverse health outcomes, and policymakers should consider selectively reducing out-of-pocket costs for key breast cancer services.

The effects of post-traumatic depression on cognition, pain, fatigue, and headache after moderate-to-severe traumatic brain injury: a thematic review

BACKGROUND

Post-traumatic depression (PTD) is one of the most common secondary complications to develop after moderate-to-severe traumatic brain injury (TBI). However, it rarely manifests singularly, and often co-occurs with other common TBI impairments.

OBJECTIVE

The objective of this thematic review is to evaluate studies examining the relationships between PTD and cognition, fatigue, pain, and headache among individuals with moderate-to-severe TBI.

RESULTS

We reviewed 16 studies examining the relationship between PTD and cognition (five articles), fatigue (five articles), pain (four articles), and headache (two articles). Two studies failed to identify the significant associations between PTD and neuropsychological test performance, while one study found a positive association. Two other studies found that early PTD was associated with later executive dysfunction. Studies on fatigue suggest it is a cause, not consequence, of PTD. Individuals with PTD tended to report more pain than those without PTD. Studies examining relationships between PTD and post-traumatic headache were equivocal.

CONCLUSIONS

Studies evaluating the effects of PTD on common TBI impairments have yielded mixed results. Evidence suggests PTD precedes the development of executive dysfunction, and a strong link exists between fatigue and PTD, with fatigue preceding PTD. Future prospective studies evaluating PTD relationships to pain and headache are warranted to elucidate causality.

Drivers of expenditure on primary care prescription drugs in 10 high-income countries with universal health coverage

BACKGROUND

Managing expenditures on pharmaceuticals is important for health systems to sustain universal access to necessary medicines. We sought to estimate the size and sources of differences in expenditures on primary care medications among high-income countries with universal health care systems.

METHODS

We compared data on the 2015 volume and cost per day of primary care prescription drug therapies purchased in 10 high-income countries with various systems of universal health care coverage (7 from Europe, in addition to Australia, Canada and New Zealand). We measured total per capita expenditure on 6 categories of primary care prescription drugs: hypertension treatments, pain medications, lipid-lowering medicines, noninsulin diabetes treatments, gastrointestinal preparations and antidepressants. We quantified the contributions of 5 drivers of the observed differences in per capita expenditures.

RESULTS

Across countries, the average annual per capita expenditure on the primary care medicines studied varied by more than 600%: from $23 in New Zealand to $171 in Switzerland. The volume of therapies purchased varied by 41%: from 198 days per capita in Norway to 279 days per capita in Germany. Most of the differences in average expenditures per capita were driven by a combination of differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed.

INTERPRETATION

Significant international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures were lower among single-payer financing systems that appeared to promote lower prices and the selection of lower-cost treatment options.

Burden of out-of-pocket spending among high-deductible health plan members with metastatic breast cancer

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Background: 50% of workers have high-deductible health plans (HDHP) that require major outofpocket (OOP) spending for cancerrelated care. The OOP burden among patients with advanced cancer in HDHPs is unknown. Our objective was to estimate OOP spending for women with metastatic breast cancer (mbc) stratified by health plan type. Methods: Our data source was administrative health insurance claims and enrollment data of members insured though a large national health plan. We included 7142 women age 25-64 with mbc who had at least 6 months enrollment before the diagnosis and at least 12 months followup. We used a time series design and plotted OOP spending stratified by HDHP vs low-deductible plan. Primary outcome measures included: (1) 20042012 calendar trends in total annual OOP spending, (2) monthly total OOP spending in the 6 months before and 24 months after women were diagnosed with mbc, and (3) monthly total OOP spending in the last 6 months of life. Plots were adjusted for age, socioeconomic status, race/ethnicity, and US region of residence, and we then conducted linear regression to assess for statistical significance of trends. Results: In 2004, average annual OOP spending for women with mbc cancer in low-deductible health plans was $1196.2 and increased to $2570 in 2012, a yearly increase of $159.2 (113.2205.2). For women in HDHP average OOP spending in 2004 amounted to $2648 and increased to $3736.4 in 2012, representing an annual increase of $160.4 per year (105.4215.4) Average OOP spending per person month peaked in the month of diagnosis to $1633.8 for women in HDHPs and to $643 among low-deductible plan members. Average OOP spending in the last 6 months of life were $285.7 per person month among low-plan ($1714.2 per 6 months) and $607.3 among HDHP ($3644 per 6 months). Conclusions: To our knowledge, this is the first analysis to estimate OOP spending for women with mbc accounting for enrollment in HDHPs versus low-deductible plans. We found that OOP spending is increasing over time and is high in the last 6 months of life. HDHP members with mbc faced much higher OOP spending than women in traditional plans across all analyses. Findings raise concerns that HDHPs could worsen access to mbc treatments.

A rapidly changing global medicines environment: How adaptable are funding decision-making systems?

BACKGROUND

With the launch of very highly priced therapies and sudden price increases of generics, pressures on health systems have drastically increased.

OBJECTIVES

We aimed to elicit opinions of key decision makers responsible for national assessment and funding decisions on their experiences to adapt to these new realities.

METHODS/SETTING

Through interviews with decision makers of pharmaceutical assessment and/or funding agencies, we describe the challenges systems are currently facing, systems' responses and systems' characteristics facilitating or hindering responses to changes and overarching topics for the future.

RESULTS

Among the most common challenges are increased funding pressures, increased uncertainty and lack of transparency in decision-making. Systems' responses include utilization management, changing of assessment processes, stakeholder engagement and a focus on outcomes and on coordinated negotiations. Integrated delivery systems, fixed health care budgets and geographic and historical characteristics facilitate or sometimes hinder responses to change. Future policy emphasis lays on expanding data structures, managing the exit of drugs funded early, and implementing processes for communications with patients and the public.

CONCLUSIONS

Going forward emphasis has to be given to structured communications with all stakeholders with a specific emphasis on the broader public and patients about financial limits and priority setting in health care.

Expanding access to high-cost medicines through the E2 access program in Thailand: effects on utilisation, health outcomes and cost using an interrupted time-series analysis

OBJECTIVE

In 2008, the Thai government introduced the 'high-cost medicines E2 access program' as a part of the National List of Essential Medicines to increase patient access to medicines, improve clinical outcomes and make medicines more affordable. Our objective was to examine whether the 'high-cost medicines E2 access program' achieved its goals.

DESIGN

Interrupted time-series design study.

SETTING

3 tertiary hospitals in different regions of Thailand, January 2006 to December 2012.

PARTICIPANTS

Patients with target acute and chronic disease diagnoses who newly met E2 program criteria for selected study medicines.

INTERVENTION

High-cost medicines E2 access program.

MAIN OUTCOMES MEASURES

Level and trend changes over time in the proportions of eligible patients who received the indicated E2 medicines and who improved clinically, as well as in costs of treatment.

RESULTS

A total of 2024 patients were included in utilisation analyses and 1375 patients with selected acute diseases contributed to analyses of clinical outcome. After 1 year of the E2 program implementation, the percentage of eligible patients receiving the indicated E2 program medicines increased significantly (relative change 12.7% (95% CI 4.4% to 21.0%), especially among those insured by the government's universal coverage scheme (relative change 19.9% (95% CI 9.5% to 30.5%)). The increase in the proportion of clinically improved patients with acute conditions was not significant (relative change 6.2% (95% CI -1.9% to 15.1%)). Quarterly healthcare costs per patient dropped significantly (relative change -13.5% (95% CI -26.9% to -1.7%)).

CONCLUSIONS

In the study hospitals, the E2 access program seems to have facilitated patient access to specialty medicines, may have contributed to improved health outcomes, and decreased treatment costs. Routine monitoring is needed to assess effects of expanding the programme, including effects on quality of care and financial sustainability.

Thirty Years of Media Coverage on High Drug Prices in the United States--A Never-Ending Story or a Time for Change?

In recent years drug prices have increasingly become a topic of debate for patients, providers, payers and policy makers. To place the current drug price debate into historical context, we searched the New York Times and Wall Street Journal from 1985 - 2015 and found that concerns about drug prices have commonly featured in the press over the study period with recently stronger calls for change. Price levels, types of innovations, stakeholder responses, and strategies to address high prices discussed in the media suggest that concerted efforts are required to enable affordable and high-value innovations.

Impacts of a new insurance benefit with capitated provider payment on healthcare utilization, expenditure and quality of medication prescribing in China

OBJECTIVES

To assess a new Chinese insurance benefit with capitated provider payment for common diseases in outpatients.

METHODS

Longitudinal health insurance claims data, health administrative data and primary care facility data were used to assess trajectories in outpatient visits, inpatient admissions, expenditure per common disease outpatient (CD/OP) visit and prescribing indicators over time. We conducted segmented regression analyses of interrupted time series data to measure changes in level and trend overtime, and cross-sectional comparisons against external standards.

RESULTS

The number of total outpatient visits at 46 primary care facilities (on the CD/OP benefit as of July 2012) increased by 46 895 visits/month (P = 0.004, 95% CI: 15 795-77 994); the average number of CD/OP visits reached 1.84/year/enrollee in 2012; monthly inpatient admissions dropped from 6.4 (2009) to 4.3 (2012) per 1000 enrollees; the median total expenditure per CD/OP visit dropped by CNY 15.40 (P = 0.16, 95% CI: -36.95~6.15); injectable use dropped by 7.38% (P = 0.03, 95% CI: -14.08%~-0.68%); antibiotic use was not improved.

CONCLUSIONS

Zhuhai's new CD/OP benefit with capitated provider payment has expanded access to primary care, which may have led to a reduction in expensive specialist inpatient services for CD/OP benefit enrollees. Cost awareness was likely raised, and rapidly growing expenditures were contained. Although having been partially improved, inappropriate prescribing of antibiotics and injectables was still prevalent. More explicit incentives and specific quality of care targets must be incorporated into the capitated provider payment to promote scientifically sound and cost-effective care and treatment.

Effects of safety warnings and risk management plan for Thiazolidinediones in Taiwan

PURPOSE

To evaluate changes in thiazolidinedione use and quality of prescription following safety warnings for thiazolidinediones and cardiac risk in 2007, Risk Management Plan (RMP) policy for rosiglitazone in 2010, and warning for pioglitazone and bladder cancer risk in 2010 in Taiwan.

METHODS

We obtained 2003-2011 claims data from Taiwan's National Health Insurance Research Database. Using an interrupted time series design and segmented regression, we estimated changes in monthly prescribing rates for thiazolidinediones among all and prevalent diabetes patients with and without cardiovascular disease history (CV history). We also compared time to prescription of thiazolidinediones among new diabetes patients with CV history before and after each regulatory action using survival analysis.

RESULTS

Among prevalent patients with and without CV history, the prescribing rates of rosiglitazone decreased 36.88% and 28.92% after safety warnings in 2007 respectively. Pioglitazone prescriptions increased 13% among patients with CV history, but no changes were detected among patients without CV history. After rosiglitazone's RMP policy in 2010, large reductions in prescriptions were observed in patients with CV history (-101.67%) and those without CV history (-88.04%). Among new diabetes patients with CV history, cardiac safety warnings in 2007 significantly delayed the prescription of rosiglitazone, but no significant change was found for pioglitazone.

CONCLUSIONS

The Taiwan FDA regulatory actions for thiazolidinediones communicated possible risks of cardiac events and bladder cancer. Different safety regulatory actions had differential impacts on the use of rosiglitazone and pioglitazone and the quality use of these drugs among the high-risk patients.

How Did Multiple FDA Actions Affect the Utilization and Reimbursed Costs of Thiazolidinediones in US Medicaid?

PURPOSE

The US Food and Drug Administration (FDA) communicated the potential cardiovascular risk of thiazolidinediones (rosiglitazone and pioglitazone) in 2007 and required a Risk Evaluation and Mitigation Strategy (REMS) for rosiglitazone in 2010. It also communicated in 2010 the potential risk of bladder cancer with pioglitazone use. This study examined the effects of these multiple FDA actions on utilization and reimbursed costs of thiazolidinediones in state Medicaid programs.

METHODS

State Drug Utilization Data from the Centers for Medicare & Medicaid Services were assessed. An interrupted time series design and segmented linear regression models were used to examine changes in market shares according to both prescription volume and reimbursed costs for rosiglitazone and pioglitazone in the Northeast and Midwest regions of the United States after multiple FDA actions.

FINDINGS

Compared with expected rates, there were relative reductions of 65.84% (Northeast region) and 55.09% (Midwest region) in the use of rosiglitazone at 1 year after the 2007 FDA actions for thiazolidinediones and cardiac risk. At the same time, relative increases of 7.30% and 9.28% in the use of pioglitazone were observed in the Northeast and Midwest regions, respectively. Changes in both use and costs of rosiglitazone after the 2010 REMS program could not be estimated because of the already low rates (~1%) before REMS was implemented. One year after the 2010 FDA actions for pioglitazone and its possible association with bladder cancer, relative reductions in pioglitazone use of 21.41% (Northeast region) and 18.12% (Midwest region) were detected.

IMPLICATIONS

The Northeast and Midwest regions reported similar patterns of changes after the FDA actions. Use and costs of rosiglitazone were substantially reduced after the 2007 FDA actions for cardiovascular risk, and this drug was rarely used after the 2010 REMS program. Conversely, use and costs of pioglitazone were substantially reduced after the 2010 FDA actions regarding the drug's possible risk of bladder cancer.